Adult Degenerative Scoliosis: Symptoms, Treatment & Surgery

Also called degenerative scoliosis, adult-onset scoliosis, or de novo scoliosis — a spinal curve that develops or worsens with age, causing back pain, leg pain, or difficulty standing upright.

By Francis C. Lovecchio, MD · Attending Spine Surgeon, Hospital for Special Surgery, New York, NY

What is adult degenerative scoliosis?

Scoliosis is a sideways curve in the spine. In adults, degenerative scoliosis develops when the spine wears down unevenly. Rather than the vertebrae degenerating symmetrically, the degeneration is asymmetric — one side of a disc collapses more than the other, or arthritis accumulates in the facet joints on one side. Over time, that asymmetry produces a curve.

This is distinct from the scoliosis associated with teenagers. Adolescent idiopathic scoliosis develops during growth. Degenerative scoliosis develops later in life — typically after age 50 — as a result of cumulative wear. Some patients had a mild curve in youth that was never treated and progresses as the spine degenerates; others develop a curve de novo.

Importantly, while we use the term "scoliosis," the problem is three-dimensional. The spine can curve to the side (scoliosis), lose its normal inward curve in the lower back (loss of lordosis), or pitch forward (kyphosis). Most patients present with some combination of all three.

How adult degenerative scoliosis presents

A common presenting symptom in adult degenerative scoliosis is leg pain — not back pain. Many patients are surprised by this, because the assumption is that a curved spine should be primarily painful in the back. While back pain does occur, what more often brings patients into the office is that the prior "long-standing back aches" tend to change — the back pain gets worse, the legs start cramping, going numb, or weaken when they walk.

A typical pattern: a patient can walk a certain distance and then begins to experience cramping or heaviness in the legs. It improves with sitting and returns when they stand and walk again. Standing still for more than 10 or 15 minutes becomes difficult. They often feel better leaning forward — pushing a shopping cart, for example. This pattern is called neurogenic claudication, and it results from compression of the nerve roots in the lumbar spine.

Another typical symptom is called radiculopathy. This is pain from a single nerve root being pinched or compressed. This often presents as "shooting" pain that radiates in a specific location down one leg — patients will often describe a "stripe" of pain that occurs when they stand and walk. This type of pain also tends to occur in the lower leg or into the foot, though it can also occur in specific nerve distributions (called "dermatomes") in the thigh.

A second group of patients presents with difficulty standing upright. The deformity is often visible — the body is pitched forward or leaning to one side. These patients usually have a more severe form of the disease.

Watch: How Adult Scoliosis Is Treated

What are the symptoms?

Adult degenerative scoliosis can present with a wide range of symptoms, which contributes to the complexity of evaluation. Symptoms generally fall into three categories.

Mechanical back pain arises from the arthritic changes themselves — bone-on-bone arthritis in the spine. Disc degeneration is also a form of spine arthritis. Patients describe a deep ache that worsens with activity and improves with lying down. Back pain also arises from "altered mechanics": when a person is standing or walking, the spine collapses on itself. This type of pain should improve when the person is lying down.

Nerve symptoms are another reason patients seek surgical consultation. As the spine degenerates and the curve progresses, the space available for the nerve roots narrows. Connective tissue called the ligamentum flavum thickens and contributes to the compression. The result is radiculopathy — pain radiating down the leg — or neurogenic claudication, the cramping and heaviness in the legs that develops with walking.

Postural problems develop when the deformity becomes severe enough that the patient cannot stand upright. The body falls forward or leans to one side, regardless of conscious effort to compensate. At that stage, the supporting musculature is exhausted from working against a malaligned spine.

"We have a love-hate relationship with this condition. We love it because it's academically interesting — it means we have to consider all types of things. But it can be very frustrating because sometimes we're balancing the need to decompress the nerve roots with the pre-existing deformity."

How is it diagnosed?

Diagnosis begins with a physical exam — assessing posture, gait, balance, reflexes, and strength. The exam alone often gives a clear sense of the underlying issue before imaging is reviewed.

Full-body X-rays are the baseline study. These show the curve, the alignment, and how much effort the patient is using to stand upright. An MRI is used to evaluate the soft tissues — discs, nerves, and the ligamentum flavum — to determine whether nerve roots are being compressed and where. Finally, a CT scan provides additional detail about the bone anatomy and bone quality, which can be important for surgical planning.

