Adult Scoliosis: What to Look For, When to Treat, When to Refer

Adult scoliosis is sitting in your practice right now, largely unnamed. A 2020 systematic review and meta-analysis of adult de novo scoliosis pooled a prevalence estimate of 37.6 percent, rising from 13 percent in adults under 60 to 36 percent in those over 60, and running higher in women than in men.¹ Yet these patients present with low back pain, leg pain or “one hip higher than the other,” and are managed as ordinary mechanical low back cases for months. The general-practice chiropractor is frequently the first clinician positioned to name the condition, and what happens at that first visit sets the trajectory.

Know Which Patient You Have

Adult scoliosis divides into two clinically distinct populations, and they do not behave alike.^2,3

Adolescent scoliosis in the adult (ASA) began in the teen years and persisted past skeletal maturity.⁵ It presents much as adolescent idiopathic scoliosis does – thoracic or thoracolumbar, with rib prominence and shoulder asymmetry – and progresses slowly and steadily, roughly 0.5 to 1 degree per year depending on curve pattern.³

Degenerative de novo scoliosis (DDS) arises after 50 from asymmetric disc and facet breakdown, and is by far the more prevalent of the two. It is typically a shorter lumbar curve with loss of lordosis, progresses considerably faster (averages near 3 degrees per year have been reported), brings stenotic and claudication-pattern leg symptoms, and is accelerated by postmenopausal bone loss.^2-3

Distinguishing the two via imaging alone is difficult once a curve has progressed. The single most useful discriminator is the history: Did anyone tell this patient they had scoliosis as a teenager? Ask directly.

What to Look For

• History: Adolescent diagnosis, family history, height loss, clothing that no longer hangs correctly, waistline asymmetry, and bone density status in postmenopausal women.
• Observation: Unequal shoulder or scapular height, rib or lumbar prominence on Adams forward bend, waist crease asymmetry, trunk shift, apparent leg-length inequality, and flattening of the lumbar lordosis.
• Measure height precisely and record it. Progressive shrinkage in adult scoliosis correlates with curve progression and with rotatory olisthesis, and it is free to track.³
• Assess the sagittal plane, not just the coronal. Forward postural shift is the strongest predictor of pain and disability in the adult scoliosis patient, more so than Cobb angle.⁶
• Scoliometer for angle of trunk rotation, then standing radiographs when indicated. Films must be standing and reproducible; a Cobb angle from a supine or inconsistently positioned study is not a baseline you can track against.
• On film, look specifically for lateral listhesis. It is common in adult scoliosis and rare without it, appears after 50, and slippage beyond 5 mm is a recognized progression risk factor — particularly in older women with lumbar curves.^3,4

When to Treat

Chiropractors have a real role here, provided goals are stated honestly and in the right order: control pain first, then halt progression, then improve posture and sagittal balance, and only then ( to a limited degree in a mature, degenerated spine) reduce curve magnitude.

One point deserves emphasis: Small adult curves are not benign. Research on adult progression has failed to find a correlation between initial Cobb angle and rate of progression, meaning small curves progress at rates comparable to large ones.^3-4 “It’s only 15 degrees, we’ll watch it” is not a management plan.

Active care outperforms passive care. Curve-specific exercise programs built on active self-correction, targeted stretching, neuromuscular re-education, and trunk endurance have supporting evidence for pain and function in adults.⁷ Manipulation is a reasonable adjunct for pain and segmental restriction, but belongs inside a rehabilitative framework the patient participates in daily, not as an indefinite stand-alone service. In a subset of adults, corrective bracing on a limited daily schedule adds meaningful control of pain and postural collapse.⁷

When to Refer

Refer or co-manage when documented progression exceeds 5 degrees between comparable standing films; when neurological deficit is new or progressive; when stenotic symptoms are disabling and unresponsive; when sagittal imbalance has advanced to where the patient cannot stand erect; and with significant osteoporosis and vertebral fracture.² Unbearable pain preventing normal function, bowel or bladder changes, and progressive limb weakness are surgical emergencies. Refer to a scoliosis-focused conservative provider when curve-specific rehabilitation or adult bracing is indicated but outside your training. Referring well is how you keep a patient for life, not how you lose one.

Five Mistakes to Avoid

• Treating the pain and never naming the curve. Months of care without standing films means the deformity goes unmeasured and unmonitored.
• Reassuring adults that because growth is finished, progression is finished. Degenerative curves can progress several degrees annually, and menopause is an inflection point for them.
• Watching small curves instead of treating them. Progression rate is not predicted by starting curve size.
• Relying on manipulation alone, or promising correction instead of management. Neither survives contact with the evidence, and both damage patient trust and professional credibility.
• Monitoring without a protocol. If you have not defined in advance the radiographic interval, the imaging conditions, and the finding that will trigger referral, you are not monitoring – you are collecting films.

The Bottom Line

Adult scoliosis rewards the chiropractor who asks the adolescent-history question, measures height and sagittal balance as routinely as Cobb angle, treats actively with honestly ordered goals, and refers without ego. Few conditions give the general-practice DC a clearer opportunity to be the clinician who finally identified what no one else did.

References

1. McAviney J, Roberts C, Sullivan B, Alevras AJ, Graham PL, Brown BT. The prevalence of adult de novo scoliosis: a systematic review and meta-analysis. Eur Spine J, 2020;29(12):2960-2969.
2. Aebi M. The adult scoliosis. Eur Spine J, 2005;14(10):925-948.
3. Marty-Poumarat C, Scattin L, Marpeau M, et al. Natural history of progressive adult scoliosis. Spine, 2007;32(11):1227-1234.
4. Chin KR, Furey C, Bohlman HH. Risk factors for progression in adult idiopathic scoliosis. Orthopedics, 2009;32(6):411.
5. Danielsson AJ, Nachemson AL. Back pain and function 22 years after brace treatment for adolescent idiopathic scoliosis. Spine. 2003;28(18):2078-2085.
6. Glassman SD, Bridwell K, Dimar JR, et al. The impact of positive sagittal balance in adult spinal deformity. Spine, 2005;30(18):2024-2029.
7. Negrini S, Donzelli S, Aulisa AG, et al. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord, 2018;13:3.