Leg Claudication Research Articles

Use of Internal Endoconduits as an Adjunct to Endovascular Aneurysm Repair in the Setting of Challenging Aortoiliac Anatomy

The combination of Trans-Atlantic Intersociety Consensus (TASC) D aortoiliac occlusive disease as well as a symptomatic abdominal aortic aneurysm (AAA) is not a common occurrence. Extensive calcified atherosclerotic disease, occlusions, and small iliofemoral segmental arteries make transfemoral access difficult, if not impossible, for endovascular aneurysm repair (EVAR) in these patients. We present a case in which "controlled rupture" of the external iliac artery with a covered stent allowed transfemoral delivery of an aortouni-iliac stent graft with a completion femoral-to-femoral bypass. The patient is a 60-year-old male with a 5.3 cm symptomatic infrarenal AAA and a history of one block right leg claudication. Preoperative computed tomography angiography revealed the patient to have occlusion of the right common iliac artery, extensive calcified stenoses of his aortoiliac segments, and a prohibitively small left external iliac artery, which measured 4.5 mm at its narrowest diameter. The patient, despite discussions concerning the suitability of his iliac arteries as conduits for the delivery of the stent graft, insisted on an endovascular approach to lessen his chances of postoperative sexual dysfunction as well as minimize his length of stay. Access was obtained through bilateral femoral artery cutdowns, and attempts at dilating the left external iliac artery using 16-French dilators were performed without success. An 8 mm x 5 cm covered self-expanding stent was deployed in the diseased 4.5 mm left external iliac artery, followed by angioplasty performed with an 8 mm noncompliant balloon to disrupt the vessel. This endoconduit now allowed accommodation of our 18-French introducer for the aortouni-iliac stent graft. The operation was completed with a femoral-femoral bypass. Flow to both hypogastric arteries was preserved. We believe use of such techniques will ultimately expand the number of patients eligible for EVAR and avoid devastating access-related complications.

Bilateral Asymmetric Popliteal Entrapment Syndrome Treated With Successful Surgical Decompression and Adjunctive Thrombolysis

Popliteal artery entrapment syndrome (PAES) is the most common cause of lower leg claudication in patients younger than 50 years. The different types of PAES can result in different rates of arterial damage, leading to aneurysmal degeneration or occlusion. We report a rare case of a young patient presenting with asymmetrical bilateral popliteal artery entrapment. Type III PAES on the right resulted in severe limb ischemia and was treated by division of the accessory tendon and replacement of damaged artery with vein graft. On the left, the medial head of gastrocnemius was resected to release a type I PAES.

Extraanatomic Bypass and Coronary Artery Grafting for Coral Reef Aorta

A 63-year-old man complained of abdominal angina and intermittent claudication. Multidimensional angiography showed focal calcified obstruction of the suprarenal aorta, occlusion of the right external iliac artery, and instent restenosis in the right coronary artery. Extraanatomic bypass was performed from the ascending aorta to the left external iliac and right femoral arteries, using an 8-mm bifurcated graft, with concomitant off-pump coronary artery grafting. The patient's digestive symptoms and leg claudication disappeared.

A Case of Polyarteritis Nodosa Presenting Initially as Peripheral Vascular Disease

Polyarteritis nodosa is a rare necrotizing vasculitis that can be progressive and fatal, and its initial presenting symptom may be leg claudication due to peripheral vascular ischemia. To date, there have been fewer than ten case reports of polyarteritis nodosa presenting as peripheral vascular disease. We report a case of a 38-year-old man initially diagnosed to have premature peripheral vascular disease who presented 1 year later with symptoms consistent with giant cell arteritis and subsequently developed bowel ischemia leading to a fatal outcome. Based on the autopsy and the patient's clinical course, the final diagnosis was polyarteritis nodosa. This case illustrates the challenges in diagnosing polyarteritis nodosa and the importance of considering vasculitis in young patients presenting with atypical presentations of diseases such as peripheral vascular disease or giant cell arteritis.

