Two Patients, Decades Apart in Age From Their Diagnosis, and What Their Films Told Me About Where Their Pain Was Actually Coming From

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I published a case series in Cureus this spring on two geriatric patients with a history of adolescent idiopathic scoliosis, and I want to walk through the reasoning behind it, because the finding runs against how most of us are trained to think about scoliosis pain in older adults.

**The standard assumption**

When a geriatric patient with a decades-old AIS diagnosis presents with chronic pain, the reflex is to attribute it to the curve itself. Bigger Cobb angle, more pain, that's the mental model most of us carry. It's not wrong as a general trend, but I don't think it's the whole picture, and I don't think it explains what I was seeing in these two patients specifically.

**The alternative framework**

AIS starts in adolescence but the compensatory loading pattern doesn't stop there. Decades of the body organizing itself around an asymmetric curve does something to the kinetic chain that isn't captured by the Cobb angle alone. My working hypothesis going into these two cases was that a meaningful share of the chronic pain in this population is coming from accelerated degeneration and compensatory dysfunction elsewhere in the chain, not from the primary curve itself.

**The cases**

Both patients were geriatric, both had a documented history of AIS, both presented with chronic pain, and both went through a multimodal non-surgical rehabilitation program built on the CLEAR Institute protocol. I took pre- and post-treatment radiographs and paired them with self-reported outcome measures rather than relying on imaging alone, since pain is the thing the patient actually came in for.

Both patients showed meaningful reductions in reported pain alongside measurable improvement in sagittal alignment on the follow-up films.

**What I'm willing to claim and what I'm not**

Two patients is a case series, not a study. I'm not claiming this proves the kinetic chain framework over the curve-focused one, and I'm not claiming this protocol works generally for geriatric AIS pain based on two charts. What I am claiming is that the framework held up well enough in these two cases to justify testing it properly, in a larger prospective cohort with a comparison group. That's the honest scope of what a case series can support, and I said as much in the discussion section of the paper itself.

**Why I think the framework matters anyway**

If a patient's pain is coming primarily from decades of compensatory loading rather than the curve magnitude itself, that changes what you're actually treating. Chasing the Cobb angle in a 70-year-old with a stable curve and calling it done misses the mechanism that's likely driving their day-to-day pain. These two cases are a small data point toward taking that distinction seriously in how geriatric AIS patients get worked up, not a closed argument.

Full text and citation: Dick JM. Radiographic Sagittal Alignment and Kinetic Chain Alterations in Geriatric Patients With Scoliosis: A Case Series. Cureus. 2026 Mar 25;18(3). DOI: 10.7759/cureus.105827.

— Justin Dick, DC