**6. Advanced clinical imaging**

In the presence of claudication and neurological symptoms, computed tomography and magnetic resonance imaging (MRI) may be indicated for diagnosis, monitoring, and follow-up. When decreased BMD is suspected, bone density measurement using a DEXA scan or radiofrequency echographic multi spectrometry (REMS) method is indicated. Computed tomography generally shows signs of facet arthropathy and spinal stenosis, including central spinal stenosis, lateral recess stenosis, and foraminal stenosis.

Magnetic resonance imaging of the lumbar spine is used to assess the soft tissues of the spine, including the spinal cord and tissues within the spinal canal. It is also useful for the assessment of the degenerative changes of disc and facets as well as to assess the extent of spinal stenosis. Recent studies have shown that bone marrow edema was associated with low back pain [57, 58]. In a study of 120 DLS patients, Nakamae et al. [57] found that bone marrow edema was associated with low back pain (**Figure 8**) and that the bone marrow edema score was positively associated with low back pain severity [57]. Bone marrow edema was often seen in the concavity of the curve [57]. Buttermann et al. [58] found that the painful scoliosis which was located at the apex of the scoliosis curve or at the lumbosacral junction was associated with a higher frequency of end plate inflammatory changes [58]. The study showed that the end plate changes demonstrated a bimodal distribution, with peaks at L2–L3 and L5–S1 [58].

**Figure 8.** *Bone marrow edema is evident just below the inferior end plate of L2 and superior end plate of L3 in the left.*

MRI may also reveal a reduction in muscle mass in the lumbar paraspinal muscles in patients with DLS [59, 60] as paraspinal muscles are involved in the stability of the lumbar spine; Barker et al. [59] suggested that their atrophy was associated with lumbar instability [59]. The percentage of fat infiltration areas in paraspinal muscles was significantly higher on the concave side than the convex side. Further the asymmetry of the multifidus muscle change is positively correlated with the lumbar curvature, lateral vertebral translation, and apical vertebral rotation [60].

Studies showed that BMD was lower in DLS patients than normal controls [7]. Also, BMD was found to correlate negatively with the Cobb angle [61]. Patients with DLS and Cobb angle ≥20° had lower BMD than those with curves less than 20° [7]. A low BMD was associated with increased risk of curve progression. Thus assessment of BMD is of importance in DLS patients.

BMD can be assessed using either the DEXA or the REMS methods. Though DEXA is the gold standard in the assessment of BMD, it has to be noted that DEXA is prone to errors, which includes wrong inclusion of vertebrae and positioning of patient [62]. In the presence of DLS, the spinal BMD could be falsely elevated [62], *Conservative Treatment of Degenerative Lumbar Scoliosis DOI: http://dx.doi.org/10.5772/intechopen.90052*

as the degenerative changes, such as aortic calcification, vertebral osteophytes, facet degeneration, end plate sclerosis, and vertebral rotation, may all have artificially elevated readings obtained from a standard anteroposterior lumbar DEXA scan [63], causing errors in clinical management. A study by Pappou et al. [62] study showed that the falsely elevated scores increased with Cobb angles in excess of 22.5° [62]. The viable alternative for conducting a BMD evaluation of patients with DLS are the hip DEXA values [62]. Alternately, REMS measurement can be used. It relies on a machine algorithm and takes into consideration the entire bony profile including the vertebral microarchitecture, compact bone to trabecular bone mineral density ratio, and collagen index, thus reducing the many errors that are associated with the DEXA measurement [64, 65].

### **7. Body composition assessment**

The body composition of the patient needs to be evaluated, when sarcopenia or loss of muscle mass with aging is suspected. Recent studies have shown that 46.6% of patients with DLS had reduced muscle mass involving the extremities and the trunk [26]. The trunk SMI was found to be significantly negatively correlated with sagittal vertical axis, pelvic tilt (PT), lumbar scoliosis, and apical vertebral rotation, suggesting that the reduction in trunk muscle mass was related to the stooped posture, pelvic retroversion, and lumbar scoliosis [26].

