Scoliosis in Adults: Understanding Spinal Curvature, Pain, and Management

What Is Scoliosis?

Scoliosis is a three-dimensional structural deformity of the spine characterised by a lateral curvature of greater than ten degrees (measured by the Cobb angle on standing radiograph) combined with vertebral rotation. In clinical practice, two broad categories are encountered. Adolescent idiopathic scoliosis (AIS) — the most common form — develops during the pubertal growth spurt in otherwise healthy children and adolescents, with a cause that remains incompletely understood. Adult degenerative scoliosis (also called de novo scoliosis) develops in mid-life and beyond as asymmetrical disc degeneration, facet joint arthropathy, and vertebral wedging progressively tilt and rotate spinal segments. The two types coexist when an individual with AIS reaches adulthood and develops superimposed degenerative changes. Understanding which type is present — or which combination — guides both prognosis and management.

Why Scoliosis Causes Pain

Not all scoliosis causes pain. Mild curves in young adults are frequently asymptomatic and discovered incidentally. Pain in adult scoliosis arises from several mechanisms. Asymmetrical loading: the rotated, curved spine distributes load unequally across discs, facet joints, and paraspinal muscles — accelerating degeneration on the concave side of the curve and producing chronic muscular overactivation on the convex side. Curve progression: adult degenerative curves tend to progress more rapidly than adolescent idiopathic curves, increasing compressive and shear forces over time. Nerve root involvement: in lumbar degenerative scoliosis, foraminal narrowing on the concave side — from a combination of curve, rotation, and spondylosis — produces radicular leg pain that may dominate the clinical picture. Muscular imbalance and fatigue: the paraspinal musculature works asymmetrically and inefficiently in a scoliotic spine, producing deep aching fatigue that worsens with standing and improves with lying down — a characteristic symptom pattern.

Conservative Management

Conservative management is appropriate for the majority of adults with scoliosis, including those with moderate pain and functional limitation. The evidence supports: targeted exercise therapy — particularly the Schroth method and similar scoliosis-specific exercise approaches that address the three-dimensional correction of curve, rotation, and breathing mechanics — for reducing pain and curve progression in skeletally mature patients. General strengthening and aerobic exercise reduces pain, improves functional capacity, and maintains bone density. Manual therapy — mobilisation and soft tissue work targeting the hypertonic convex-side paraspinals, restricted rib cage mobility, and adjacent hip and thoracic joint stiffness — provides meaningful pain relief and improves mobility. Bracing in adults is not used to correct the curve (as in adolescents) but may provide symptomatic pain relief during high-demand activities. Surgical intervention — posterior spinal fusion — is considered for curves progressing beyond 50 degrees, severe functional limitation, or significant neurological compromise from nerve root compression; outcomes are substantially better when patients approach surgery with good physical conditioning.