The Journal of International Medical Research

2012; 40: 399 – 405

Surgery is an Effective and Reasonable

Treatment for Degenerative Scoliosis:
a Systematic Review
C-Z LIANG, F-C LI, H LI, Y TAO, X ZHOU AND Q-X CHEN
Department of Orthopaedic Surgery, Second Affiliated Hospital, Zhejiang University School
of Medicine, Hangzhou, China

OBJECTIVE: A systematic review to
evaluate the role of surgery for treating
degenerative scoliosis (DS) in terms of
improved function (Oswestry Disability
Index [ODI]) and correction of deformity
(Cobb angle); safety outcomes included
complication and repeat surgery rates.
METHODS: A search of the MEDLINE, ISI
Web of Knowledge and Cochrane Library
databases was performed. The
methodological quality of each study was
assessed according to standardized
criteria and data were extracted.
RESULTS: A total of 16 studies including
553 patients with DS met the eligibility
criteria for inclusion. The mean ODI score
at final follow-up was 36.0 ± 7.8 (304
patients) and the mean decrease in ODI
was 23.3 ± 11.3 (302 patients). Mean
reduction in curve angle (as a percentage
of the original curve) was 48.5 ± 21.0% (527
patients). The overall incidence of
complications was 49.0% (171 in 349
patients) and the rate of repeat surgery
was 15.3% (61 in 398 patients).
CONCLUSIONS: Despite a high incidence
of complications and reoperations, surgery
was an effective and reasonable treatment
for DS, providing significant functional
improvement and deformity correction.

KEY WORDS: DEGENERATIVE SCOLIOSIS; SURGERY; OSWESTRY DISABILITY INDEX; COBB ANGLE;
COMPLICATION RATE; REOPERATION RATE; SYSTEMATIC REVIEW

Introduction generally sufficient to relieve pain and

Degenerative scoliosis (DS), also known as
primary degenerative scoliosis or de novo
scoliosis, occurs in elderly adults without a
previous history of scoliosis,1 – 3 and affects
approximately 6% of those aged > 50 years.4
It is defined as a spinal deformity that
develops after skeletal maturity, with a Cobb
angle of > 10° in the coronal plane due to
asymmetric disc and facet joint
degeneration.5 The incidence of DS has
increased concurrently with life
expectancy.1,5 Nonsurgical treatment is
restore normal activity,5 – 7 but a systematic
review found that there was very weak
evidence of success for any nonsurgical
treatment options for adults with DS.6
Surgery is mainly indicated for severe
back pain and/or progressive neurological
symptoms refractory to nonsurgical
treatment,1,5,8 and for significant deformity
per se.9 Few large-scale studies have assessed
functional improvement, deformity
correction, and complications and repeat
operations following surgery for patients