The most consequential part of diagnosis is correlating the symptoms with the imaging. A spine can look severe on X-ray with the patient experiencing no symptoms, or appear relatively mild while the patient is significantly limited. The principle is straightforward: we treat patients, not X-rays.

What are the treatment options?

Treatment depends on the dominant symptoms. The right approach varies considerably from patient to patient.

Non-surgical treatment

For patients whose symptoms are limited to back pain, treatment is generally arthritis-directed therapy. Because the pain originates in the arthritic changes, the most effective approach is strengthening the supporting musculature with physical therapy. By strengthening the muscles around the spine, we can support the degenerated discs and joints. These patients are also good candidates for evaluation by a physiatrist or pain management specialist — non-operative spine experts who can offer treatments such as facet ablations, trigger point injections, or epidural steroid injections.

For nerve symptoms, epidural injections can reduce inflammation around the compressed nerve roots and provide meaningful relief. Medications such as gabapentin may help manage numbness and tingling. Many patients respond well enough to these treatments that surgery is never required.

When surgery makes sense

Surgery is reliably helpful only when three criteria are met:

Symptoms match imaging. If the symptoms do not align with the findings on MRI and X-ray, surgery is not indicated. The pathology being addressed must correlate with the symptoms.

Non-operative treatments tried. Patients who have not yet attempted physical therapy, injections, or medications are generally not good surgical candidates. The one exception is the patient with an inability to stand upright due to a severe deformity.

Good surgical candidate. Patients who are heavy smokers, have uncontrolled diabetes, or have significant cardiac disease may be harmed more by surgery than helped, even when the pain is severe. The same goes for very old patients, or those with poor bone quality. A patient must have the physiologic capacity to undergo such a surgery.

"Sometimes patients think: my pain is so bad, that must mean I need surgery. But that's not always the case. Surgery has to make sense. We have to know what we're operating on."

What does scoliosis surgery involve?

Surgical treatment for adult degenerative scoliosis takes several different forms, depending on the specific symptoms and contributing pathology. The decision-making is rarely straightforward. There are usually multiple types of surgeries that could be considered, with advantages and disadvantages of each approach.

Surgery to address nerve compression

When a patient's main limiting symptom is nerve compression — when the predominant symptoms are neurogenic claudication or radiculopathy — there are often two types of surgeries that could be considered: a minimally invasive tubular decompression or a short-segment fusion. "Decompression" is a contemporary term that encompasses any type of laminectomy, laminotomy, or hemilaminectomy, and should not be confused with the MILD procedure. The bone and ligament pressing on the nerve roots are removed to create more space. Out of all possible surgeries, this is the least involved, and patients typically go home the same day.

The second type of surgery that could be considered is called a "short-segment" fusion. When decompression of the nerves will lead to instability of the segment, or when the nerves must be "indirectly" decompressed (as is often the case for foraminal stenosis), we will only fuse 1–3 spinal segments instead of fusing the entire scoliosis curve. This option is highly dependent on the stability of the entire curve. It is usually more involved than a decompression, with a slightly longer hospital stay and recovery.

Watch: How Spinal Stenosis Is Treated: Fusion or Laminectomy?

Patient story: Marc Salis — How a targeted spine surgery got him back on his feet

With these types of surgeries, we still do not know whether these procedures accelerate progression of the degenerative scoliosis. Most studies suggest that this is not the case, but it is a very difficult question to study for a simple reason: we cannot know whether the curve would have worsened or symptoms would have progressed regardless of surgery. Therefore, patients undergoing these types of surgeries should always be aware that a reconstructive surgery could be needed in the future.

Surgery to address back pain and postural problems

When mechanical back pain or postural complaints are the major limiting symptoms, then a reconstructive surgery is often required. The procedure realigns the spine to restore balance: correcting the curve, restoring the natural lordosis, and fusing the spine in its corrected position. The curve is stabilized and straightened by connecting vertebrae with screws, rods, and sometimes interbody spacers/cages. Once connected, bone graft is placed to allow the bones to grow together — this is the actual "fusion" part. Depending on the case, this may involve a procedure from the front of the spine (such as an ALIF), from the side (LLIF), from the back (TLIF), or a combined approach. These are larger operations and come with certain costs — the patient is trading "straightness for stiffness." However, for appropriately selected patients, this surgery can lead to long-term, life-changing improvements in their quality of life.

