Scheuermann's Kyphosis

Table of Contents
Introduction
Anatomy
Causes
Symptoms
Diagnosis
TreatmentIntroduction

Scheuermann's kyphosis is a "developmental" type of kyphosis, meaning that it happens during growth. The vertebral bodies wedge forward. Normal vertebrae are rectangular-shaped and stacked on top of one another like building blocks, with a soft cushion between each one. If the front of the vertebrae wedges closer together in a triangular shape, the spine starts to curve forward more than normal. This disease develops in adolescents while their bones are still growing. It happens to about one percent of this age group, affecting an equal number of boys and girls.

Learn about Scheuermann's Kyphosis including

how the thoracic spine is affected
what causes the condition
what symptoms are present
how a diagnosis is made
what treatment options are available

Anatomy

In order to understand your symptoms and treatment choices, it is helpful to start with a basic understanding of the anatomy of the mid back. Become familiar with the various parts that make up the thoracic spine and how they work together. Learn more about the anatomy of the thoracic spine.

Learn more about the anatomy of the thoracic spine.

The normal spine has three natural curves. The cervical spine curves slightly inward, the thoracic slightly outward, and the lumbar slightly inward. This shape provides an even distribution of weight and helps the spine withstand all kinds of forces. Even though the lower portion of the spine holds most of the body's weight, each segment relies upon the strength of the others to function properly.

Kyphosis refers to the natural shape of the thoracic spine, which usually has a forward curve of 20 to 40 degrees. This rounded shape is a normal kyphosis, a "C" curve, with the opening of the C in the front. If this curve is more than 40 to 45 degrees, it is considered abnormal or a spinal deformity. Sometimes this deformity is described as "round back posture" or "hunchback."

With Scheuermann's kyphosis, the thoracic curve is usually 45 to 75 degrees. There will also be vertebral wedging greater than five degrees in three or more vertebrae in a row. The affected vertebrae have a triangular appearance. They wedge forward, which reduces the space between them. The thoracic spine angles forward into more kyphosis.

With Scheuermann's kyphosis, there are typically other abnormalities in the affected vertebrae. Schmorl's nodes are areas where the disc (cushion) between each affected vertebra pushes through the bone surface at the bottom and the top (endplates) of the vertebra.

Ligaments are the structures that connect bones to bones, including vertebrae. Patients with Scheuermann's kyphosis commonly have thickening in the ligament that runs along the front of the spine (the anterior longitudinal ligament). Some spine specialists believe that the tightness of this ligament may be partly responsible for the spinal deformity. The thickened ligament may affect the growth of one or more vertebrae during childhood. This leads to more growth on the back of the vertebrae and less in the front, resulting in one or more wedged vertebrae.

Causes

The cause of Scheuermann's kyphosis has not been discovered, but there are many possible theories about its development. Scheuermann, a Danish radiologist, proposed that the problem started because cartilage of the spinal bone's ring died from a lack of blood supply. He suggested that this interrupted bone growth during development, leading to wedging of the affected vertebrae.

Most researchers think that some sort of damage to the growth area of the vertebrae starts the process. The abnormal growth produces wedging of the vertebrae, which eventually leads to problems of kyphosis. For instance, there may be a vertebral disorder during the rapid growth spurts of adolescence, which causes abnormal bone growth. Many spine specialists also suspect that a problem with the mechanics of the spine (the way it is put together and functions) plays a part in Scheuermann's kyphosis. Others suggest mild osteoporosis could contribute to the deformity. Muscle abnormalities have also been considered as a possible cause. And there does seem to be a high genetic predisposition to this disease (runs in families).

Scheuermann originally noticed this spinal deformity in agriculture workers who were frequently hunched or bent over. This of course led to the question of whether poor posture could lead to extra kyphosis. While this is a logical question, the connection between posture and this deformity has never been confirmed. However, poor posture has been shown to play a role in making the problem worse. Therefore, correcting postural problems can sometimes help improve the abnormal kyphosis.

Symptoms

Symptoms of Scheuermann's kyphosis generally develop around puberty, between the ages of 10 and 15. It's hard to determine when the problem begins because X-rays don't show the changes until the child turns 10 or 11. The disease is often discovered when parents notice the onset of poor posture, or slouching, in their child. The adolescent might experience pain and fatigue in the mid back. The pain is rarely disabling or severe at this point, unless the deformity is severe.

The extra kyphosis is generally slow to develop. When it progresses to the point the rounded curve becomes noticeable, a concerned parent or teacher will suggest a doctor visit. This is what leads most children to get medical help-not the presence of pain. By comparison, adults who developed Scheuermann's early in life tend to seek help because pain from the deformity becomes unbearable.

A rigid curve in the spine is common with Scheuermann's kyphosis. The curve gets worse with bending over and only partially corrects when standing up straight. Pain typically increases with time and severity of the deformity. Some patients with Scheuermann's kyphosis also have scoliosis-about one third. Scoliosis is another type of spinal deformity that usually occurs in teenagers. Looking at an X-ray from the front, scoliosis curves side to side, like an "S" rather than a straight line. Learn more about adolescent idiopathic scoliosis.