Interposition Grafting of Popliteal Artery Cystic Adventitial Disease: Case Report

Cystic adventitial disease of the popliteal artery is a rare cause of leg claudication occurring primarily in young adults. We report a case of a 41-year-old athletic man who presented with rapidly progressive left leg claudication. Using duplex ultrasound and magnetic resonance angiography, a diagnosis of popliteal artery cystic adventitial disease was made. The cystic popliteal artery was resected and replaced using a prosthetic interposition graft. At the 1.5-year follow-up, the cysts have recurred; however, the related symptoms have not. This is in contrast to a previously reported case of interposition saphenous vein grafting requiring resection due to invasion by recurrent cysts within 6 months.

Variation in PCSK9, low LDL cholesterol, and risk of peripheral arterial disease

Background We hypothesized that variants in PCSK9 that lower LDL cholesterol levels are associated with reduced prevalence and incidence of peripheral artery disease (PAD). Methods The Atherosclerosis Risk in Communities (ARIC) Study assessed risk factors and PCSK9 variants Y142X and C679X (relevant to blacks) and R46L (relevant to whites) in a cohort of 45–64-year olds in 1987–1989 ( n = 13,634). Prevalent PAD ( n = 619 cases) was defined by an ankle-brachial index <0.9 or a history of leg claudication. Incident PAD ( n = 895) was identified from 1987 to 1998 by the same PAD criteria or a PAD hospitalization. Results As expected, greater LDL cholesterol was a risk factor for prevalent and incident PAD. 2.4% of blacks and 3.1% of whites were carriers of one of the race-specific PCSK9 variants. Carriers had lower prevalence of PAD compared with non-carriers (2.3% vs. 4.6%). The corresponding age- and sex-adjusted odds ratio of PAD was 0.47 (95% confidence interval, 0.24–0.92). In contrast with the cross-sectional findings, there was no association between PCSK9 variants and incident PAD (age- and sex-adjusted hazard ratio, 1.09 (95% confidence interval, 0.76–1.57)). Conclusions Our study provides mixed evidence that variation in PCSK9 may contribute to genetic risk of PAD.

Self-Reported Difficulty in Climbing Up or Down Stairs in Nondisabled Elderly

Verghese J, Wang C, Xue X, Holtzer R. Self-reported difficulty in climbing up or down stairs in nondisabled elderly. ObjectiveTo examine clinical and functional correlates of self-reported difficulty in climbing up or climbing down stairs in older adults. DesignCross-sectional survey. SettingCommunity sample. ParticipantsOlder adults (N=310; mean age, 79.7y; 62% women), without disability or dementia. InterventionsNot applicable. Main Outcome MeasuresClinical and functional status as well as activity limitations (able to perform activities of daily living [ADLs] with some difficulty). ResultsOf the 310 subjects, 140 reported difficulties in climbing up and 83 in climbing down stairs (59 both). Self-reported difficulty in climbing up stairs was associated with hypertension, arthritis, and depressive symptoms. Difficulty in climbing up stairs was also associated with poor balance and grip strength as well as neurologic gait abnormalities. Subjects with difficulty climbing down stairs had more falls. Both activities were associated with leg claudication, fear of falling, non-neurologic gait abnormalities, and slow gait. Examined individually, self-reported difficulty climbing down stairs captured a wider spectrum of ADL limitations than climbing up stairs. However, combined difficulty in both phases of stair climbing had a stronger association with activity limitations (vs no difficulty; odds ratio, 6.58; 95% confidence interval, 3.35−12.91) than difficulty in any one phase alone. ConclusionsSelf-reported difficulty in climbing up and down stairs revealed commonalities as well as differences in related clinical correlates. Difficulty in both climbing up and down stairs should be separately assessed to better capture clinical and functional status in older adults.