399
 C-Z Liang, F-C Li, H Li et al.
Surgery for degenerative scoliosis
with DS.10,11 These studies suggest that due to
advanced age, osteoporosis, comorbidities
and spinal imbalance, surgery for DS is
associated with considerable complications,
and severe back pain and disability may
persist postoperatively.10,11
For surgery to be considered as an effective
and reasonable treatment it should improve
function, correct deformity and have a
relatively low incidence of complications and
repeat surgery. The current systematic review
was undertaken to evaluate the role of
surgery for treating DS and to determine
whether surgery can improve function
(based on the Oswestry Disability Index
[ODI]12) and correct deformities (Cobb
angle). Rates of complications and repeat
surgery were also evaluated.
Materials and methods
LITERATURE SEARCH STRATEGY
Electronic database searches of MEDLINE
(from January 1950 to December 2010), ISI
Web of Knowledge (from January 1960 to
December 2010), and the Cochrane Library
(Issue 12, December 2010) were performed
on 31 December 2010. The following terms
were used to search the key words, abstract
and title fields: (degenerative scoliosis OR de
novo scoliosis) AND (surgery OR operation).
Two reviewers (C.-Z.L. and F.-C.L.)
independently evaluated the titles, abstracts
and full texts to select appropriate studies. If
there was any question as to the relevance of
any article, a consensus was taken among
all authors. The reference lists of selected
articles were also reviewed to identify any
additional studies.
INCLUSION AND EXCLUSION
CRITERIA
The following were eligible for inclusion: (i)
clinical studies; (ii) randomized controlled
trials; (iii) controlled clinical trials with
400
quasi-randomized methods; (iv) prospective
studies; (v) retrospective studies; (vi) case
series; and (vii) studies involving patients
with a preoperative Cobb angle > 10°.
Excluded were: (i) articles not in English; (ii)
animal studies; (iii) review articles or letters
to the editor; (iv) studies involving patients
of age < 40 years at the time of presentation;
(v) studies involving patients with previous
spine surgery or trauma, metabolic spinal
pathology, asymmetrical anomalies at the
lumbosacral junction, and a history of
adolescent scoliosis or kyphosis, ankylosing
spondylitis or osteoporotic vertebral fracture;
(vi) studies involving patients with a
preoperative Cobb angle ≤ 10°; (vii) studies
that included nonsurgical treatment; (viii)
studies with a duration of follow-up < 2
years; (ix) studies in which the specific
outcome data were not presented or could
not be transformed into a compatible format
for use in this review.
CRITICAL APPRAISAL
Two reviewers (C.-Z.L. and F.-C.L.) assessed the
methodological quality and extracted the
data from each study independently;
disagreement was resolved by discussion and,
if necessary, by consensus of all authors. Data
quality (level of evidence) was classified from
class I to class V according to a previous
report,13 with class I being the strongest
(randomized controlled trials) and class V
being the weakest (expert opinion).
Additionally, the methodological quality of
the studies was assessed according to the
modified Jadad scale (MJS)14 for randomized
controlled trials and the methodological
index for non-randomized studies (MINORS)
for nonrandomized studies.15 The MJS score
ranged from 0 to 8, with high quality defined
as ≥ 4. MINORS comprises 12 items, with an
ideal score of 16 for noncomparative studies
and 24 for comparative studies.
 C-Z Liang, F-C Li, H Li et al.
Surgery for degenerative scoliosis
DATA EXTRACTION
Data on three specific outcomes were
extracted: (i) function (ODI and change in
ODI); (ii) deformity correction (Cobb angle,
curve reduction and curve reduction as a
percentage of the original curve); and (iii)
incidence of complications and repeat
surgeries.
DATA ANALYSES
Weighted means of age, duration of follow-
up, preoperative ODI, ODI at final follow-up,
change in ODI, Cobb angles, curve
reduction, curve reduction as a percentage of
the original curve, and the incidence of
complications and repeat surgery were
calculated. A pooled analysis of the data
recorded in the individual studies was
undertaken. The incidence of complications
was calculated as the total number of
complications divided by the total number of
patients in the reported studies. The
incidence of repeat surgery was calculated as
the total number of patients who underwent
repeat surgery divided by the total number of
patients in the reported studies. SPSS®
version 10.0 (SPSS Inc., Chicago, IL, USA) for
Windows® was used for data processing.
Results
The literature search retrieved 322 articles
from MEDLINE, 359 from ISI Web of
Knowledge and 20 from the Cochrane
Library. A total of 415 articles were identified
after deleting duplicates. The abstracts and
full texts were retrieved and 397 articles were
excluded according to the exclusion criteria.
A further two articles were excluded because
they reported the results of a previous study.
This meant that 16 articles met the inclusion
criteria2,16 – 30 and they included 553
surgically-treated patients. The characteristics
of the studies are presented in Table 1. The
follow-up duration in the included studies
401
ranged from 2.0 to 13.4 years, the mean
follow-up in most studies being < 5 years. The
data quality of the included studies was not
high; according to the MJS, the randomized
controlled study by Ploumis et al.29 was the
only one of high quality, the 15
nonrandomized studies2,16 – 28,30 were low
quality according to their MINORS scores.
The ODI was used as a measure of
functional improvement in nine studies,2,21 –
24,26,27,29,30
including data from 321 patients
(Table 2). The mean ODI score at final
follow-up was 36.0 ± 7.8 (304
patients2,21,23,24,26,27,29,30) and the mean
decrease in ODI score (from preoperative to
final follow-up) was 23.3 ± 11.3 (302
patients2,21,22,24,26,27,29,30).
Pre- and postoperative Cobb angles were
reported in 14 studies2,17 – 21,23 – 30 which
included data from 527 patients. The range
of mean Cobb angle in these studies was
16.5° – 50.0° preoperatively and 6.0° – 25.0°
at final follow-up. Overall, the mean Cobb
angle was 26.7 ± 10.6° preoperatively and
13.3 ± 7.0° at final follow-up. The mean
decrease in Cobb angle from preoperative to
final follow-up was 13.5 ± 10.1° and the
mean curve reduction as a percentage of the
original curve was 48.5 ± 21.0%.
Incidences of surgical complications
and repeat surgery were reported in
14 studies.2,16,17,20 – 22,24 – 30 The overall
complication rate was 49.0% (171 compli-
cations in 349 patients) from 12
studies.2,16,17,20 – 22,24 – 26, 28 – 30 There were 61
incidences of repeat surgery in 398 patients
(15.3%) from 12 studies.2,16,17,20,22 – 28,30
Discussion
Although surgery is a treatment option for
DS, controversy exists about its use. This
systematic review demonstrated that, despite
a high rate of complications and repeat
procedures, surgery is an effective and
 C-Z Liang, F-C Li, H Li et al.
Surgery for degenerative scoliosis

