Adult Scoliosis
When most people hear the word scoliosis, they picture a teenager in a brace. But scoliosis is not exclusively a pediatric condition, and for a significant number of adults it is either a continuation of a curve that began in adolescence or an entirely new problem that develops as the spine ages. Adult scoliosis brings its own distinct clinical challenges — pain, functional limitation, difficulty standing or walking for extended periods, and in some cases neurological symptoms from nerve compression — and it deserves the same thoughtful, individualized approach that any complex spine condition requires.
THE BASICS
What Adult Scoliosis Is and Why It Develops
Adult scoliosis is an abnormal lateral curvature of the spine in a skeletally mature individual, and it generally falls into one of two categories. Adult idiopathic scoliosis represents the continuation or progression of a curve that was present in adolescence — one that may have been stable for decades and becomes symptomatic as the degenerative changes of aging are superimposed on an already asymmetric spine. Adult degenerative scoliosis, also called de novo scoliosis, develops in a previously straight spine as age-related disc degeneration, facet arthritis, and ligamentous laxity produce asymmetric collapse and rotational deformity over time. This second category is increasingly common as the population ages, and it is frequently underdiagnosed because clinicians and patients alike tend not to associate a new onset of complex low back pain in a sixty-year-old with a developing spinal deformity.
Symptoms vary considerably depending on the magnitude of the curve, the degree of associated degenerative change, and whether nerve structures are being compressed. Chronic low back pain and muscle fatigue are the most common presenting complaints. Visible asymmetry of the trunk, rib prominence, or uneven shoulder and hip heights may be apparent on examination. Difficulty standing upright or walking for extended periods — a phenomenon related to global sagittal imbalance — is a particularly functionally significant symptom that affects independence and quality of life. Radiating leg pain consistent with sciatica or neurogenic claudication can develop when the scoliotic deformity produces lateral recess stenosis or foraminal narrowing at affected levels.
CLINICAL EVIDENCE
Diagnosis and What the Research Supports
Diagnosis is established through a combination of clinical examination and standing spinal radiographs, which allow measurement of the Cobb angle and assessment of global coronal and sagittal alignment. MRI and CT scanning are added when neurological symptoms are present, when advanced degenerative changes need to be characterized for treatment planning, or when surgical evaluation is being considered. The natural history of adult scoliosis is variable — curves below 30 degrees tend to be more stable, while larger curves, particularly those with significant rotational deformity or associated sagittal imbalance, are more likely to progress. Monitoring with periodic imaging allows progression to be identified and treatment escalated accordingly.
The evidence supporting nonoperative management of adult scoliosis is robust for the majority of patients. Physical therapy using scoliosis-specific approaches including the Schroth Method addresses the three-dimensional nature of the deformity through individualized exercise programs focused on curve-specific elongation, rotational breathing mechanics, and postural correction — producing meaningful improvements in pain, function, and curve stability in multiple prospective studies. Core stabilization, flexibility training, and ergonomic coaching reduce the mechanical load driving symptom generation without requiring surgical intervention. Osteopathic manipulative medicine including myofascial release, muscle energy techniques, and counterstrain provides additional tools for addressing the soft tissue dysfunction and mobility restriction that develop secondary to the structural deformity.
PATIENT SELECTION
A Comprehensive Nonoperative Approach
For most adults with scoliosis, a well-coordinated nonoperative strategy produces meaningful symptom control and functional improvement without surgery. Pain management in this context is multimodal and tailored to the specific generators driving each patient's symptoms. Anti-inflammatory medications provide baseline pain control during flares. Neuropathic agents including duloxetine and gabapentin address the nerve-mediated component when radicular or neuropathic features are present. Image-guided interventional procedures allow precise treatment of the specific pain generators identified on examination and imaging — epidural steroid injections for sciatica and spinal stenosis, facet joint blocks and medial branch blocks for facetogenic pain, and radiofrequency ablation for longer-term facet-mediated pain relief in appropriately selected patients. Bracing in adults serves a different purpose than in adolescents — not curve correction, but segmental support, postural improvement, and fatigue reduction during activity — and is selected carefully to avoid the deconditioning that can result from excessive reliance on external support. Lifestyle optimization including weight management to reduce axial load, anti-inflammatory nutrition, daily walking or aquatic therapy, and structured activity pacing rounds out the comprehensive nonoperative program.
Surgical referral is appropriate when the curve exceeds 50 to 60 degrees, when pain is unrelenting despite comprehensive conservative management, or when progressive neurological symptoms or spinal instability develop. I coordinate directly with fellowship-trained spine surgeons when surgical evaluation is warranted, ensuring that the transition is seamless and that the surgical team has a complete picture of what has been tried, what has worked, and what the patient's functional goals are.
FOR REFERRING CLINICIANS
Adult scoliosis is a condition that benefits significantly from physiatric co-management — both in the nonoperative phase and in the perioperative period when surgery becomes necessary. Appropriate referral candidates include adults with chronic low back pain and known or suspected spinal curvature, patients with progressive functional limitation from scoliosis-related pain, and patients with neurological symptoms attributable to scoliotic deformity who require interventional evaluation before surgical consideration. I offer comprehensive standing radiograph assessment, Cobb angle measurement and progression monitoring, scoliosis-specific physical therapy coordination, the full range of image-guided interventional procedures for pain management, and direct surgical coordination when indicated. I welcome direct physician-to-physician consultation.
PERSPECTIVE
A Note on Living Well With Adult Scoliosis
Adult scoliosis is not a diagnosis that should lead automatically to resignation or to surgery. For the majority of patients it is a manageable condition — one that responds to the right combination of targeted exercise, precise pain management, and thoughtful lifestyle modification. What I find most important in treating this population is taking the time to understand what each patient is actually trying to accomplish. The retired teacher who wants to walk her grandchildren to school without pain has different goals than the fifty-year-old executive who wants to return to recreational golf, and the treatment plan should reflect that difference. Scoliosis imposes structural constraints, but it does not determine what a person is capable of. With the right approach, most adults with scoliosis can remain active, functional, and genuinely well — and that is the outcome I am working toward with every patient I see.
DISCLOSURE & REFERENCES
This article is for educational purposes and reflects clinical experience and interpretation of published literature. It is not a substitute for individualized medical evaluation. Key references: Schwab F et al. 2005 (adult scoliosis prevalence and natural history, Spine); Negrini S et al. 2018 (SOSORT guidelines, Scoliosis Spinal Disord); Schreiber S et al. 2016 (Schroth Method in adults, JAMA Pediatrics); Manchikanti L et al. 2010 (facet joint interventions, Pain Physician); Glassman SD et al. 2005 (sagittal balance and outcomes in adult scoliosis, Spine).
ABOUT THE AUTHOR
Dr. Mahajer is a double board-certified physiatrist and sports medicine physician, fellowship-trained in Interventional Spine & Sports Medicine at the Icahn School of Medicine at Mount Sinai. He is an Assistant Professor of Neuroscience at FIU Herbert Wertheim College of Medicine. He is the Immediate Past President of the American Osteopathic College of Physical Medicine and Rehabilitation (AOCPMR), holds medical licenses in Florida, New York, and California, and has been recognized as a Top Physiatrist and Top Doctor in both Florida and New York.
