Degenerative lumbar scoliosis and hip pain. Exploring non-surgical treatment options

Ross Hauser, MD., Danielle R. Steilen-Matias, PA-C., Brian Hutcheson, DC.

Lumbar scoliosis and hip pain. Exploring non-surgical treatment options.

If you are reading this article you are likely someone who has been diagnosed with scoliosis “since I was a kid,” or, you are someone recently diagnosed with adult-onset degenerative scoliosis. Your spine, over time, as it was probably explained to you, is curving sideways. Also, in many cases, maybe like yours, you were treated with a “watch and see” treatment program to see how your scoliosis continued to develop.

You may have been given recommendations for fittings for back braces, physical therapy, and various exercise programs. On occasion, you were given guidelines for some over-the-counter medications on the “rough” days. But, as the rough days got closer and closer together and more frequent, you may have been told at some point in the future you will need to call in a neurosurgeon or an orthopedic surgeon for their opinion moving forward.

Maybe you have reached this point already. Maybe your case sounds like this:

Sharp, stabbing pain:

I have scoliosis in my lumbar region, it never really progressed beyond that point but I know it has affected my entire spine all my life. I have been managing my low back pain very well until recently. Suddenly I developed a burning, sharp, constant stabbing pain in my back. When I stand up I literally have to catch my breath because as I start standing the pain in my lower back causes spasms and more pain in my buttocks, hips and radiates down into my legs. As soon as I stand up straight I have to stop for a moment, “regroup,” and start moving. It has now reached the point that I can only walk a little bit before I have to sit down and start the whole process over again.

I have been told that I have developed lumbar stenosis, it is pinching at my nerves and that is why I have this pain. I have been given strong pain medications which I do not want to take and physical therapy has now been ruled out as not helpful. My next two steps are steroid or cortisone injections and if they don’t help, laminectomy, laminotomy, or fusion surgery. Which I also want to avoid.

Often we hear from people who have a wide range of symptoms. From dull aching constant pain to “lightning bolt” or “electric shock” type pain that strikes from buttocks into the legs that comes and goes with activity and then subside with rest.

We are going to address all these concerns below and present treatment options. For some people, even though they have a great desire to avoid surgery, they may need to have one. Many people do very well with these surgeries. These are not the people we see at our center. We typically see more complicated cases where surgery is not given a realistically good chance of being successful. We will present our treatment options below and discuss other options.

Conservative care treatment options

Many people will be able to manage their scoliosis-related problems with conservative care. It is likely that many people reading this article have been doing these treatments for years already and they are exploring other ways to achieve pain relief and some degree in the improvement of function.

A June 2020 paper in the journal Pain Medicine (1) evaluated the effectiveness of nonsurgical treatments in symptomatic adult degenerative scoliosis. The researchers reviewed six previously published studies which included outcome studies specifically on injections, bracing, or yoga and multiple treatment programs. The conclusion the study team reached was: “Literature describing the effectiveness of nonoperative treatments in symptomatic adult degenerative scoliosis is scarce. The quantity and quality of the evidence regarding injections, bracing, and yoga are insufficient to advise for or against the use of these methods to improve outcomes in symptomatic adult degenerative scoliosis. For these and other nonoperative treatment forms, further research is needed.” Many of you may have found long or short-term relief in some of these treatments. Perhaps you are looking for more of the same type of treatment or these treatments no longer provide comfort.

What are we seeing in this image?

The heading reads Spine with scoliosis posterior view. We are seeing this spine from behind. The point we are making here is that scoliosis in one region of the spine causes compensation changes (noted by the arrows) in other areas of the spine. This can cause pain and functional problems throughout the whole spine.

Spine with scoliosis posterior view. We are seeing this spine from behind. The point we are making here is that scoliosis in one region of the spine causes compensation changes (noted by the arrows) in other areas of the spine.

What are we seeing in this image?

An x-ray shows severe scoliosis and multiple spinal deformities and pelvic and hip misalignments.