Periodic whole body acceleration: A novel therapy for cardiovascular disease

Periodic whole body acceleration in the spinal axis (pGz) applied by a motion platform is a novel treatment modality that induced endothelial nitric oxide release into the circulation of animals, healthy subjects and patients with inflammatory diseases during single treatment sessions in previous studies. We hypothesized that patients with advanced arteriosclerotic diseases who are not candidates for a surgical intervention would clinically benefit from repeated pGz treatments over several weeks through improvement of endothelial function. 11 patients, 5 men (37 to 71 y) with stable ischemic heart disease, LVEF < 35%, NYHA stage > II, and 6 patients (51 to 83 y, 1 woman) with intermittent leg claudication, Fontaine stage II, were enrolled after optimization of pharmacological therapy. PGz was applied for 40 min, 5 days/week during 5 weeks. Quality of life (SF-36 questionnaire), exercise performance, and endothelial function were assessed at baseline, during the treatment period, and 4 weeks after discontinuation of pGz. PGz was well tolerated. In heart failure paitents, pGz therapy improved quality of life, increased 6 min walking distance by a mean +/- SE of 105 +/- 24 m, and improved postischemic skin hyperemia (p < .05 in all instances). In 4 of 6 patients with intermittent claudication, quality of life, treadmill walking distance and post-ischemic skin hyperemia improved with pGz therapy (p < .05). Four weeks after discontinuation of pGz, most therapeutic effects had vanished in both patient groups. In patients with severe heart failure and with leg claudication who remain symptomatic despite maximal medical therapy and who were not candidates for surgery, periodic acceleration applied over several weeks improved quality of life and exercise capacity. The clinical benefits appear to be mediated through improved endothelial function.

Lumbar radiculopathy caused by extradural rheumatoid nodules

The authors report on a 51-year-old woman with a 9-year history of rheumatoid arthritis (RA) who presented with symptomatic rheumatoid nodules in the lumbar extradural region with compression on the L-5 nerve roots bilaterally. She had also suffered from dysesthesia in the right lower leg and intermittent claudication. Magnetic resonance imaging revealed masses compressing the dural sac, and on lumbar myelography and computed tomography myelography a filling defect at L4-5 was revealed, which was compressing the dural sac posterolaterally on both sides. The masses were surgically removed. On histological examination the typical characteristics of rheumatoid nodules were found. Soon after the operation all of the patient's symptoms disappeared. There have been few reports on extradural rheumatoid nodules. Patients with RA usually complain of articular symptoms, and in fact the patient in the present study had been referred to the authors' institution for total hip arthroplasty. However, various symptoms other than those arising from articular lesions were found clinically. The authors believe that if patients with RA are also examined for extraarticular lesions, it is likely that these will be more frequently detected.

Endovascular Treatment of Lower Limb Penetrating Arterial Traumas

The purpose of this study was to evaluate the effectiveness of percutaneous arterial embolization in patients with penetrating peripheral arterial trauma. Twelve patients with penetrating peripheral arterial trauma were treated with percutaneous arterial embolization between 2002 and 2007. All injuries were secondary to penetrating stab wounds. Active bleeding (eight patients), recurrent bleeding episodes (one patient), persistent pain and mass (one patient), leg edema, claudication, swelling (one patient), local hyperemia, and pain (one patient) were the presenting symptoms. Microcatheter systems were used for catheterization. We used n-butyl cyanoacrylate mixture as the embolizing agent in all patients. On angiograms the inferior gluteal artery (one patient), internal pudendal artery (one patient), perforating branch of the profundal femoral artery (six patients), superficial femoral artery (one patient), peroneal artery (two patients), and anterior tibial artery (one patient) were found to be injured. In all patients, the source of arterial bleeding could be reached, and a safe embolization was achieved. Nontarget embolization due to backflow of n-butyl cyanoacrylate mixture was detected in two patients and inguinal hematoma at the puncture site occurred in one patient. We conclude that embolization-particularly n-butyl cyanoacrylate embolization-is technically feasible in patients with penetrating peripheral arterial trauma.