### **8. Treatment**

Patients with DLS generally seek treatment for pain and disabilities, instead of deformities [52]. Conservative treatment is generally indicated, and this often involves methods to control or relieve pain, such as epidural injection, non-steroidal anti-inflammatory drugs, analgesics, traction, electrotherapies, dry needling, manipulation, mobilization, and deep tissue massage. These methods can generally provide relief, though temporarily [66, 67]. A systematic review concluded that there was only level IV evidence in support of the effectiveness of physical therapy, chiropractic care, and bracing in the treatment of adult scoliosis patients and level III evidence for steroid injection [66]. The long-term successful rate of conservative treatment of symptomatic adult scoliosis was only 27% [68, 69].

The poor outcomes of the above interventions are not unexpected, as the treatments were directed towards pain relief, but not the deformities and the global imbalance that are causing the symptoms [69]. Treatment approaches that target spinal deformities yielded better results in terms of reduction in pain and disability ratings in ADIS patients [70–76]. Yet, it has to be noted that many of the studies targeted younger cohorts who suffered from ADIS rather than DLS. Further for patients who are in pain or have difficulties performing exercises, a spinal brace may be indicated. It stabilizes the spine, improves the sagittal imbalance, and reduces the load in the lumbar spine. de Mauroy et al. [77] have shown that a spinal brace is able to stabilize progressive curves in 80% of the adults with scoliosis [76].

### **8.1 Scoliosis-specific exercises**

Many case reports and case series studies have reported that scoliosis-specific exercises (SSE) and multi-modal rehabilitation reduce pain, disability, and curves in patients ADIS [70–76]. Yet, only a few studies have targeted patients with DLS. Daily side plank exercises on the side of curve convexity for 3–22 months were reported to reduce the curves significantly in 30% of the patients with ADIS and DLS [70]. The study, however, did not evaluate the impact of the exercises on pain and disabilities [70]. A prospective pilot study by Ng et al. [72] showed that 9 months of scoliosisspecific exercises at home reduced the thoracolumbar or lumbar curves in over 30% of the ADIS and DLS subjects [72]. Also, our unpublished study showed that 6 weeks of SSE reduced pain and disability ratings of subjects with ADIS and DLS.

While many studies have addressed the coronal curves in ADIS and DLS patients, very few studies have addressed the impact of SSE on the sagittal profile of patients [72]. The effects of SSE on the sagittal profile of this group of patients are thus uncertain. Additionally while SSE may be indicated in the management of patients with DLS, our experience has shown that many older patients had difficulties in mastering the Schroth exercises or the scientific exercises approach to scoliosis (SEAS). They had difficulties in coordinating breathing together with the corrective movements needed. A number of patients encountered problems holding the spine in an erect position, while other patients had increased low back pain soon after the exercises, despite normal spine DEXA scores. This was possibly a result of the DEXA over-estimating the spinal BMD scores when the patient was actually osteopenic. Instead of focusing on corrective exercises, the patients may need to be instructed to adopt corrective postures during daily activities as they are easier to master.

In the presence of a left lumbar curve, the patient can stand, with his or her right knee flexed to lower the right pelvis. Alternately, the patient can raise the left heel. This raises the left pelvis [78]. Either way, this lowers the right sacrum, in relation to the left, and reduces the lumbar scoliosis. This may enable the patient to stand longer. To further reduce the left lumbar curve or reverse the curve, the patients could side shift to the left [78]. Conversely, in the presence of a right lumbar curve, the patient should reverse the above postures.