TABLE 1:
Characteristics of the 16 studies included in the systematic review of surgery for the
treatment of degenerative scoliosis, arranged in chronological order of publication date2,16 – 30
Level of MJS/MINORS
Study No. of patients Study design evidencea score
Marchesi et al., 199116 9 Retrospective III 10b
Grubb et al., 199417 24 Retrospective IV 12b
Iizuka and Yamada, 200618 21 Retrospective III 8b
Cho et al., 20072 47 Retrospective III 10b
Pateder et al., 200719 80 Retrospective III 8b
Berven et al., 200720 38 Retrospective IV 8b
Wu et al., 200821 26 Retrospective III 8b
Glassman et al., 200922 17 Prospective III 11b
Kluba et al., 200923 19 Retrospective II 9b
Crandall and Revella, 200924 40 Prospective IV 12c
Khan et al., 200925 14 Retrospective III 9b
Di Silvestre et al., 201026 29 Retrospective IV 8b
Transfeldt et al., 201027 84 Retrospective III 10c
Ploumis et al., 201029 28 Prospective I 7d
Keorochana et al., 201030 31 Prospective IV 9b
Li et al., 201128 46 Retrospective IV 8b
aLevel of evidence indicates data quality classified from class I strongest evidence based on randomized

controlled trials to class V the weakest (expert opinion).13

b
The scores of nonrandomized and noncomparative studies according to MINORS.15
cThe scores of nonrandomized and comparative studies according to MINORS.15
dThe scores of randomized controlled trials according to MJS.14

MJS, modified Jadad scale14; MINORS, methodological index for nonrandomized studies.15

reasonable treatment for DS, providing effective treatment for DS.

improvement in ODI and in deformity
correction as measured using the Cobb angle.
The ODI is a valid and rigorous functional
measure used for assessing spinal disorders.12
The mean decrease in ODI of 23.3
points2,21,22,24,26,27,29,30 suggests significant
functional improvement in these patients.
Taken together with the mean ODI at
final follow-up of 36.0 (moderate
disability),2,21,23,24,26,27,29,30 these data suggest
that surgery is an effective and reasonable
treatment option for DS.
Deformity correction, as measured by the
Cobb angle, is another criterion for
measuring the efficacy of surgery for DS.
Patients in the current analysis gained
considerable curve correction after surgery,
providing further evidence that surgery is an
Complications and repeat operations
undermine the value of surgery for DS,31 and
the incidence of surgical complications has
been reported to be high (> 50%).2,17,24,32 The
overall rate of complications was 49.0% in
the present analysis,2,16,17,20 – 22,24 – 26,28 – 30
which is similar to the findings of others
where the complication rate was 41% for
patients aged 41 – 60 years and 64% for
those aged 61 – 85 years.33 The rate of repeat
surgery was 15.3% in the present analysis,
which is similar to published rates.34,35 The
rate of complications and repeat surgery was
generally high and this must be taken into
account when deciding to proceed with
surgery.
This systematic review had several
limitations. First, the heterogeneity between