Effects of peripheral vascular intervention on ischemia-modified albumin

Ischemia -modified albumin was regarded as an early marker of cardiac ischemia. On the other hand, it has been reported that increased ischemia-modified albumin levels are associated with unstable plaque processes like percutaneous coronary intervention, acute coronary syndrome or myocardial infarction. This prospective study aimed to investigate the role of ischemia-modified albumin in patients with peripheral vascular disease undergoing peripheral vascular intervention, a plaque-altering procedure without evidence of tissue ischemia. Peripheral vascular intervention was performed in 21 consecutive patients (68.2+/-13.3 years) with typical leg claudication and documented peripheral vascular disease. Additionally, 96 consecutive patients (66+/-12.0 years) undergoing routine exercise stress test for the exclusion of functionally relevant coronary artery disease were defined as controls. It was assumed that in the latter patients no unstable plaque-altering processes were present. Blood samples were drawn before, and 30 min and 3 h after, revascularization in the peripheral vascular intervention group, as well as before, and 30 min and 3 h after, maximum stress testing in the control group, respectively. Ischemia-modified albumin levels were analyzed using the albumin cobalt-binding test. In patients undergoing peripheral vascular intervention, ischemia-modified albumin increased from 116.6+/-19.1 U/ml at baseline to 132.0+/-19.3 U/ml 30 min after intervention (+14.4+/-15.7%, P<0.001) and decreased to 123.5+/-17.8 U/ml 3 h later (-5.7+/-10.5%, P<0.001 compared with postintervention, P<0.001 compared with baseline). The control group showed a slight but significant decrease in ischemia-modified albumin from 103.0+/-11.0 to 100.2+/-11.6 U/ml poststress (-2.2+/-11.5%, P<0.05) and returned close to baseline 3 h later (101.8+/-10.3 U/ml, +2.4+/-10.9%, P=NS, compared with poststress and with baseline). For both groups, ischemia-modified albumin showed no correlation with albumin (at baseline P=0.62) and total protein (P=0.67), but significant correlation with creatinine (P=0.04) and C-reactive protein (P=0.02). In addition, ischemia-modified albumin was independent of age, sex, alanine aminotransferase, aspartate aminotransferase, creatine kinase, creatine kinase-MB, cholesterol, and triglycerides. This study showed an increased basal ischemia-modified albumin level in patients with peripheral vascular disease undergoing peripheral vascular intervention. Ischemia-modified albumin levels transiently increased shortly after peripheral vascular intervention, indicating a strong correlation between serum concentration of ischemia-modified albumin and processes associated with acute plaque disruption/rupture.

A 13-year-old textiloma (gossypiboma) after discectomy for lumbar disc herniation: a case report and review of the literature

Background context A paraspinal retained surgical sponge (textiloma) is rare and mostly asymptomatic in chronic cases but can be confused with other soft-tissue masses. Therefore, it is important to be aware of patients with a paraspinal soft-tissue mass with unusual or atypical symptoms. Purpose A patient with asymptomatic chronic paraspinal textiloma who was operated on 13 years ago for lumbar disc herniation is presented. Study design Case report. Methods A patient presented with complaints of back pain radiating to leg and neurogenic claudication. Computed tomography imaging revealed canal stenosis at L3–L5 levels and a soft-tissue mass at the paraspinal muscles of the L5–S1 level. Results Surgical treatment was performed for both to excise or obtain biopsy from the soft-tissue mass and to treat spinal stenosis. During the operation, a retained surgical sponge was found and excised completely with fibrous capsule surrounding it and decompression and posterior spinal instrumentation performed without fusion for spinal stenosis with dynamic pedicle screws (Cosmic Pedicle Screw System; Ulrich AG, Germany). Recovery was uneventful, and the patient's stenosis symptoms were resolved soon after surgery. Conclusion Retained surgical sponges do not show mostly any specific clinical and radiological signs. They should be included in differential diagnoses of soft-tissue masses at the paraspinal region with a history of a previous spinal operation.

Endofibrosis of Iliac Arteries in High-Performance Athletes: Diagnostic Approach and Minimally Invasive Endovascular Treatment

The aim of this article is to report our experience in the diagnosis of two cases of iliac artery endofibrosis or arteriopathy, a rare entity occurring in high-performance athletes, presenting with intermittent claudication (right-sided in both) after maximal exercise. External iliac artery endofibrosis or arteriopathy is a likely diagnosis in competitive athletes free of cardiovascular risk factors who present with leg claudication. Arteriography and a papaverine-assisted mean pressure gradient across the iliac arteries of more than 10 mmHg is a useful diagnostic approach. Moreover, balloon angioplasty of the iliac artery in that patient, in whom a pressure gradient was detected, resulted in symptomatic relief for 2 months followed by mild symptom recurrence. Thus, although balloon angioplasty is feasible and safe, it might not be adequate to treat this entity and, thus, its value remains undefined.