### **Figure 9.**

*Contraction of the gluteus medius would level the pelvis. (a) The patient was standing naturally. The right pelvis can be seen shifted to the right and was higher, with pelvis obliquity. (b) Contraction of the right gluteus medius leveled the pelvis. The patient was instructed to learn walking in this corrected position.*

*Conservative Treatment of Degenerative Lumbar Scoliosis DOI: http://dx.doi.org/10.5772/intechopen.90052*

**Figure 10.** *This patient with left thoracolumbar scoliosis can derotate the left lumbar spine forward during daily activities.*

### **Figure 11.**

*Patient should refrain from faulty habitual postures, which would aggravate the scoliosis. (a) Frontal lumbar radiograph showed a right lumbar scoliosis, with apex at L2 in a female patient with ADIS. (b) When sitting on the floor, he habitually flexed her left hip and knee, increasing the right lumbar scoliosis. (c) When she flexed her right hip and knee, however, the lumbar curve reduced. Yet, the latter posture should also be discouraged, as lumbar lordosis was not maintained.*

Yet, it is difficult to maintain the correct standing posture during ambulation, unless the patient learns how to level the pelvis. Patients with a left thoracolumbar or lumbar curve needs to contract the right hip abductor to bring the pelvis to the midline and level it (**Figure 9**) while derotating the left lumbar curve forward [51] (**Figure 10**). Similarly, patients with right thoracolumbar or lumbar curves need to derotate the right lumbar curve forward while contracting the left hip abductors [51]. The patient then learns to walk with the gluteus medius contracted.

When sitting, the patient needs to maintain the lumbar lordosis, as forced thoracolumbar lordosis was found to reduce double major curves [79]. In the presence of a loss of lumbar lordosis, the patient may be advised to wear a wearable lumbar cushion at all times, though its effects in single thoracolumbar or lumbar curve have not to date been investigated. It is also crucially important that the patient refrains from adopting postures or activities that reinforce the faulty scoliosis pattern (**Figure 11**).

### **8.2 Sole lift**

Functional leg length discrepancy is common, as compensation in patients with DLS. Prescription of a sole lift, in the presence of an apparent LLD, but not anatomical LLD, may induce a compensatory lumbosacral hemicurve, instead of reducing the main lumbar curve [51]. Patients should preferably be advised to contract the gluteus medius on the side of higher pelvis to level the pelvis [51], to flex the knee on this side to lower the pelvis or to raise the heel of the leg ipsilateral to the convexity of the lumbar curve [78] to raise the pelvis.

### **8.3 Spinal bracing**

Spinal bracing has been advocated in the management of adult scoliosis, to halt progression of curves, restore sagittal balance, and treat pain and disability. The effectiveness of braces, however, has been controversial [77, 80]. A number of studies opined that spinal braces do not halt curve progression. Any benefits of pain relief are offset by the deconditioning of the lumbar paraspinal muscles [80].

Recent studies, however, have shown that spinal bracing is effective in reducing pain and halting curve progression (**Figure 12**) [77, 80]. A study which used a lordosing bivalve polyethylene overlapping brace to treat 158 adults with spinal deformities for over 5 years showed that 24% of the curves improved by ≥5°, 56% of the curves stabilized, and 20% worsened by ≥5° [77]. The findings were supported by a long-term follow-up study of 22 years [80]. It was shown that brace wear reduced the progression of curves in both ADIS and DLS patients [80]. The yearly progression for curves in patients with DLS reduced from 1.47° to 0.24° per year [80]. de Mauroy [77] suggested that the brace treatment not only is palliative but also helps to stabilize the lumbar spine in lordosis [77].

### **8.4 Increase paraspinal muscle mass**

Apart from SSE to reduce the scoliosis angles, patients should be encouraged to perform exercises to improve muscle mass, as sarcopenia is prevalent in patients with DLS [26].