An x-ray shows severe scoliosis and multiple spinal deformities and pelvic and hip misalignments. 

Can spine manipulations help?

A December 2020 study (2) To investigate the effect of spinal manipulation on degenerative scoliosis by evaluating patients’ visual analog scale (VAS) scores, Cobb angles (a standard measurement to categorize spinal deformities), the sagittal vertical axis (SVA) which is a measurement of the spine to assess imbalance (excessive curvature), and apical vertebral rotation (AVR) and to explore factors that influence treatment effect.

What were the results of this study?

An earlier study (3) suggested: “Spinal leveraging manipulation for degenerative scoliosis could regulate muscle balance on both side of the spine, correct coronal imbalances in the spine, recover the normal sequence of the spine, reduce and remove oppressions and stimulation of nerve root, relieve pain in leg and waist and further improve quality of life.”

Research: Decompressive laminectomy (as a stand-alone treatment) for degenerative lumbar scoliosis is not recommended because it can lead to further instability

This is a December 2020 study published in the medical journal Clinics in Orthopedic Surgery. (4)

Here are the learning points of this research:

Did the surgery CAUSE the instability or did the surgery fail to address the instability or both? 

That is the question asked by the surgeons. Here is what they found:

The surgeons then examined the case files of sixty (60) patients with degenerative lumbar scoliosis.

One in 5 needed another surgery, one in 4 had a new instability

Conclusions: The development of post-laminectomy instability was not always related to laminectomy at the index level. However, post-laminectomy instability developed more rapidly at the index level, compared to the natural progression of the scoliotic curve at the adjacent segments.

In other words, the surgery caused it.

Here are further resources and research you can explore on our site: 

Muscle degeneration at the local level

An August 2021 paper in the Global Spine Journal (5) investigated the effect of paraspinal muscle degeneration in degenerative lumbar scoliosis cases where patients had corrective surgery. In this study:

Our explanatory note: Muscles atrophy when they are overworked. Why would the paraspinal muscles be overworked? Because they are trying to correct for spinal instability. They are in spasm and under constraint strain. What could cause this situation? Ligament damage at the local vertebrae level as described below.

Lumbar Scoliosis Surgery, then hip replacement?

They have been trying to talk me into surgery for years

As you have seen, and as many of you know personally, hip pain is often accompanied by scoliosis, or scoliosis is often accompanied by hip pain. That is not a play on words, it depends on what your primary diagnosis is. For many people who have been managing their lumbar scoliosis and have developed hip pain along the way, they are told that they should consider prioritizing their pain so that the proper sequence of surgeries can be scheduled. For some people, surgery is the only way because they may have a level of degeneration in their hip where the ball of the hip has collapsed and bone spurs have now frozen the joint, or there is continued, burning nerve pain and numbness in the feet.

For some people, the thought of a sequence of surgeries is very unappealing.

For some people, the thought of a sequence of surgeries is very unappealing. This could be especially true in active, physical people who see surgery as a prolonged period of inactivity. Some are also concerned that once you do one surgery, then you open yourself up for more and repeated surgeries. Here is a sample of a concern expressed to us:

I have been suffering from a lot of hip pain. I have wear and tearing of my labrum and general hip instability. Over the last few years, my hip pain has really accelerated and I have had to cut back on a lot of my fitness routines and I can feel myself getting “out of shape.” I don’t do physical therapy because of how active I am, I don’t want to do medications because I think they will eventually do more harm than good. 

I have been told now on a few occasions that I should consider a hip replacement. I am in my early 50’s and I also have an issue with lumbar scoliosis which has never really slowed me down but now with my hip pain, I feel the scoliosis is getting worse as well. It is especially painful if I sit too long and then try to stand up. My concern is, if I get the hip replacement, I will be immobile and then scoliosis will get worse. I can see where I will be in recovery and rehab for years, and that is if everything goes right. I am concerned that I may have surgical complications and then I will never get my fitness back.