Lower Limb Arteriovenous Communications in Diabetes Mellitus: A Potential Reason for Aggravation of Ischemic Symptoms

The aim of this study was to assess the prevalence and to evaluate the clinical associations of arteriovenous communications in patients with diabetes mellitus (DM) and lower limb peripheral arterial ischemia. Peripheral arteriography of DM patients from an eight-year period (1993-2000) was evaluated retrospectively by two observers. The presence of arteriovenous communications, defined as occurring without evidence of a preceding precipitating event, and the distribution and severity of the vascular disease were evaluated. The type (non-insulin-dependent DM or insulin-dependent DM) and the duration of the DM, the presenting symptoms, and the presence of a peripheral neuropathy were documented by a review of the clinical records. A total of 348 arteriography studies in 285 DM patients were evaluated (duration of DM: median, 16 years; range, 7-42 years); an arteriovenous communication was present in 14/285 patients (4.9%), 9 male and 5 female (median age, 71 years; range, 17-84 years). Symptoms were those of a peripheral leg ulcer (n = 11), claudication (n = 3), and gangrene (n = 1), with symptoms ipsilateral to the side of the arteriovenous communication in 13/14 patients. The sites of the arteriovenous communications were infra popliteal (n = 7), popliteal (n = 3), superficial femoral artery (n = 3), and common femoral artery (n = 1). Features of a peripheral neuropathy were found in 12/14 and ipsilateral to the side of the communication in 11/12. Arteriovenous communications in the peripheral femoral arterial system of patients with DM is an uncommon finding. Although not proven in the current study, arteriovenous communications might be associated with more severe symptoms than that attributable to the underlying vascular disease alone.

The United States Preventive Services Task Force Recommendation Statement on Screening for Peripheral Arterial Disease

Under the auspices of the Agency for Healthcare Research and Quality, the United States Preventive Services Task Force (USPSTF) recently released an update to its 1996 Peripheral Arterial Disease (PAD) Screening Recommendation Statement. The USPSTF recommended against PAD screening, giving the practice a "D" level recommendation. This level suggests that little or no benefit could accrue from PAD screening and that screening-associated harm could occur. The present commentary disputes the Task Force's recommendation. The USPSTF statement omitted important peer-reviewed data on the prevalence, screening efficacy, and short-term adverse prognosis of patients with PAD and failed to consider the beneficial outcomes that probably would result from timely diagnosis and treatment of this important manifestation of atherosclerosis. The Task Force implied that screening may lead to unnecessary tests, including increased risk associated with use of contrast angiographic studies. However, most patients with PAD have neither classic symptoms of leg claudication nor threatened limbs but have an extraordinarily high rate of adverse cardiovascular events, such as myocardial infarction, stroke, and death--events that should serve as a key rationale for screening. Medical therapy, including risk factor modification and antiplatelet medications, is known to reduce cardiovascular morbidity and mortality rates in these patients. The Task Force's recommendation against PAD detection may itself adversely result in inadequate recognition and treatment of PAD, with adverse public health consequences. We encourage the USPSTF to reevaluate the extant data, add vascular specialty expertise to its review group, and reconsider its recommendation.

Severe obstructive calcifications affecting the descending and suprarenal abdominal aorta without coexisting peripheral atherosclerotic disease – coral reef aorta

The case of a 58-year-old woman with leg claudication due to a very rare form of atherosclerosis affecting the descending thoracic and abdominal aorta--known as coral reef aorta--without involvement of the femoro-distal vessels is reported. The patient was treated with a polyester bifurcation graft from the proximal descending aorta to both common iliac arteries via a left dorsal mini-thoracotomy and a second left retroperitoneal approach. This unusual approach was chosen instead of direct aortic replacement in order to prevent paraplegia. In case of future visceral or left renal malperfusion the diseased artery can be connected to the prosthesis directly or by the use of an additional bypass graft. This would not be the case with a conventional axillo-bifemoral graft.

