Kyphosis and Scheuermann’s disease

Kyphosis is the apical-dorsal curvature of the spine in the sagittal plane (i.e. curves away from the body).  There is normal thoracic kyphosis of around 20-40°.  Abnormal kyphosis is a curvature (measured as Cobb’s angle (between T2-T12)) of >45°.

Background/Aetiology

  • Pathological kyphosis most commonly occurs in the thoracic spine although rarely can occur elsewhere in the spine.
  • It is not uncommon amongst the elderly population (occurs in around 20-30% of patients >65) and is more common in women
  • Risk factors include
    • Osteoporosis; vertebral (wedge) fractures and degenerative disc disease
    • Problems with proprioception; poor posture; spinal muscle weakness/attenuation
    • Other causes include trauma; ankylosing spondylysis and other arthritides; and rarely neoplasms and infections
  • Kyphosis can impair physical functioning; quality of life and mortality directly and indirectly
    • Increased risk of vertebral fracture
    • May affect balance and likelihood of falls
    • Decline in gait speed/mobility
    • In some cases, can impair pulmonary, GI and gynaecological function

Presentation

  • Most patients are asymptomatic and kyphosis is purely aesthetic
  • Some may present with back pain
  • On examination, there is usually a thoracic kyphosis and there may also be compensatory lumber hyperlordosis
    • Tight hamstrings/difficulty with straight leg raise may also be present
  • Rare but important features include those of myelopathy i.e. neurological problems (including pain/altered sensation, weakness, altered tone/reflexes, problems with gait etc)
  • Indications for surgical management (note not absolute)
    • Neurological deficits
    • Kyphosis >70° (no pain) or >65° with pain
    • Loss of anterior vertebral height >50%

Management

  • For purely postural related kyphosis, exercises and education about posture may benefit patient symptoms (may not entirely relieve kyphosis)
  • Surgical management is reserved only for severe cases
    • Smith-Peterson osteotomy, pedicle subtraction and vertebral column resection can all be options for corrections
    • Anterior release spinal fusion may also be used in Scheuermann’s disease/severe cases

Scheuermann’s disease

  • In children and adolescents, abnormal kyphosis can occur as what is thought to be the result of a genetic defect causing collapse of the vertebrae
    • A family history is common
    • Patients
  • Classically defined as anterior wedging of >5° across three consecutive vertebrae, and is different from postural kyphosis by the rigidity of the kyphosis (not corrected by hyperextension)
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