Many studies have shown that physical exercises, proper nutrition, and optimal hormonal homeostasis are the three pillars to fight or treat (pre)-sarcopenia [81, 82]. Physical exercises should consist of resistance and endurance exercise training (50% resistance training and 50% endurance training). They should be

*Conservative Treatment of Degenerative Lumbar Scoliosis DOI: http://dx.doi.org/10.5772/intechopen.90052*

### **Figure 12.**

*The man aged 73 years of age complained of right anterior thigh pain with intermittent claudication. The lumbar radiograph and MRI (a) showed a right thoracolumbar scoliosis (b) with a reduction in thoracolumbar lordosis (c) and mild sagittal imbalance. The patient was treated by exercises that increased the thoracolumbar lordosis and a lordotic spinal brace. (d) Despite that the patient was non-compliant and wore the brace only at home for 4 hours daily, the brace treatment increased the walking distance from 10 minutes to around 30 minutes.*

performed at least three times a week [83]. Resistance exercise training aims at improving muscle strength, muscle mass, and BMD and optimizing the hormonal milieu [81], whereas endurance exercise training targets at improving the cardiovascular function, increasing the insulin sensitivity and the anti-inflammatory effects, as well as maintaining the endocrine milieu [81, 83]. Thus patients with DLS should also be encouraged to take up a regular exercise program. Nourishment with

optimal protein intake is also important. Patients should take 25–30 g of protein with essential amino acids daily [82]. Supplements should include long-chain omega 3 fatty acids and antioxidants (e.g., polyphenols such as hydroxytyrosol, resveratrol, epigallocatechin 3 gallate, curcumin, quercetin) and vitamin D [81, 84]. Ideally, vitamin D should be dosed to attain a serum level of 30 ng/L [82]. Depending on the hormonal level, testosterone and creatine may also be prescribed to treat the (pre)-sarcopenia [82].

### **8.5 Osteoporosis management**

Reduction in BMD is common in patients with DLS. A study by Eguchi et al. [26] showed that trunk skeletal muscle mass correlated positively with BMD [26]. The presence of sarcopenia would thus be indicative of osteoporosis [26]. Depending on the BMD, treatment by medication and/or nutritional supplementation may be required. Pharmacological agents are indicated in the presence of a moderate or high risk of fracture. Common medications prescribed for postmenopausal osteoporosis include estrogen, estrogen + progestin, bisphosphonates, selective estrogen receptors modulators (SERMS), the denosumab, calcitonin, and teriparatide. Each of them has different indications and contraindications [85]. Whether these medications help stabilize or halt the progression of DLS has however not been studied to date. Clinically, however, the author has seen cases of rapidly progressing DLS controlled by administration of bisphosphonates.

Together with pharmacological agents, nutritional supplements such as calcium, vitamin D3, vitamin K2, and silica and abstinence from alcohol and smoking are indicated [86]. Recent studies have demonstrated that calcium supplementation is associated with a low bone calcium content with a parallel increase in vascular calcium content [86] and that low BMD is correlated with an increased cardiovascular mortality [87, 88]. The calcium paradox is speculated to be related to vitamin K2 deficiency [89]. It is thus prudent to advise patients with DLS and osteoporosis to take vitamin K2 along with a calcium supplement.

### **8.6 Surgery**

When conservative treatment fails to provide pain relief or control the symptoms, the patient needs to be referred for surgery, particularly in the presence of neurological signs and symptoms [90], as the outcome of surgery has been reported to be superior to conservative treatment [48], albeit with a much higher risk of complications.

## **9. Conclusions**

When treating patients with DLS, we should not only target symptomatic relief, but it is also necessary to address the underlying aggravating or risk factors of the condition. Physiotherapy, manipulation, and needling can be used to treat pain, together with spinal bracing. Scoliosis-specific exercises should be prescribed, and corrective postures should be encouraged during daily activities to improve the sagittal and coronal spinal imbalances. In the presence of sarcopenia and decreased BMD, resistance exercise training and nutritional supplements are also indicated.

### **Conflict of interest**

The author declares no conflict of interest.

*Conservative Treatment of Degenerative Lumbar Scoliosis DOI: http://dx.doi.org/10.5772/intechopen.90052*