Patient story: Micky Padway — A reconstruction that gave him back his life

Getting your body ready for surgery

Among the most important factors in spine surgery outcomes is the patient's overall health going into the operation. The objective of pre-operative preparation is to optimize physiological reserve, so the body tolerates surgery well and recovers efficiently. For patients with adult degenerative scoliosis, we focus on four specific areas.

1. Bone density

Spinal fusion relies on screws and rods anchored into the vertebrae, and the strength of that fixation depends on bone quality. Osteoporosis is common in patients presenting with adult degenerative scoliosis — particularly postmenopausal women and patients over 65 — and is frequently undiagnosed at the time of evaluation.

We evaluate bone density in any patient undergoing a fusion using a "QCT scan" to understand the bone density specific to the spine. Other tests, such as DEXA, often overestimate bone quality in patients with degenerative scoliosis. When osteoporosis is identified, treatment is initiated. Anabolic bone agents such as teriparatide and romosozumab have been shown to help mitigate the surgical risks of osteoporosis.

2. Cardiovascular fitness

Spine reconstruction places real demands on the cardiovascular system, both during the operation and throughout the recovery period. Approximately 20 minutes per day of cardiovascular exercise in the months leading up to surgery improves the body's reserve.

For most patients with scoliosis, walking long distances is itself part of the problem they are seeking to address, so low-impact alternatives are typically more practical:

3. Muscle conditioning (prehab)

Most patients arriving at the surgical decision have already completed multiple courses of physical therapy. The purpose of prehabilitation is not to resolve the underlying spinal pathology — that is no longer realistic at this stage — but to strengthen the supporting musculature so that post-operative recovery is more efficient. Gains in core stability, lower-extremity strength, and postural mechanics translate directly into better functional outcomes after surgery.

"If we can get a patient's muscles closer to where a 50-year-old's are, they undergo the surgery and have a better result. How good can we make someone before surgery? That's the question we find most interesting."

4. Medical optimization

Several common conditions warrant attention before surgery is scheduled:

Diabetes — well-controlled blood glucose supports healing. We aim for an A1C in the appropriate range prior to scheduling.

Smoking — nicotine impairs bone healing and is associated with higher rates of pseudarthrosis following fusion. Cessation before surgery is mandatory, and resources for support are available.

Cardiac conditions — patients with known heart disease typically obtain cardiology clearance before surgery is scheduled.

Medications — certain medications, particularly anticoagulants, may need to be paused or adjusted around the time of surgery.

Pre-operative optimization can take anywhere from several weeks to several months, depending on what needs to be addressed. A patient who arrives at surgery well-prepared has a meaningfully better recovery than one who does not — and that preparation is the single most consequential thing we can do together to improve the outcome.

Not every scoliosis patient needs a major operation

This point is worth emphasizing for patients. An X-ray that shows a severe curve can look as though it requires an extensive reconstruction. But the surgery has to match the symptoms, not the X-ray.

One illustrative case: a patient with a substantial scoliosis. Her spine was curved, the vertebrae looked uneven, and several disc spaces had collapsed entirely. The imaging looked severe. Her only problem, however, was leg pain. She did not have back pain, and she had no difficulty standing upright. A full reconstruction would have been overkill.

Instead, we focused on the source of the leg pain. The MRI showed that nerve compression was concentrated at a single segment, so we addressed that segment. She may develop back pain in the future. She may develop a postural problem later. But the most pressing symptom was treated with the smallest surgery that resolved it.

Watch: This Severe Scoliosis Patient Doesn't Need A Big Operation

What is recovery like?

Recovery depends on the type of surgery performed. A single-level decompression is a very different recovery from a multi-level spinal reconstruction.

For a decompression or short fusion, most patients go home the same day or the next day. At HSS, patients are typically up and walking the same day as surgery. The first few weeks involve rest, short walks, and avoiding heavy lifting. Leg symptoms often improve relatively quickly — some patients notice a difference within days. Back pain from the surgical site itself takes longer to settle.

For larger reconstructions, hospital stays are longer — typically 4 to 6 days — and the recovery is more gradual. Physical therapy plays a larger role. Recovery tends to occur in three stages.