Let’s stop here for a second and remind everyone that many people do very well with hip replacements and then subsequent surgery for lumbar scoliosis. Some people do not.

Surgeons talking to surgeons about these very concerns of numerous surgeries and proper sequencing

A December 2020 study in The Journal of International Medical Research (7) has surgeons talking to surgeons about these very concerns and how to plan the sequence of surgeries to give the patient the best chance at achieving the surgical goals of less pain.

Here are the learning points:

So which group did better? Hip replacement then spinal surgery (Group A) or spinal surgery than hip replacement (Group B)?

So what was the concluding advice the surgeons recommended to their colleagues?

“Spinal surgery may be performed first to resolve lumbar nerve symptoms and restore the sagittal balance of the spine; hip replacement may then be performed to simplify hip replacement difficulties and resolve the imbalance after spinal surgery. Severely limited range of motion exists after lumbar surgery and before total hip arthroplasty.”

In other words, do the spinal surgery first, prepare the patients that they will have severe and significant limitations, including the inability to walk until a hip replacement can be performed.

Here are further resources and research you can explore on our site: 

Danielle R. Steilen-Matias, MMS, PA-C explains hip-spine syndrome

Learning points summary:

As I got older, my lumbar scoliosis became worse. Why?

In this section, we are going to start by introducing the idea of lumbar ligament laxity for the progression of lumbar scoliosis and how to treat it. Lumbar ligament laxity is a weakening or “stretched-out,” ligament problem that is allowing for lumbar hypermobility and a worsening curvature. This will be explained further below.

Unfortunately, for the many people who had scoliosis “since they were a kid,” and did their best to manage it, their symptoms became worse. If this is happening to you, you are not unique to the idea of degenerative disc disease caused by worsening scoliosis but you probably feel alone and isolated when your back pain really flairs up. Researchers have been trying to figure out a way to help you by at least understanding what you are going through.

“Lumbar curvature that developed during adolescence accelerates intervertebral disc degeneration in adulthood.”

Let’s look at a November 2020 study in the aptly named medical journal Spine Deformity (8) Here doctors want to understand how the “Residual lumbar curvature that developed during adolescence accelerates intervertebral disc degeneration in adulthood.” That is actually the title of the paper.

Here are the learning points:

The findings:

Conclusion: This study showed that the residual lumbar curvature from adolescent idiopathic scoliosis may have accelerated disc degeneration in adulthood, especially in patients aged under 30 years old.

The turning rotating vertebrae

A brief summary up until this point. Scoliosis means that the spine is crooked. It can become crooked because the spine is held together by the spinal ligaments. The patient often experiences pain at the site where the spine curves. At the apex of this curve, the ligaments are being stretched with scoliosis, and localized ligament weakness is one of the etiological bases for it

A July 2021 study published in the journal World Neurology (9) focused on a rotating top (apical or apex area) vertebrae as the cause of vertebral rotatory subluxation (your “wandering” vertebrae has cause caused parts of your spine to rotate out of place) and cause the problems of scoliosis. In this study 86 patients with degenerative lumbar scoliosis were divided into 2 groups: with vertebral rotatory subluxation (rotated vertebrae) and without vertebral rotatory subluxation (the vertebrae themselves have not rotated). The researchers then measured the impact of vertebral rotatory subluxation on the spine and pelvis. What was the impact? “Vertebral rotatory subluxation is an important characteristic to consider in degenerative lumbar scoliosis that can affect the coronal and sagittal alignment.” The wandering rotating vertebrae are causing the scoliosis situation.

So what can this mean? Possibly strengthening the ligament attachments in the spine can help.

Prolotherapy injections: Treating the ligaments in the lumbar spine

When people search for help with their scoliosis related pain and they start to focus on why their spine is curving, like the researchers above, they may come across an article, like this one, where the possible cause of the worsening curve of their spine is thought to come from weakened ligaments. There are not many of these types of articles unless you are searching for why surgery to correct this condition may have failed and you found out that your scoliosis was worse after surgery because of surgical damage to the ligaments.

