The incidence of adult lumbar scoliosis is expected to rise as the proportion of the population over the age of 65 increases. Surgeons generally begin with conservative management for symptoms of lumbar scoliosis due to the high complication rates associated with surgical care and poor bone quality in this age group. Additionally, patients are generally reluctant to consider major reconstructive surgery without efforts at non-operative treatment. Many health insurers also require that surgeons document failure of conservative treatment prior to proceeding with surgical intervention. There is a lack of consensus on the most successful conservative clinical treatment. Steroid injections, physical therapy, bracing, and nonsteroidal anti-inflammatory drugs (NSAIDs) are currently the mainstays of non-operative treatment. However, there is little literature to support the efficacy of nonsurgical modalities.

The utilization of epidural steroid injections has grown considerably. From 1999 to 2009, lumbar epidural steroid injections have increased by nearly 900,000 treatments per year [1]. Epidural steroid injections are commonly prescribed to help treat pain from the spinal stenosis and radiculopathy that may be associated with adult lumbar scoliosis. Degenerative changes leading to spinal stenosis can precede a spinal deformity resulting in de novo scoliosis [2]. Lumbar stenosis from degenerative changes can also occur within a preexisting deformity. Epidural steroid injections are widely used to treat leg pain caused by neurogenic claudication in lumbar spinal stenosis patients. However, rigorous data is lacking regarding the effectiveness and safety of these injections. A double-blinded multi-site trial failed to show any significant difference between Roland–Morris Disability Questionnaire (RMDQ) and leg pain intensity scores at 6 weeks in a group of 400 randomized spinal stenosis patients receiving epidural steroid injections with lidocaine versus lidocaine alone [3]. This study concluded that epidural injection of glucocorticoids plus lidocaine offered minimal or no short-term benefit as compared with epidural injection of lidocaine alone.

The use of epidural steroid injections for the treatment of radicular pain appears to be more promising. Lumbar radicular pain can be caused by foraminal stenosis and other conditions in the lumbar spine such as lumbar disk herniations or facet cysts. Cooper et al. explored the effectiveness of transforaminal epidural steroid injections in a retrospective study of 61 patients with degenerative scoliosis of greater than 10° with radicular complaints [4]. In this study, a successful outcome was defined as a patient who was both satisfied with his or her results and experienced at least a 2-point improvement in numeric rating scale, summary pain, and summary function scores. The results showed that 59.6 % of the patients had a successful outcome at 1 week postinjection, 55.8 % at 1 month postinjection, 37.2 % at 1 year postinjection, and 27.3 % at 2 years postinjection (p < 0.01). However, the conclusions are limited as this study used historical recall. Another prospective randomized study compared the outcomes of transforaminal injection of steroid and local anesthetic, local anesthetic alone, or normal saline, and an intramuscular injection of steroid or normal saline in patients with disk herniations and lumbar radicular pain [5]. Patients and outcome evaluators were blinded to the agent administered. The primary outcome measure was the proportion of patients who achieved at least 50 % pain relief 1 month after treatment. A greater proportion of patients treated with transforaminal injection of steroid (54 %) achieved relief of pain than did patients treated with transforaminal injection of local anesthetic (7 %) or transforaminal injection of saline (19 %), intramuscular steroids (21 %), or intramuscular saline (13 %). Relief of pain was corroborated by significant improvements in function and disability and reductions in the use of other health care. Outcomes were equivalent for patients with acute or chronic radicular pain. However, the number of patients who maintained relief diminished over time, and only 25 % reported pain relief at 12 months. Overall, there is Level III, weak evidence, for the use of transforaminal epidural steroid injections in the treatment of radiculopathy and/or spinal stenosis associated with adult lumbar scoliosis.

Spondylosis of the lumbar facet joints is also thought to be a common pain generator causing chronic back pain in patients with adult degenerative scoliosis. Non-operative management of symptomatic facet arthrosis includes intra-articular facet injections, facet joint nerve blocks, and radio-frequency neurotomy. Although these procedures are commonly utilized to treat facet joint pathology, there is little evidence to support their use. In a systematic review by Manchikanti et al., 21 randomized controlled trials and five observational studies were analyzed to access the efficacy of these treatment modalities. In the lumbar spine, for long-term effectiveness (>6 months of pain relief), there is Level II evidence for radio-frequency neurotomy and lumbar facet joint nerve blocks, whereas the evidence is Level III for lumbosacral intra-articular injections [6].

Physical therapy is also a commonly prescribed modality used in the conservative treatment of adult lumbar scoliosis. Physical therapy referrals for adult degenerative spine disorders have increased by 1.4 million visits per year between 1999 and 2009 [1]. In a clinical study performed by Barrios et al., 30 patients with adult degenerative scoliosis with Cobb angles ranging from 25 to 65° were evaluated for curve correction and pain control using physiotherapy [7]. The patients were initially treated with heat and lumbar traction, followed by the use of a traction device with pressure applied to the apex of the deformity. Patients were treated with 20–60 sessions of physical therapy with the use of NSAIDs as needed. The results were compared with a control group of patients with scoliosis, but their treatment is not described in detail. The authors found a statistically significant improvement in curve magnitude (38.75 %) compared with the control group (18.75 %). The results in this study also reported a significant reduction in pain as 77 % of the patients were stated to be symptomatic prior to treatment, compared to only 7 % after treatment. However, the method of pain assessment, therapy protocols, and independence of the radiographic reviewers were not well described, making the study conclusions difficult to extrapolate to specific patient populations. Another study looking at exercise-specific therapy was also reported in skeletally mature patients with scoliosis [8]. The patients in this study underwent the use of a side-shift exercise toward the concavity with a 4-year follow-up. The study failed to show any significant benefit as the patients within this study stayed essentially the same or improved slightly in relation to degree of curve.

The Schroth method, first described in the 1920s, is another exercise-specific program that has been used in the treatment of scoliosis. The Schroth method is a rehabilitation program that focuses on the correction of posture and breathing patterns. Although recently repopularized and used in the treatment of adult scoliosis, there is little data to support its efficacy. In one case report, a 26-year-old woman with scoliosis (Cobb’s angle of 20.5°) and back pain was treated with 8 weeks of Schroth exercises [9]. It was reported that her thoracic Cobb’s angle decreased from 20.5 to 16.3° and pain decreased from a visual analogue scale (VAS) 5–1. However, follow-up was only 8 weeks for this single case. Overall, there is Level IV, weak evidence on the use of physical therapy for the treatment of adult lumbar scoliosis.

There is also a lack of research to support the use of chiropractic manipulation in the non-operative management of adult scoliosis. In a case series of two adult scoliosis patients with back pain and Cobb angles of 40 and 63, chiropractic manipulation was reported to help with pain reduction [10]. It was also suggested in this study that the routine chiropractic care in the patient with the larger curve led to reduced curve progression. However, the reports of pain reduction were subjective, and the suggestion of decreased curve progression was anecdotal. There is very limited and weak, Level IV, data to support the use of chiropractic care for non-operative management of adult scoliosis.