402
 TABLE 2:
Summary of the surgical outcomes of patients with degenerative scoliosis from the 16 studies included in the systematic review
of surgery for the treatment of degenerative scoliosis, arranged in chronological order of publication date2,16 – 30
Major Major
curve curve No. of
No. of Age Follow-up ODI reduction reduction No. of repeat
Study patients (years) (years) ODI reduction (°) (%) complications surgeries
Marchesi et al., 199116 9 57.1 3.5 (2.8 – 3.9) a a a a 7 1
Grubb et al., 199417 24 63.3 2.8 (2.0 – 9.0) a a 6.9 24.0 35 2
Iizuka and Yamada, 200618 21 68.7 3.6 (2.0 – 6.0) b b 8.9 50.3 a a

Cho et al., 20072 47 66.6 3.8 (2.0 – 8.1) 40.5 17.2 9.2 49.5 32 7
Pateder et al., 200719 80 c 4.4 (a) a a 25.0 50.0 c a

Berven et al., 200720 38 64.0 4.5 (2.0 – 13.4) b b 8.7 29.2 17 9

Wu et al., 200821 26 64.2 3.0 (2.0 – 6.0) 25.8 32.2 9.1 55.2 4 a

403
Glassman et al., 200922 17 63.6 2.0 (a) a 20.6 a a 7 2
Kluba et al., 200923 a a
19 61.5 4.8 (3.1 – 5.6) 42.0 17.1 68.4 6
Crandall and Revella, 200924 40 68.0 3.1 (2.0 – 5.6) 49.3 21.2 19.3 69.7 32 10
Khan et al., 200925 c c
14 65.0 3.6 (2.5 – 6.5) 40.0 87.0 10 3
Di Silvestre et al., 201026 29 68.5 4.5 (3.2 – 5.6) 27.4 24.4 5.8 37.5 8 2
C-Z Liang, F-C Li, H Li et al.

Transfeldt et al., 201027 c

84 69.2 4.7 (2.0 – 8.1) 36.6 5.8 4.7 16.6 17
a
Surgery for degenerative scoliosis