Number and Function of Endothelial Progenitor Cells as a Marker of Severity for Diabetic Vasculopathy

Peripheral arterial disease (PAD) is a threatening complication of diabetes. As endothelial progenitor cells (EPCs) are involved in neovasculogenesis and maintenance of vascular homeostasis, their impairment may have a role in the pathogenesis of diabetic vasculopathy. This study aimed to establish whether number and function of EPCs correlate with PAD severity in type 2 diabetic patients. EPCs were defined by the expression of CD34, CD133 and KDR, and quantified by flow cytometry in 127 diabetic patients with and without PAD. PAD severity has been assessed as carotid atherosclerosis and clinical stage of leg atherosclerosis obliterans. Diabetic patients with PAD displayed a significant 53% reduction in circulating EPCs versus non-PAD patients, and EPC levels were negatively correlated with the degree of carotid stenosis and the stage of leg claudication. Moreover, the clonogenic and adhesion capacity of cultured EPCs were significantly lower in diabetic patients with PAD versus patients without. This study demonstrates that EPC decrease is related to PAD severity and that EPC function is altered in diabetic subjects with PAD, strengthening the pathogenetic role of EPC dysregulation in diabetic vasculopathy. EPC count may be considered a novel biological marker of peripheral atherosclerosis in diabetes.

Medical Treatment of Peripheral Arterial Disease

Peripheral arterial disease (PAD) affects approximately 20% of adults older than 55 years and is a powerful predictor of myocardial infarction, stroke, and death due to vascular causes. The goals of treatment are to prevent future major coronary and cerebrovascular events and improve leg symptoms. To review the best evidence for medical treatment of PAD. MEDLINE and the Cochrane database were searched from 1990 to November 2005 for randomized trials and meta-analyses of medical treatments for PAD. References from these articles were also searched. Search terms included, singly and in combination: peripheral arterial disease, peripheral artery disease, PAD, randomized controlled trial, controlled trial, randomized, and meta-analysis. Particular attention was directed toward randomized controlled trials and meta-analyses of clinically relevant medical treatments for PAD. Outcome measures included leg symptoms (intermittent claudication and walking distance), death, and major coronary and cerebrovascular events. Symptoms of leg claudication, walking distance, and quality of life can be improved by smoking cessation (physician advice, nicotine replacement therapy, and bupropion), a structured exercise program, statin drugs, cilostazol, and angiotensin-converting enzyme inhibitors. The risk of major coronary and cerebrovascular events can be reduced through lowering blood pressure with angiotensin-converting enzyme inhibitors and other antihypertensive drugs, use of statin drugs, antiplatelet therapy with aspirin or clopidogrel, and probably by stopping smoking. The substantial and increasing burden of PAD, and its local and systemic complications, can be reduced by lifestyle modification (smoking cessation, exercise) and medical therapies (nicotine replacement therapy, bupropion, antihypertensive drugs, statins, and antiplatelet drugs).

Aortoiliac Endarterectomy: A Lost Art?

Endarterectomy was first performed on a superficial femoral artery in 1946 by Cid dos Santos and subsequently on the abdominal aorta by Wylie in 1951. During the 1950s and 1960s, aortoiliac endarterectomy (AIE) was the standard procedure for treatment of aortoiliac occlusive disease. When prosthetic graft material became available, aortobifemoral bypass (ABFB) replaced AIE in most cases because occlusive disease commonly affects the external iliac arteries also, which were difficult to endarterectomize. As a result, aorto-common iliac endarterectomy became almost a lost art. However, we believe there is still a place for AIE in selected patients based on a review of our results with the procedure. We reviewed 205 patients who survived 10 years after undergoing operation for aortoiliac occlusive disease by either aorto-common iliac endarterectomy (n = 39) or ABFB (n = 166). Ten-year primary patency was 89.2% for AIE and 78% for ABFB. Graft infection or aneurysmal formation occurred in 5% of ABFB and 0% of AIE cases. Ten male patients who underwent AIE for leg and hip claudication with positive penile/brachial indices of </=0.6 enjoyed improvement of erectile dysfunction. Twenty of the 39 AIEs were in female smokers with small vessels, localized disease, and elevated triglycerides. Three patients with end-to-side infected ABFB grafts, two with enteric fistula (one ours, two referred), had their grafts removed, followed by AIE with vein patching of their bypass sites. All three patients survived and at 10-year follow-up had patent reconstructed aortofemoral vessels. Since AIE avoids prosthetic material, it is preferable to ABFB in (1) patients whose aortoiliac occlusive disease does not involve the external iliac arteries; (2) male patients with aortoiliac occlusive disease who, in addition to claudication, have erectile dysfunction with penile/brachial indices of </=0.6 and stenotic internal iliac origins; (3) patients with aortoiliac disease including the external iliac arteries who are not candidates for ABFB because of infection risk or small vessels; (4) patients with localized aortoiliac disease; and (5) patients after removal of an infected ABFB graft (with or without an enteric fistula) that had initially been placed end-to-side for aortoiliac occlusive disease.