People who have Scheuermann's kyphosis usually don't have nerve problems from the spinal deformity. However, a severely rounded spine can squeeze the contents of the chest and abdomen. The disorder may eventually put pressure on the heart, lungs, and abdomen. This can mean chest pain, shortness of breath, and a loss of appetite.

Diagnosis

History and Physical Exam

When you visit the doctor, you will initially be asked for a history of your condition. After taking a history, the physician will give you a physical exam. This helps the doctor to rule out possible causes of kyphosis, including Scheuermann's kyphosis, and to try to determine what is causing the spinal deformity.

Diagnostic Tests

An X-ray of the spine will probably be taken. The extra kyphosis will show up on the X-ray and can be measured in degrees. If the problem is simply due to postural problems, nothing else abnormal will show up on the X-ray. But if the kyphosis is due to Scheuermann's disease, the X-ray will show three or more adjacent vertebra that are wedged together at least five degrees each. In addition, the X-ray will show if there are Schmorl's nodes (the small herniations of disc through the endplates of the vertebrae).

Arthritis may show up on X-rays in adults with extra thoracic kyphosis. These changes generally coincide with an increase in pain.

Treatment Options

Treatment of Scheuermann's kyphosis is somewhat controversial. It depends on many things such as your age, the severity of the curve, and the flexibility of the curve.

Conservative Treatment

Bracing

If possible, the deformity will be treated without surgery. One option is bracing. The goal of bracing is to try to "guide" the growth of the vertebrae in order to straighten the spine. The brace will only successfully straighten the spine in patients who are still growing. The brace is designed to hold the spine in a straighter, upright posture. This is thought to work by taking pressure off the front half of the vertebra, allowing the growth of the bone in the front to catch up with the growth in the back. A brace may be used in older patients to support the spine and relieve pain, but it will not improve the curve.

There are many braces are available that keep the shoulders pulled back and the chin upright. Braces are usually effective in adolescents with curves of less than 75 degrees. Learn more about braces used to treat back problems.

If young patients are consistent in wearing the brace, worsening of the curve can be limited and there may be correction of the deformity within two years. The brace allows remodeling and corrected growth of the developing spine. The brace is usually worn from 16 to 24 hours each day for one year, then just at night for two years.

Physical Therapy

The doctor may prescribe physical therapy. A well-rounded rehabilitation program assists in calming pain and inflammation, improving mobility and strength, and making daily activities easier. People who are prescribed a brace tend to benefit even more when physical therapy is included.

Exercise has not proven helpful for changing the kyphotic curve in the mid back. However, it can be helpful when combined with bracing. Treatments address flexibility of the low back and hamstring muscles, back strength and posture, and ways to exercise at home. Patients may require rechecks with the physical therapist once or twice each year during periods of growth.

The goals of physical therapy are to help

learn correct posture and body movements to counteract the effects of kyphosis
maximize range of motion and strength
foster aerobic fitness
learn ways to manage your condition

Learn more about spinal rehabilitation.

Surgical Treatment

Surgery is usually only recommended if X-rays show a kyphosis over 75 degrees. A curve less than 75 degrees is usually treated with observation or a brace. Surgery is occasionally performed for cosmetic reasons. Because the surgery is serious and involves the spine, it generally is not recommended just to improve appearance.

Fusion surgery is mainly used to correct Scheuermann's kyphosis. The operation has two parts. One operation is done on the front of the spine (anterior), and another one is done on the back (posterior). These two surgeries used to be done about one week apart. Now many doctors are doing both operations on the same day.

The anterior operation is usually done to "release" tight ligaments along the front of the spine. Cutting these ligaments and removing the discs between the vertebrae increases flexibility in the spine. This allows the spine to be straightened easier when rods are put in from the back of the spine. Next, the surgeon begins the posterior procedure by working from the back of the spine. This is where the actual correction of the spinal curve happens. Rods are attached along the spine to align the spine and hold the spine in its corrected position.

Because most surgeries to correct kyphosis involve a rigid spine, both anterior and posterior procedures are generally needed. There are some cases of kyphosis, however, that can be corrected by the posterior procedure alone. In fact, some surgeons are performing posterior-only surgery for Scheuermann's kyphosis regardless of the size of the curve.

For the posterior-only approach, pedicle screws are used at each spinal level to be fused. Rods are connected to the screws, allowing a large amount of correction to occur. When this approach is chosen, the anterior procedure is not used. For some patients, the posterior procedure alone can realign the spine.

The doctor will advise which type of surgery is best. The surgical approach used will depend upon the age of the patient, the flexibility of the spine, the location and degree of the curve, and whether there is pressure on any of the nerve roots.

 

In order to understand your symptoms and treatment choices, it helps to begin with a basic understanding of spinal anatomy. This includes becoming familiar with the various parts that make up the spine and how they work together. Learn more about the anatomy of the spine.