Stage one — the "healing phase" — involves healing from the surgery itself. This is the toughest part of the process, usually taking around 6 weeks, but can be up to 3 months. During this phase, patients are simply focusing on getting back to normal life.

Stage two — the "strengthening phase" — starts at 3 months. This is when we start strengthening the body, making up for all those years that it took to get to the point of needing surgery. We increase activity with physical therapy, representing a crucial time for patients to be engaged in their recoveries.

Stage three — the "normalization phase" — occurs between 6 and 12 months after surgery. During this phase, the patient learns the permanent state of their new spine. There will be many things they notice are easier and more enjoyable, but there will inevitably be some new quirks or limitations of their new body — difficulty putting on socks is probably the most common one we hear.

Surgery sets the body up to heal, but it cannot do the healing on its own. Recovery capacity varies between patients — some recover faster than expected, others take longer. Our major research focus is finding ways to improve patients' physiological reserve before surgery, with the goal of better recovery on the back end. Currently, based on our previous research,[^1] we are running an exciting trial on how hormonal therapies could be used to enhance, not just optimize, a patient's ability to recover after surgery.

What are the risks?

As with any spine surgery, there are risks, and these increase with the size of the procedure. This is precisely why being a good surgical candidate matters, and why some patients are advised against surgery even when pain is severe. At HSS, this is managed through careful patient selection, thorough preoperative planning that includes bone quality testing, and a team approach to recovery. Patients undergoing surgery receive a detailed preoperative packet outlining all risks.

Frequently asked questions

Does scoliosis get worse with age?

Yes — in many cases. Adult degenerative scoliosis develops when the spine wears down asymmetrically, and the curve typically progresses over time as discs collapse and facet joints develop arthritis on one side. Some patients had a mild curve in youth that was never treated and progresses as the spine degenerates; others develop a curve de novo after age 50. Whether the progression is fast or slow varies considerably from patient to patient.

How is adult scoliosis treated?

Treatment depends on the dominant symptoms. For patients with limited back pain only, we typically use arthritis-directed therapy: physical therapy, facet ablations, trigger point injections, and epidural steroid injections. For nerve symptoms (radiculopathy, neurogenic claudication), epidural injections and medications such as gabapentin often provide meaningful relief. When non-surgical options fail and symptoms match the imaging, surgical options range from a focused decompression at a single level to a short-segment fusion to a full spinal reconstruction — depending on whether the dominant problem is nerve compression, postural collapse, or both.

Can adult scoliosis be corrected without surgery?

Many patients can be managed without surgery, using physical therapy, injections, and medications. Non-surgical treatment cannot reverse the curve itself, but it can reduce pain, manage nerve symptoms, and improve function — often well enough that surgery is never required. Surgery becomes the right answer when symptoms match the imaging, non-operative options have been tried, and the patient is medically optimized to undergo the operation.

What is the difference between adolescent and adult scoliosis?

Adolescent idiopathic scoliosis develops during growth, typically between ages 10 and 18, and the cause is unknown. Adult degenerative scoliosis develops later in life — typically after age 50 — as a result of cumulative wear on the spine. The treatment principles are different: adolescent scoliosis is often managed with observation, bracing, or growth-modulating surgery, while adult degenerative scoliosis is driven by symptoms (pain, nerve compression, postural collapse) rather than the curve magnitude itself.

Considering scoliosis surgery in NYC?

Dr. Francis Lovecchio is an attending spine surgeon at the Hospital for Special Surgery in New York City, specializing in adult spinal deformity correction, complex scoliosis surgery, and spinal reconstruction. He sees patients from across the New York tri-state area — Manhattan, Brooklyn, Queens, Long Island, New Jersey, and Connecticut.

Schedule a consultation →

Key takeaways

Definitions

Adjacent segment disease. Degeneration that develops at the spinal levels directly above or below a previous fusion. Because the fused segment no longer moves, the neighboring segments absorb more stress, which can accelerate wear.

Anabolic bone agents. Medications that actively build new bone, used to improve bone density before or after spine surgery. Examples include teriparatide and abaloparatide. Administered as daily injections for a defined treatment period.