Ploumis et al., 201029 28 72.0 2.0 (a) 32.2 44.6 4.5 19.5 3
Keorochana et al., 201030 31 64.9 2.6 (2.0 – 5.0) 34.2 20.2 7.9 54.6 7 2
b b
Li et al., 201128 46 66.4 3.5 (2.0 – 5.0) 21.5 67.8 9 0
Data presented as number of patients, means, or mean (range) or percentage as appropriate.
a
Data were not mentioned in the study.
b
Data were not presented in or could not be transformed into the forms used in this review.
c
Data could not be extracted or calculated.
ODI, Oswestry Disability Index.12
 C-Z Liang, F-C Li, H Li et al.
Surgery for degenerative scoliosis
individual studies was substantial because
the indications for surgery, surgical
procedures and outcome measures varied
among the studies. Secondly, only one
study24 reported the data for pelvic
incidence, and two studies2,25 reported the
data for coronal and sagittal imbalance. As
restoration of sagittal balance is an
important aspect that correlates with clinical
improvement,25,36 a lack of these data
introduced another limitation. Thirdly, the
data quality of the included studies was not
high. Finally, there may have been some
selection bias because the included series
were confined to limited search terms and
databases.
In conclusion, despite a high rate of
complications and repeat surgery, this
systematic review demonstrates that surgery
is an effective and reasonable treatment
intervention for DS, providing an
improvement in ODI and in deformity
• Received for publication 26 November 2011 • Accepted subject to revision 28 November 2011
• Revised accepted 14 March 2012
Copyright © 2012 Field House Publishing LLP
References
1 Aebi M: Correction of degenerative scoliosis of
the lumbar spine. A preliminary report. Clin
Orthop Relat Res 1988; 232: 80 – 86.
2 Cho KJ, Suk SI, Park SR, et al: Complications in
posterior fusion and instrumentation for
degenerative lumbar scoliosis. Spine (Phila Pa
1976) 2007; 32: 2232 – 2237.
3 Ploumis A, Transfledt EE, Denis F: Degenerative
lumbar scoliosis associated with spinal stenosis.
Spine J 2007; 7: 428 – 436.
4 Vanderpool DW, James JI, Wynne-Davies R:
Scoliosis in the elderly. J Bone Joint Surg Am
1969; 51: 446 – 455.
5 Aebi M: The adult scoliosis. Eur Spine J 2005; 14:
925 – 948.
6 Everett CR, Patel RK: A systematic literature
review of nonsurgical treatment in adult
scoliosis. Spine (Phila Pa 1976) 2007; 32 (19
suppl): S130 – S134.
7 Daffner SD, Vaccaro AR: Adult degenerative
lumbar scoliosis. Am J Orthop (Belle Mead NJ)
2003; 32: 77 – 82.
8 Oskouian RJ Jr, Shaffrey CI: Degenerative
lumbar scoliosis. Neurosurg Clin N Am 2006; 17:
404
correction as measured using the Cobb
angle. Standardizing both the indications for
surgery and methodology for measuring
changes in function and deformity
correction should enhance the comparability
and validity of future studies on this subject.
In addition, analysis of sagittal and coronal
balance should be regularly performed.
Large scale, high quality studies with long
term follow-up are needed to provide reliable
evidence for future evaluation.
Acknowledgements
This study was partly supported by grants
from the Science and Technology Planning
Project of Zhejiang Province (2009C33093)
and the National Nature Science Foundation
of China (81171756).
Conflicts of interest
The authors had no conflicts of interest to
declare in relation to this article.
299 – 315.
9 Bradford DS, Tay BK, Hu SS: Adult scoliosis:
surgical indications, operative management,
complications, and outcomes. Spine (Phila Pa
1976) 1999; 24: 2617 – 2629.
10 Prommahachai A, Wittayapirot K,
Jirarattanaphochai K, et al: Correction with
instrumented fusion versus non-corrective
surgery for degenerative lumbar scoliosis: a
systematic review. J Med Assoc Thai 2010; 93:
920 – 929.
11 Yadla S, Maltenfort MG, Ratliff JK, et al: Adult
scoliosis surgery outcomes: a systematic review.
Neurosurg Focus 2010; 28: E3.
12 Fairbank JC, Pynsent PB: The Oswestry
Disability Index. Spine (Phila Pa 1976) 2000; 25:
2940 – 2952.
13 Wright JG, Swiontkowski MF, Heckman JD:
Introducing levels of evidence to the journal. J
Bone Joint Surg Am 2003; 85-A: 1 – 3.
14 Oremus M, Wolfson C, Perrault A, et al:
Interrater reliability of the modified Jadad
quality scale for systematic reviews of
Alzheimer’s disease drug trials. Dement Geriatr
Cogn Disord 2001; 12: 232 – 236.
 C-Z Liang, F-C Li, H Li et al.
Surgery for degenerative scoliosis
15 Slim K, Nini E, Forestier D, et al: Methodological
