Adult Spinal Deformity
Adult spinal deformity (ASD) is a three-dimensional curvature of the spine in adults: sideways curvature (scoliosis), forward stooping (kyphosis) and loss of the lower-back curve (lordosis). It most often develops on an age-related degenerative background, causing back pain, a forward-leaning posture and imbalance. The concept of sagittal balance is central to treatment.
Ostatnia aktualizacja: 2026-06-06
Definition
Adult spinal deformity (ASD) describes three-dimensional deformity of the spine in skeletally mature adults. Its components include sideways curvature in the coronal plane (scoliosis, >10° Cobb angle), forward stooping in the sagittal plane (kyphosis), and flattening of lumbar lordosis with sagittal imbalance (a forward-tilted trunk posture). Unlike adolescent idiopathic scoliosis, ASD is dominated by pain and loss of function.
Causes and Classification
The most common type is de novo (primary degenerative) deformity: loss of disc height, facet arthrosis, asymmetric degeneration and osteoporotic fractures lead to progressive curvature over time; the typical patient is an older woman with osteoporosis. Other causes include adult progression of childhood idiopathic scoliosis, iatrogenic deformity from prior surgery, and secondary causes (neuromuscular disease, congenital anomalies, infection, tumor). Age, female sex, osteoporosis, smoking and obesity are the main risk factors. Prevalence rises markedly with age.
Spino-Pelvic Parameters and Sagittal Balance
Sagittal balance is the most important determinant of functional outcome in adult deformity, and it is defined by mathematical parameters: pelvic incidence (PI, a fixed individual anatomic angle), pelvic tilt (PT, a marker of compensation), sacral slope (SS) and the relationship PI = PT + SS. Ideal lumbar lordosis should be close to the PI value (the larger the PI-LL mismatch, the greater the imbalance). When the distance from a vertical line dropped from C7 to the sacrum (SVA) exceeds 5 cm, functional limitation, pain and fall risk increase. The SRS-Schwab classification combines these parameters with curve type.
Symptoms
The most frequent complaint is back pain that worsens with standing and walking and partly eases with rest. With sagittal imbalance the patient compensates by flexing the hips and knees to stand upright; this leads to early fatigue and, in advanced cases, a forward-stooped, downward-gazing posture. Accompanying canal stenosis causes leg pain and neurogenic claudication, and nerve-root compression causes radiculopathy. Cosmetic change (stooping, trunk asymmetry, height loss) and reduced quality of life are common.
Diagnosis
The basis of diagnosis is full-spine (36-inch) standing radiographs. The anteroposterior film measures the Cobb angle, coronal balance and shoulder/pelvis level; the lateral film measures thoracic kyphosis, lumbar lordosis and spino-pelvic parameters (PI, PT, SS, SVA). MRI shows nerve-root and canal compression and disc degeneration. CT is used for bony anatomy and surgical planning (pedicle screw placement). Low-radiation standing 3D imaging (EOS) aids parameter measurement and assessment of lower-limb compensation. Bone densitometry is important to evaluate osteoporosis.
Treatment Options
Patients with mild-to-moderate symptoms and without marked imbalance are managed conservatively: exercise and physical therapy, core strengthening, pain management, osteoporosis treatment and, in selected cases, injections. Surgery is considered for progressive deformity, marked sagittal imbalance, intractable pain and neurological deficit. The goal is adequate decompression together with restoration of sagittal/coronal balance and lordosis. Techniques include posterior fusion and instrumentation, interbody fusion and, when needed, osteotomies (PSO, VCR) as well as minimally invasive approaches. ASD surgery is a major undertaking with potentially high complication and revision rates, so patient selection and surgical planning are critical.
Prognosis and Complications
In appropriately selected patients, restoration of balance brings marked improvement in pain and function. However, ASD surgery is known for high complication rates; proximal junctional kyphosis (PJK), pseudarthrosis, infection and implant failure can occur, with risk increased in older and osteoporotic patients. To reduce complications, osteoporosis is optimized, blood-loss-sparing measures are used and appropriate fusion strategies are applied. Outcomes vary individually with age, bone quality and deformity severity.
Źródła
- Greenberg MS. Greenberg's Handbook of Neurosurgery. 10th ed. Thieme; 2023:1352-1361.
- Winn HR, ed. Youmans Neurological Surgery. 6th ed. Saunders; 2011.
- Schwab F, et al. Scoliosis Research Society—Schwab Adult Spinal Deformity Classification. Spine. 2012.
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