Spinal pain is one of the most common musculoskeletal problems managed in primary care as one in six people have back problems (ABS data). Around 3% of all GP appointments are for the management of this issue increasing to approximately one in three males or one in four females aged 55 to 64.
Rates in those aged under 25 is significantly lower but results in the highest rate of hospitalisation for any age group – possibly reflecting a more sinister aetiology. New Clinical Care Standards for low back pain, currently under consultation, will help guide management.
Adult Degenerative Scoliosis
The development of scoliosis in patients aged over 60 is not uncommon (prevalence reported from 2% to 30%). This may be only an incidental finding on a chest or abdominal radiograph requiring no specific management. In some it is the fundamental cause of their increasing back pain, sciatica, and declining mobility.
These patients are usually complex, and consideration of concurrent lower limb arthritis and cardiovascular pathology is necessary. Spinal CT or MRI imaging can identify specific nerve root impingement and illustrate the deformity.
First line management involves self-guided exercise; 20 minutes walking in water three times per week is a good start that most tolerate. Physiotherapy and guided epidural steroid injections can be helpful. Onward referral can be necessary if pain is recalcitrant, or the deformity is progressing clinically or radiographically.
Surgery to treat adult spinal deformity is a demanding task, even utilising the most modern, minimally invasive techniques. Many are too frail to be considered candidates. Most over age 75 or with significant medical comorbidities are more safely managed with a pain medicine specialist.
Advances in surgical techniques and technology, particularly 3D intraoperative imaging, are increasingly affording safe deformity corrections. These treatments are usually comfortably offered to patients in their 60s with progressing deformity and significant pain symptoms.
Decision making for the treatment of those with only moderate symptoms but significant deformity in a younger age bracket (50-60) is more complex. For some surgical treatment preventing a predictable deterioration is favourable before they become too frail for major surgery and its rehabilitation.
Adolescent Idiopathic Scoliosis
Present in approximately 5% of females, this common diagnosis can provoke significant anxiety and concern. The idiopathic aetiology is only confirmed once specific diagnosis including syrinx, tumour or an underlying syndrome is excluded.
Curve magnitude as measured by the ‘Cobb angle’ and the degree of skeletal maturity as measured by the ‘Risser grade’ are key to guiding management. Skeletally immature patients (typically under age 14) with a cobb angle more than 10 degrees usually require referral as they may benefit from treatment to guide their spinal growth and minimise the scoliotic deformity. Those with cobb angles more than 40 degrees warrant prompt surgical referral given the predictable worsening of deformity in time.
Historically, in WA, this surgery was solely performed in the public sector. There is now a private hospital option for these patients that some may not be aware of. A specific scoliosis physiotherapy clinic can also provide treatments. Older, skeletally mature (Risser grade >4) patient with a cobb angle <40 degrees are typically well managed on a specialised physiotherapy pathway, rarely if ever requiring surgical treatment.
Pars fractures
Stress fractures through the pars are common incidental findings on up to 7% of lumbar imaging, rarely requiring treatment in the adult population in the absence of sciatica or major spinal deformity.
Pars stress fractures in the adolescent athlete are the opposite, needing aggressive management for optimal outcomes. Approximately half of adolescent athletes with low back pain will have a spondylolysis. Sports involving lumbar extension such as cricket, football and soccer are typically causative.
Initial management of a suspected pars stress fracture is cessation of all sport until a diagnosis and treatment plan is made. A GP-referred Lumbar MRI for patients under 16 can attract a Medicare rebate. The 3D-VIBE MRI sequence can be performed if requested to yield equal diagnostic accuracy to a CT scan in identifying a pars fracture. There is no role for CT in the adolescent lumbar spine.
If a pars fracture is identified without anterolisthesis, treatment with a specialist sports physician is recommended to guide the safe rehabilitation and return to sports, aiming to heal the fracture and prevent recurrence. A mismanaged acute pars stress fracture can result in significant impairment and inability to return to sports.
Key messages
- Adolescent Idiopathic Scoliosis often requires referral with both public and private services available
- In adults, age and co-morbidity significantly influence treatment decisions
- Pars fractures in adolescent athletes require prompt diagnosis and treatment.
Authors competing interests – nil