In one patient category, however, ligament laxity or weakness is described at length. That is in people with hEDS or Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders. This is a topic of another article, we invite you to begin this exploration here: Prolotherapy for Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders.

At our center, we see many adult patients with spinal instability and a history of scoliosis. They are at our center because the many problems and challenges that these people have in their spine are getting worse.

We do see many patients who have had surgery for their spinal deformities whose outcomes had less than the desired results. We also see many patients considering adult spinal deformity surgery. As we discussed above surgery is a treatment that should be given great and careful consideration. Many people do very well with surgery. Some do not. Those who do well should be monitored because they can develop degenerative disc disease of the lumbar spine.

Weak, damaged, overstretched lumbar spine ligaments that are not holding the vertebrae in their natural position.

There are many causes for the development of scoliosis, perhaps one of the simplest, overlooked, and easier to treat problems is a problem of weak, damaged, overstretched lumbar spine ligaments that are not holding the vertebrae in their natural position.

In common language, scoliosis means that the spine is crooked. The spine is held together by the same thing that holds all the bones together, ligaments. As you know firsthand, people often experience pain at the site where the spine curves. At the apex of this curve, the ligaments are being stretched with scoliosis, and localized ligament weakness is one of the etiological bases for it.

In other words, weak ligaments are causing the vertebrae to move out into “C” or “S” shapes and the “C” or “S” shape is pulling on these ligaments in a tug of war that is making them weaker. It is a cycle.

Traditional treatments for scoliosis, especially during adolescence, include observation, bracing, and surgery. Very few people are assessed for ligament weakness.

Damage or weakness to these ligaments will cause the vertebrae to move out of place and could result in problems of the curvature of the spine including scoliosis.

What are we seeing in this image?

In this illustration, we are using the springs as a visual image to help understand the natural movement of a spinal ligament. In flexion, bending your head forward with your chin moving towards your chest we see that the spring is stretched to accommodate that movement. In extension, this would be with your chin pointed upwards in the air, we see that the spring is compressed. In lateral flexion, you are moving your head with your ear moving towards your shoulder. You get both ligament motions. Damage or weakness to these ligaments will cause the vertebrae to move out of place and could result in problems of the curvature of the spine including scoliosis.

In this illustration we are using the springs as a visual image to help understand the natural movement of a spinal ligament. In flexion, bending your head forward with your chin moving towards your chest we see that the spring is stretched to accommodate that movement. In extension, this would be with your chin pointed upwards in the air, we see that the spring is compressed. in lateral flexion, you are moving your head with your ear moving towards your shoulder. You get both ligament motions. Damage or weakness to these ligaments will cause the vertebrae to move out of place and could result in problems of the curvature of the spine including scoliosis.

Summary and Learning Points of Prolotherapy to the low back

The black crayon line is the scoliosis guide

Prolotherapy for Back Pain

Prolotherapy treats low back pain by addressing the root cause of pain: ligament laxity.  Very few cases of low back pain actually stem from a herniated disc. Rather, the herniated disc is proof that ligament laxity exists. Prolotherapy is an injection technique that induces a mild inflammation to stimulate the body’s immune system to heal the injured area. When compared to Prolotherapy, percutaneous disc decompression raises some red flags in the case of low back pain:

In Caring Medical published research in the Journal of Prolotherapy, (10) we cited our own research and that of others in demonstrating the effectiveness of Prolotherapy for back pain.

In our research, we reported on 145 patients who experienced low back pain for an average of 58 months, who were treated on average with four sessions of dextrose (12.5%) Prolotherapy, quarterly, at a charity clinic.

The patients were contacted on average 12 months after their last Prolotherapy session. In these patients:

Results were similar in the patients who were told by at least one medical doctor that there was no other treatment option (55 patients) or that surgery was the only option (26 patients).

