Deformity of the adult spine includes patients with curvature of the spine (scoliosis) of varying degrees caused or impacted by degenerative disc and joint disease. Adult scoliosis may be the result of persistent or progressive deformity since adolescence or a new, de novo, onset of deformity resulting from degeneration or aging of the spine. Degenerative scoliosis accounts for the majority of scoliosis cases in older populations aged 65 years and older, as reflected in the low proportion of older patients with a diagnosis of primary idiopathic scoliosis.
Degenerative scoliosis is one of the most challenging spine conditions to treat because of the variability of the condition. Generally, it is thought to originate with the degeneration of the intervertebral discs, which leads to misalignment of the vertebral column. Degenerative scoliosis, particularly in the very elderly, is often associated with other conditions, such as osteoporosis. Treatment outcomes for both nonsurgical and surgical procedures are not well documented; hence, recognition and earlier intervention are important to ward off the more complex problems of adult scoliosis. The role played by undiagnosed, mild idiopathic adolescent scoliosis on the development of degenerative scoliosis in later life is unknown.
While scoliosis is the primary form of spinal curvature, two other spine curvature disorders are included in the data cited here. These are lordosis, also known as swayback, where the spine curves significantly inward at the lower back, and kyphosis, characterized by an abnormally rounded upper back with a curvature of more than 50º.
The clinical presentation and management of adults with scoliosis is characterized by a great deal of variability. There is a poor correlation between the magnitude of deformity and the impact of scoliosis on health status, as patients with large spinal curvatures may have limited pain and disability with and patients with relatively mild deformity may be severely impaired. Deformity in the sagittal plane (lateral) is most closely associated with disability.1 Patients with adult scoliosis seek medical care for symptoms including back pain, neural symptoms, and progression of deformity.
The prevalence of adult spinal deformity and scoliosis is not well established, with estimates ranging from 2.5% to 25% of the population.1,2,3,4,5,6 A 2005 study reported mild to severe adult scoliosis prevalence as high as 68% in a healthy (no known scoliosis or spine surgery) population aged 60 years and older.7 Many cases of degenerative scoliosis are undiagnosed, but elderly patients often seek care because of back and leg pain that may be caused by scoliosis and associated spinal stenosis.
According to 2010 US Census Population Estimate, there were 235,205,658 people in the United States over the age of 18 years. Prevalence of adult scoliosis cited in the literature ranges from 2.5% to 60%, depending on severity. A conservative estimate (2.5%) of the prevalence of adult scoliosis yields an incidence of a minimum of 5.88 million adults in the United States with adult scoliosis. In 2010–2011, an estimated 1.61 million of these adults received treatment either as an inpatient or on an outpatient basis. (Reference Table 3.1.2 PDF [1] CSV [2])
Estimates for prevalence of lordosis or kyphosis as the primary diagnoses is approximately 17% of spine curvature diagnoses in hospital and emergency departments, with patient hospital discharges higher (23%). (Reference Table 3.2.2 PDF [3] CSV [4])
The management of adult scoliosis includes nonsurgical and surgical resources. Nonsurgical treatments of adult scoliosis utilize significant resources, and include interventions such as exercises, physical therapy, injections, pain medications, and manual manipulation.1 Data on nonsurgical treatments is not available; however, a 2010 non-randomized study reported that two years of nonsurgical treatment in adult scoliosis patients resulted in substantial expenditures and yielded no improvement in health status.2
Operative management of scoliosis in the adult encompasses a spectrum of procedures including decompression alone, decompression with limited fusion, and fusion of the deformity. In 2011, a query of the Healthcare Costs and Utilization Project (HCUP) Nationwide Inpatient Survey (NIS) resulted in approximately 229,100 hospitalizations associated with a discharge diagnosis of scoliosis or spinal curvature (ICD-9-CM of 373). The majority of these, or 155,900 patients, were diagnosed as idiopathic scoliosis, or scoliosis of unknown cause. Most of the remaining discharges, 66,000 people, were associated with a primary diagnosis of acquired adult scoliosis, while the remaining 10,500 discharges were associated with adult scoliosis as the secondary diagnosis to another condition. (Reference Table 3.1.1 PDF [5] CSV [6])
In 2011, nearly 27.6 thousand patients admitted to the hospital with a diagnosis of scoliosis underwent a decompression procedure. Among patients having decompression, 82% also had spinal fusion, with 42% undergoing fusion of one to three levels, while 34% had fusion of four or more levels. Overall, 22% of all scoliosis patients underwent a fusion procedure (N=50,009), with 10% having fusion of one to three levels and 12% fusion of four or more levels.
In 2011, only about one-half (53%) of patients with a scoliosis diagnosis were discharged to home, while 70% of patients discharged for any diagnosis had a routine discharge. Patients with a scoliosis diagnosis are more likely to be transferred to a skilled nursing or intermediate care facility than are patients with all diagnoses. This is particularly true for the elderly population, with 46% of persons age 75 and older with a scoliosis diagnosis moving to a long-term care facility. (Reference Table 3.3.1 PDF [7] CSV [8])
The cost of care for adults with scoliosis includes direct costs and indirect costs including lost wages, time from work, cost of care providers, and opportunity costs. Estimates of the direct costs of nonsurgical care in adult scoliosis are estimated to be as high as $14,000 per year.1
The national mean cost of a hospitalization (presumably for surgical treatment) for patients with a primary diagnosis of idiopathic scoliosis was $67,400 in 2011 for an average hospital stay of 5.6 days. The HCUP NIS database does not provide hospitalization costs associated with secondary discharge diagnoses, and does not include fees to doctors, tests, and other typical charges associated with hospitalization. Therefore, the most conservative estimate of only the hospitalization cost for adult scoliosis in 2011 was an estimated $15.44 million (229,000 hospitalizations). The real cost of the management of adult scoliosis to our healthcare system is significant, and the value of care measured by change in health status remains incompletely defined for both nonsurgical and surgical care. (Reference Table 3.4.1 PDF [9] CSV [10])
Mean charges for scoliosis diagnosed patients are similar to those for other spinal deformity diagnoses, but significantly higher than for all hospital discharge patients.
Links:
[1] https://www.boneandjointburden.org/docs/T3.1.2.pdf
[2] https://www.boneandjointburden.org/docs/T3.1.2.csv
[3] https://www.boneandjointburden.org/docs/T3.2.2.pdf
[4] https://www.boneandjointburden.org/docs/T3.2.2.csv
[5] https://www.boneandjointburden.org/docs/T3.1.1.pdf
[6] https://www.boneandjointburden.org/docs/T3.1.1.csv
[7] https://www.boneandjointburden.org/docs/T3.3.1.pdf
[8] https://www.boneandjointburden.org/docs/T3.3.1.csv
[9] https://www.boneandjointburden.org/docs/T3.4.1.pdf
[10] https://www.boneandjointburden.org/docs/T3.4.1.csv