Compression fracture. A fracture in which a vertebra collapses or wedges, typically caused by osteoporosis or trauma. Often visible on X-rays even in patients who did not realize they had a fracture, and a strong indication that bone density should be evaluated.

DEXA scan. A low-dose X-ray that measures bone mineral density. Used to diagnose osteoporosis and osteopenia — both of which are important to identify and treat before spine surgery, because weak bone holds screws less reliably.

Osteoporosis. A condition where bones become weaker and more porous, often without noticeable symptoms until a fracture occurs. Common in postmenopausal women and older adults. Requires treatment before spine surgery because weakened bone may not securely hold screws and rods.

Adolescent idiopathic scoliosis. A sideways curvature of the spine that develops during childhood or adolescence, usually between ages 10 and 18. "Idiopathic" means the cause is unknown. May require observation, bracing, or surgery depending on the severity and progression of the curve.

Adult spinal deformity. A broader term for adult scoliosis that accounts for the three-dimensional nature of the problem — including sideways curvature (scoliosis), loss of the lower back's natural curve (lordosis), and forward pitching (kyphosis).

Arthritis-directed therapy. Non-surgical treatments aimed at the arthritic component of spinal pain. Includes physical therapy to strengthen supporting muscles, facet ablations, trigger point injections, and anti-inflammatory medications.

Decompression. A surgical procedure that creates more space for the nerve roots by removing bone, ligament, or other tissue that is pressing on them. The goal is to relieve nerve compression without necessarily fusing the spine.

Degenerative scoliosis. A sideways curvature of the spine that develops in adulthood — typically after age 50 — as a result of asymmetric disc degeneration, facet joint arthritis, and other age-related wear. Different from adolescent scoliosis, which originates during growth.

Epidural steroid injection. An injection of corticosteroid medication into the space around the spinal nerves (the epidural space) to reduce inflammation and relieve pain from nerve compression.

Facet ablation. A non-surgical procedure where a small nerve near an arthritic facet joint is heated with a radiofrequency probe to interrupt pain signals. Can provide months to years of relief from facet-related back pain.

Facet joints. Small joints at the back of each vertebra that allow the spine to bend and twist. When these joints develop arthritis, they can become a source of back pain and contribute to spinal stenosis.

Gabapentin. A nerve medication commonly prescribed for neuropathic pain, including the numbness, tingling, and shooting pain caused by compressed nerve roots in the spine.

Kyphosis. Forward curvature of the spine, most noticeable in the upper back. When excessive, it causes a hunched or rounded posture. In adult spinal deformity, kyphosis often develops alongside scoliosis.

Laminectomy. A type of decompression surgery where the lamina — the bony arch on the back of a vertebra — is removed to open up the spinal canal and relieve pressure on the nerve roots.

Ligamentum flavum. A connective tissue ligament that runs along the back of the spinal canal. It tends to thicken and overgrow as the spine degenerates, which can compress the nerve roots and contribute to spinal stenosis.

Lordosis. The natural inward curve of the lower back (lumbar spine) and neck (cervical spine). Loss of lumbar lordosis — when the lower back flattens out — is a common component of adult spinal deformity and can make it difficult to stand upright.

Neurogenic claudication. Cramping, numbness, heaviness, and pain in the legs caused by compression of the nerve roots in the lumbar spine. Symptoms typically worsen with walking or standing and improve with sitting or leaning forward.

Physiatrist. A physician specializing in physical medicine and rehabilitation. In spine care, physiatrists are non-operative spine experts who manage pain through injections, medications, and therapy rather than surgery.

Pseudarthrosis. Failure of bone to heal after a spinal fusion. The vertebrae do not fully fuse together, which can lead to persistent pain and instability, sometimes requiring revision surgery.

Radiculopathy. Pain, numbness, or weakness that radiates along a nerve path — typically down the leg (lumbar radiculopathy) or into the arm (cervical radiculopathy) — caused by a compressed or irritated nerve root in the spine.

Spinal fusion. A surgery that permanently connects two or more vertebrae using screws, rods, cages, and bone graft. The goal is to stabilize a segment of the spine, eliminate painful motion, or maintain alignment after a deformity correction.

References

[^1]: Lovecchio FC, et al. "Hormonal modulation of recovery after major spine surgery." PubMed. pubmed.ncbi.nlm.nih.gov/40815862