The adult scoliosis

Adult scoliosis is defined as a spinal deformity in a skeletally mature patient with a Cobb angle of more than 10 degrees in the coronal plain. Adult scoliosis can be separated into four major groups: Type 1: Primary degenerative scoliosis, mostly on the basis of a disc and/or facet joint arthritis, affecting those structures asymmetrically with predominantly back pain symptoms, often accompanied either by signs of spinal stenosis (central as well as lateral stenosis) or without. These curves are often classified as "de novo" scoliosis. Type 2: Idiopathic adolescent scoliosis of the thoracic and/or lumbar spine which progresses in adult life and is usually combined with secondary degeneration and/or imbalance. Some patients had either no surgical treatment or a surgical correction and fusion in adolescence in either the thoracic or thoracolumbar spine. Those patients may develop secondary degeneration and progression of the adjacent curve; in this case those curves belong to the type 3a. Type 3: Secondary adult curves: (a) In the context of an oblique pelvis, for instance, due to a leg length discrepancy or hip pathology or as a secondary curve in idiopathic, neuromuscular and congenital scoliosis, or asymmetrical anomalies at the lumbosacral junction; (b) In the context of a metabolic bone disease (mostly osteoporosis) combined with asymmetric arthritic disease and/or vertebral fractures. Sometimes it is difficult to decide, what exactly the primary cause of the curve was, once it has significantly progressed. However, once an asymmetric load or degeneration occurs, the pathomorphology and pathomechanism in adult scoliosis predominantly located in the lumbar or thoracolumbar spine is quite predictable. Asymmetric degeneration leads to increased asymmetric load and therefore to a progression of the degeneration and deformity, as either scoliosis and/or kyphosis. The progression of a curve is further supported by osteoporosis, particularly in post-menopausal female patients. The destruction of facet joints, joint capsules, discs and ligaments may create mono- or multisegmental instability and finally spinal stenosis. These patients present themselves predominantly with back pain, then leg pain and claudication symptoms, rarely with neurological deficit, and almost never with questions related to cosmetics. The diagnostic evaluation includes static and dynamic imaging, myelo-CT, as well as invasive diagnostic procedures like discograms, facet blocks, epidural and root blocks and immobilization tests. These tests may correlate with the clinical and the pathomorphological findings and may also offer the least invasive and most rational treatment for the patient. The treatment is then tailored to the specific symptomatology of the patient. Surgical management consists of either decompression, correction, stabilization and fusion procedures or a combination of all of these. Surgical procedure is usually complex and has to deal with a whole array of specific problems like the age and the general medical condition of the patient, the length of the fusion, the condition of the adjacent segments, the condition of the lumbosacral junction, osteoporosis and possibly previous scoliosis surgery, and last but not least, usually with a long history of chronified back pain and muscle imbalance which may be very difficult to be influenced. Although this surgery is demanding, the morbidity cannot be considered significantly higher than in other established orthopaedic procedures, like hip replacement, in the same age group of patients. Overall, a satisfactory outcome can be expected in well-differentiated indications and properly tailored surgical procedures, although until today prospective, controlled studies with outcome measures and pre- and post-operative patient's health status are lacking. As patients, who present themselves with significant clinical problems in the context of adult scoliosis, get older, minimal invasive procedures to address exactly the most relevant clinical problem may become more and more important, basically ignoring the overall deformity and degeneration of the spine.