Diagnosis

- clear diagnosis facilitates treatment

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Diagnosis is made from history, examination and investigations. Some spinal deformities in adults may be very obvious particularly if there is imbalance. Others may be very subtle, and yet clinically important, and are often missed on investigations such as MRI. Xrays are therefore the main diagnostic tool in adult scoliosis and failure to recognise its presence prior to any surgery on the spine may lead to inferior outcomes. Click on links below for details of investigations you may have.

Besides standard Xrays and MRI, special stress views may be requested with the spine in different positions, bent over a block or being stretched (traction). Other pre-operative tests may include CT (to look at bony detail), CT myelography (to look at nerves in different positions), selective nerve root blocks, facet blocks, discography and DEXA scans. These help decide on the nature of surgery that is planned but the decision to proceed is multi-factorial and depends on a detailed discussion with your surgeon to include the natural history, risks, outcomes, medical co-morbidities and ultimately the decision to proceeed is a very indivdual one.

Standing Xrays        MRI                   Nerve blocks    CT
Facet Injections      Discography     Stress views    Traction view
Bolster view            Bone Scan        DEXA scan        Myelography

Standing Xrays

The most important investigation and must be taken with the patient standing. When standing the spine is loaded and the relationship between the pelvis, lower limbs and the spine can be seen. MRI scan (lying down) often does not show this. Xray gives valuable information on slips (subluxations) and rotation of the spine. Unfortunately, too many people have surgery on their spine without having had an xray when it is clearly indicated because of the perception that in some way MRI shows everything (it does not) and spinal deformity is missed. This often leads to a failure in surgery and may warrant complex revisional surgery. It is much better to identify a potential problem in advance by good history taking, clinical examination with the help of xrays to make sure that spinal deformity is not missed and enables informed consent to be given. Xrays can also be used to monitor the progression of a curve and check the spine post-operatively.  Back up

MRI

MRI is useful. It can help rule out sinister causes such as tumour, infection and fractures
as a contributing casue to adult deformity. It will aslo diagnose narrowing of the spinal canal (stenosis) in the lying position. Standing MRI has been developed and is useful but does not show bony anatomy as well, does not show the global picture and is not dynamic. Furthermore, it is not widely available and most importantly, if you are in a lot of pain then it is often not well tolerated as it takes time to do. MRI also evaluates the state of the discs and joints in the spine and is mandatory in patients undergoing surgery. Back up


CT

CT scans are often used to look at bony anatomy in 3D. They are also useful post-operatively to look at screw/meatlwork positioning, implant problems or if the spine is fused. In conjunction with a myelogram they can be very useful in adult spinal deformity. Back up


Dynamic Myelography

In pateitns where symptoms warrant surgery but more information is needed or if there is a high index of suspicion of a problem not seen on MRI then myelography can be used. A dye is injected into the spinal canal and the patient can be placed in different positions, bent, flexed, extended etc. to see if dynamic nerve compression exists. It is also useful in complex cases where surgery has already been done but should only be requested and performed by experts with clear indications. It is a relatively safe investigation and no longer assocated with the same levels of problems (arachnoiditis) that it was previously. Back up

Nerve Blocks

These have no long term proven efficacy but may give short term relief from leg pain but there main role is diagnostic. i.e. if the pain goes with an injection then that is the source of pain. To be performed diagnostically then only single levels should be done. Back up

Facet Injections

These have no long term proven efficacy but may give short term relief from back pain coming from the small joints of the spine but there main role is diagnostic. i.e. if the pain goes with an injection then that is the source of pain. To be performed diagnostically then only single levels should be done. Back up

Discography

This is a pain provoking test and is rarely used in adult deformity, but may be to see if the lowest discs in the spine contribute to back pain. ie. it would not be a good idea to have a scoliosis operation if all or some of the pain was coming from a painful disc below. Sometimes it may mean that surgery needs to incorporate this disc if it is painful. Back up

Stress views

You may be asked to bend to the left and right while xrays are taken - this enables the surgeon to look at the flexibility of the curve and make plans for surgery and in particular which levels of the spien to address. Back up

Bolster View

Patient lies on a bolster positioned at the apex of teh spinal deformity and an xray is taken. This enables the suregon to evaluate how flexible the curve is or is not and may give useful pre-operative information. Back up


Traction views

Usually done in the operating theatre if needed. the spine is stretched and as in stress views it enables the surgeon to decide on opeartive approach and levels. The problem with doing them intraoperatively is that the patient cannot be clearly counselled pre-operatively and so they are usually only used for the biggest, stiffest curves if doubt remains. Back up

Bone Scan

A radioisotope injection is given and areas of increased uptake may signify a problem. Useful to rule out deep infection in the spine, possible implant loosening but rarely used pre-operatively and only really useful over a year from surgery if a problem occurs. Back up

DEXA scan

This looks at the density of the bone and is a test for osteopenia or osteoporosis. It may be useful in decision making and whether to perfom surgery including what problems may be encountered or ensue. Back up