index for non-randomized studies (MINORS):
development and validation of a new
instrument. ANZ J Surg 2003; 73: 712 – 716.
16 Marchesi DG, Thalgott JS, Aebi M: Application
and results of the AO internal fixation system
in nontraumatic indications. Spine (Phila Pa
1976) 1991; 16(3 suppl): S162 – S169.
17 Grubb SA, Lipscomb HJ, Suh PB: Results of
surgical treatment of painful adult scoliosis.
Spine (Phila Pa 1976) 1994; 19: 1619 – 1627.
18 Iizuka T, Yamada S: Challenging degenerative
lumbar scoliosis with segmental corrective
fusion surgery. J Musculoskel Res 2006; 10: 141 –
150.
19 Pateder DB, Kebaish KM, Cascio BM, et al:
Posterior only versus combined anterior and
posterior approaches to lumbar scoliosis in
adults: a radiographic analysis. Spine (Phila Pa
1976) 2007; 32: 1551 – 1554.
20 Berven SH, Deviren V, Mitchell B, et al:
Operative management of degenerative
scoliosis: an evidence-based approach to
surgical strategies based on clinical and
radiographic outcomes. Neurosurg Clin N Am
2007; 18: 261 – 272.
21 Wu CH, Wong CB, Chen LH, et al: Instrumented
posterior lumbar interbody fusion for patients
with degenerative lumbar scoliosis. J Spinal
Disord Tech 2008; 21: 310 – 315.
22 Glassman SD, Carreon LY, Djurasovic M, et al:
Lumbar fusion outcomes stratified by specific
diagnostic indication. Spine J 2009; 9: 13 – 21.
23 Kluba T, Dikmenli G, Dietz K, et al: Comparison
of surgical and conservative treatment for
degenerative lumbar scoliosis. Arch Orthop
Trauma Surg 2009; 129: 1 – 5.
24 Crandall DG, Revella J: Transforaminal lumbar
interbody fusion versus anterior lumbar
interbody fusion as an adjunct to posterior
instrumented correction of degenerative
lumbar scoliosis: three year clinical and
radiographic outcomes. Spine (Phila Pa 1976)
2009; 34: 2126 – 2133.
25 Khan SN, Hofer MA, Gupta MC: Lumbar
degenerative scoliosis: outcomes of combined
anterior and posterior pelvis surgery with
minimum 2-year follow-up. Orthopedics 2009;
32: 258.
26 Di Silvestre M, Lolli F, Bakaloudis G, et al:
Dynamic stabilization for degenerative lumbar
Author’s address for correspondence
Professor Fang-Cai Li
Department of Orthopaedic Surgery, Second Affiliated Hospital, Zhejiang University School
of Medicine, 88 Jie Fang Road, 310009 Hangzhou, China.
E-mail: leerich@sohu.com
405
scoliosis in elderly patients. Spine (Phila Pa
1976) 2010; 35: 227 – 234.
27 Transfeldt EE, Topp R, Mehbod AA, et al:
Surgical outcomes of decompression,
decompression with limited fusion, and
decompression with full curve fusion for
degenerative scoliosis with radiculopathy. Spine
(Phila Pa 1976) 2010; 35: 1872 – 1875.
28 Li F, Chen Q, Chen W, et al: Posterior-only
approach with selective segmental TLIF for
degenerative lumbar scoliosis. J Spinal Disord
Tech 2011; 24: 308 – 312.
29 Ploumis A, Albert TJ, Brown Z, et al: Healos
graft carrier with bone marrow aspirate instead
of allograft as adjunct to local autograft for
posterolateral fusion in degenerative lumbar
scoliosis: a minimum 2-year follow-up study. J
Neurosurg Spine 2010; 13: 211 – 215.
30 Keorochana G, Tawonsawatruk T,
Laohachareonsombat W, et al: The results of
decompression and instrumented fusion with
pedicular screw plate system in degenerative
lumbar scoliosis patients with spinal stenosis: a
prospective observational study. J Med Assoc
Thai 2010; 93: 457 – 461.
31 Sansur CA, Smith JS, Coe JD, et al: Scoliosis
research society morbidity and mortality of
adult scoliosis surgery. Spine (Phila Pa 1976)
2011; 36: E593 – E597.
32 Cho KJ, Suk SI, Park SR, et al: Short fusion versus
long fusion for degenerative lumbar scoliosis.
Eur Spine J 2008; 17: 650 – 656.
33 McDonnell MF, Glassman SD, Dimar JR 2nd, et
al: Perioperative complications of anterior
procedures on the spine. J Bone Joint Surg Am
1996; 78: 839 – 847.
34 Mok JM, Cloyd JM, Bradford DS, et al:
Reoperation after primary fusion for adult
spinal deformity: rate, reason, and timing.
Spine (Phila Pa 1976) 2009; 34: 832 – 839.
35 Pichelmann MA, Lenke LG, Bridwell KH, et al:
Revision rates following primary adult spinal
deformity surgery: six hundred forty-three
consecutive patients followed-up to twenty-two
years postoperative. Spine (Phila Pa 1976) 2010;
35: 219 – 226.
36 Ploumis A, Transfeldt EE, Gilbert TJ, et al:
Radiculopathy in degenerative lumbar
scoliosis: correlation of stenosis with relief from
selective nerve root steroid injections. Pain Med
2011; 12: 45 – 50.