Prolotherapy repairs collagen fibers in the ligaments, strengthening the ligaments and restoring spinal strength and stability

In the Journal of Prolotherapy, (11) James Inklebarger, MD and  Simon Petrides, MD wrote: “Prolotherapy injections produce an inflammatory response, which can augment collagen fibre and ligament structure regeneration, resulting in tightening and strengthening of spinal ligaments, thereby reducing the incidence of discogenic low back pain by improving intersegmental stability.”

They concluded their research by suggesting: “There are currently few treatment choices other than surgical fusion for intractable lumbar discogenic pain and instability. Prolotherapy may offer a minimally invasive, cost-effective, and safe management option for these patients.

The findings in this study are in keeping with conclusions of other studies in that Prolotherapy, in conjunction with rehabilitation, would appear to be an effective intervention for the treatment of discogenic lower back pain associated with degenerative disc disease of the lumbar spine.

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your back problems and spinal instability.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References:

1 Schoutens C, Cushman DM, McCormick ZL, Conger A, Van Royen BJ, Spiker WR. Outcomes of nonsurgical treatments for symptomatic adult degenerative scoliosis: A systematic review. Pain Medicine. 2020 Jun 1;21(6):1263-75. [Google Scholar]
2 Sun W, Gao J, Zhu L, Wang B, Xiao W, Wang Z, Yang K. Effect of spinal manipulation on degenerative scoliosis. Journal of Traditional Chinese Medicine= Chung i tsa Chih Ying wen pan. 2020 Dec 1;40(6):1033-40. [Google Scholar]
3 Tian G, Shen MR, Jiang WG, Xie FR, Wei WW. Case-control study on spinal leveraging manipulation and medicine for the treatment of degenerative scoliosis. Zhongguo gu shang= China journal of orthopaedics and traumatology. 2015 Jun 1;28(6):508-11. [Google Scholar]
4 Ha KY, Kim YH, Kim SI, Park HY, Seo JH. Decompressive Laminectomy Alone for Degenerative Lumbar Scoliosis with Spinal Stenosis: Incidence of Post-Laminectomy Instability in the Elderly. Clinics in Orthopedic Surgery. 2020 Dec 1;12(4):493-502. [Google Scholar]
5 Han G, Wang W, Zhou S, Li W, Zhang B, Sun Z, Li W. Paraspinal Muscle Degeneration as an Independent Risk for Loss of Local Alignment in Degenerative Lumbar Scoliosis Patients After Corrective Surgery. Global Spine Journal. 2021 Aug 18:21925682211022284. [Google Scholar]
6 La Grone MO. Loss of lumbar lordosis: a complication of spinal fusion for scoliosis. Orthopedic Clinics of North America. 1988 Apr 1;19(2):383-93. [Google Scholar]
7 Zhang H, Yu H, Zhang M, Huang Z, Xiang L, Liu X, Wang Z. Selection of spinal surgery and hip replacement sequence in patients with both degenerative scoliosis and hip disease. Journal of International Medical Research. 2020 Dec;48(12):0300060520959224. [Google Scholar]
8 Suzuki S, Fujiwara H, Nori S, Tsuji O, Nagoshi N, Okada E, Fujita N, Yagi M, Nohara A, Kawakami N, Michikawa T. Residual lumbar curvature that developed during adolescence accelerates intervertebral disc degeneration in adulthood. Spine Deformity. 2020 Nov 27:1-0. [Google Scholar]
9 Ren J, Liu X, Chen F, Jing X, Cui X. Association between vertebral rotatory subluxation and the apical vertebra in degenerative lumbar scoliosis. World Neurosurgery. 2021 Jul 28. [Google Scholar]
10 Hauser RA, Hauser MA. Dextrose Prolotherapy for unresolved low back pain: a retrospective case series study. Journal of Prolotherapy. 2009;1:145-155.
11 Hoffman MD, Agnish V. Functional outcome from sacroiliac joint prolotherapy in patients with sacroiliac joint instability. Complementary therapies in medicine. 2018 Apr 1;37:64-8. [Google Scholar]

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