A scoliosis curve can occur in the thoracic spine, the lumbar spine, or both areas at the same time. When the vertebrae in the mid and low back curve to the side, the normal appearance and condition of the spine and its muscles changes. The severity of the scoliosis is measured in degrees by comparing the curves to "normal" angles. Curves can range in size from as little as 10 degrees to severe cases of more than 100 degrees. The amount of curve in the spine helps your doctor decide what treatment to suggest. Conservative (nonsurgical) treatment is usually suggested for curves of less than 40 degrees, while curves over this amount may require surgery.

 

Causes

Scoliosis is divided into categories based on the age the condition is diagnosed:

  • infantile is diagnosed before age three
  • juvenile is diagnosed from age three to puberty
  • adolescent is diagnosed during puberty, usually between the ages of 10 and 15
  • adult is diagnosed in adulthood after the spine has stopped growing

Scoliosis is most commonly seen in adolescents and adults. Adults can also develop scoliosis as a result of degeneration.

Adolescent Idiopathic Scoliosis

Most cases of scoliosis are first discovered and treated in childhood or adolescence-particularly during puberty when the curvature becomes more noticeable. When an adolescent has scoliosis with no known cause, doctors call the condition adolescent idiopathic scoliosis. This form of scoliosis can affect a child who is healthy and not having nerve, muscle, or other spine problems. It is the most common form of spinal deformity doctors see, affecting about three percent of the general population.

Adult Scoliosis

Scoliosis that occurs (or is discovered) after puberty is called "adult scoliosis." Adult scoliosis can be the result of untreated or unrecognized childhood scoliosis, or it can arise during adulthood. The causes of adult scoliosis are usually different from the childhood types.

Degenerative Scoliosis

Degenerative adult scoliosis occurs when the combination of age and deterioration of the spine leads to the development of a scoliosis curve in the spine. Degenerative scoliosis usually starts after the age of 40. In older patients, particularly women, it is also often related to osteoporosis. The osteoporosis weakens the bone, making it more likely to deteriorate. The combination of these changes causes the spine to lose its ability to maintain a normal shape. The spine begins to "sag" and as the condition progresses, a scoliotic curve can slowly develop.

Diagnosis

If scoliosis is suspected, a diagnosis must be made before an appropriate treatment plan can be developed.

Complete History

In order to make a proper diagnosis and rule out other possible conditions, the first step is to take a history. Your doctor will want to know about the following:

  • Family History - Scoliosis tends to run in families, so it may have a genetic cause. Your doctor will want to know if anyone else in your family has the problem.
  • Date of Onset - When did you first notice the appearance of your spinal condition?
  • Measured Curve Progression - If X-rays have been taken of your spine in the past, the doctor will want to see if the curve is getting worse. The condition can be measured by comparing new X-rays with old ones, measuring the size of the rib hump, or measuring changes in your height.
  • Presence or Absence of Pain - Not all cases of scoliosis produce pain. If there is pain, your doctor needs to know where it is, what brings it on or intensifies it, and if there is any radicular pain (pain that radiates away from the spine).
  • Bowel or Bladder Dysfunction - Are you having problems knowing when you have to urinate or have a bowel movement? This is extremely important because it could signal the presence of pressure on the spinal cord or the nerves that go to the pelvis.
  • Motor Function - Has there been a change in how your muscles work? This may be the result of pressure on the nerves or the spinal cord.
  • Previous Surgery - If you have had any surgery on your spine, it may have caused some degenerative scoliosis due to weakened bones or muscles. In order to evaluate your condition properly, it is important that your doctor knows about any previous spinal surgeries.

Physical Exam

You will then be given a physical exam. Your doctor will want to get an understanding of the curve in your back and how it is affecting you. This means first trying to get a "mental picture" of how the spine is curved from examining your back and watching you move. The doctor will look at the flexibility you have by asking you to bend in certain directions.

  • Curve Assessment - This is an observation of the three-dimensional characteristics of the spine. During your physical exam, your doctor will have you bend forward to make the curve evident.
  • Rib Hump - When bending forward, the ribs form a "hump" on the side where the spine is bent. This hump is formed by the altered angle of the ribs where they connect to the curved spine.
  • Flexibility of the Spine - Checks are done to see if the deformity is fixed in place (rigid) or if the curve changes with your position (flexible). Neurological Exam - Your doctor will check your nerves by testing sensation, reflexes, and muscle strength.

Diagnostic Tests

Usually after the exam, X-rays will be ordered that allow your doctor to see the structure of the spine and measure the curve. You will be asked to hold very still in certain positions. The following images may be taken:

  • Front or back view of the entire spine taken from the front or back
  • Lateral view of the entire spine taken from the side

Doctors use the Cobb technique to measure curves in the spine. Lines are drawn on the X-ray to form an angle. The doctor measures the angle formed by the line and assigns the number of degrees to the size of the curve.

Depending on the outcome of your history, physical examination, and initial X-rays, other tests may be ordered to look at specific aspects of the spine. The most common tests that are ordered are: an MRI to look at the nerves and spinal cord; a CT scan to get a better picture of the vertebral bones; and special nerve tests to determine if any nerves are being irritated or pinched.

Learn more about common types of scoliosis.

  • Adolescent Idiopathic Scoliosis
  • Adult Scoliosis
  • Degenerative Adult Scoliosis
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