In this article, surgeons from the Combined Orthopaedics Residency Program at Harvard Medical School put together a review of the evaluation and management of Scheuermann’s kyphosis for adults. They included discussion of who is affected, cause of the disease, pathogenesis (what happens with this condition), and clinical presentation (signs and symptoms).
They also bring us up to date on what is known about the natural history of this condition (i.e., what happens over time). Both nonsurgical and surgical care are presented along with complications of surgical treatment. Before and after X-rays to show results are presented for half a dozen patients.
Scheuermann’s disease (also called Scheuermann’s kyphosis) is named after the physician who first described the condition. It is an excess of thoracic kyphosis (when viewed from the side, this is a C-shaped curvature of the mid-back). The section of spine from below the neck to the bottom of the rib cage is called the thoracic spine.
From the side, the thoracic spine appears slightly rounded. Its shape is like the letter “C” with the opening facing the front of the body. This normal curve is called kyphosis. With excessive kyphosis, the thoracic spine takes on a hunchbacked appearance. With Scheuermann’s kyphosis, there is wedging of five-degrees or more affecting at least three consecutive vertebrae. The structural changes that form this type of hyper-kyphosis are seen on X-rays.
The condition starts in childhood and affects boys slightly more often than girls. Some reports say that less than one percent of the U.S. population is affected. But there are other reports of an incidence up to 8.3 per cent. The disease occurs mostly in children between the ages of 10 and 12. But there are some cases in which Scheuermann’s develops in the adult years.
What causes this type of wedging deformity? During normal growth, the cartilage around the vertebral body turns evenly and completely to bone. If the change from cartilage to bone doesn’t happen evenly, one side of the vertebral body grows at a faster rate. By the time the entire vertebral body turns to bone, one side is taller than the other. This is the wedge shape that leads to abnormal kyphosis.
Dr. Scheuermann thought a lack of blood to the cartilage around the vertebral body caused the wedging. Though scientists have since disproved this theory, the root cause of the disease is still unknown. Current theories include osteoporosis as a cause, mechanical factors (abnormal biomechanical stresses on the bones), and/or tight hamstring muscles (along the back of the thigh). Above-average disc height, increased levels of growth hormone, and genetics have also been suggested as possible contributing factors/causes.
Besides having a forward curved spine, most people affected by Scheuermann’s report back pain, stiffness, and loss of flexibility. The neck and low back try to compensate by increasing the natural lordotic curves in these two areas. Since the person cannot straighten the thoracic spine, the cervical and lumbar spines increase their curves to compensate for the round back. All of these changes in posture are usually accompanied by tight shoulder, hip, and leg muscles.
What is the natural history of Scheuermann’s? Studies over three decades (30 years) reveal varying results. Some studies have shown that adults with Scheuermann’s are just as well-educated as those of similar age who don’t have this condition. Although adults with Scheuermann’s kyphosis have less demanding jobs compared with the age-matched control group, the Scheuermann’s group do not miss work or use more pain medication than the control group.
Degenerative spondylosis is also reported as part of the natural history in middle-aged adults with Scheuermann’s kyphosis. Degenerative changes in the spine (usually from aging) can cause bone spurs to form around the spinal joints. The joint spaces start to narrow. This condition is called spondylosis.
There is an increased awareness of physical appearance among those adults with Scheuermann’s. Those who do not get proper treatment for the condition during childhood often experience severe back pain from the spinal deformity as adults.
Treatment for the adult with Scheuermann’s kyphosis ranges from conservative care with antiinflammatory medications and physical therapy to surgery to either keep the deformity from getting worse or possibly improve or correct the curvature. Physical therapy is a key part of the nonsurgical management of adult kyphosis.
Exercises to improve strength and posture won’t straighten the spine but will improve general conditioning and help reduce pain. Core training is an important part of the exercise management program. Some adults try using a brace but most do not like the brace because it is too confining and uncomfortable. Bracing is most likely to be recommended to or tried by adults who are not good candidates for surgery.
Surgery is primarily focused on providing patients with pain relief. This applies most often to those patients who have tried nonsurgical treatment without a change in their painful symptoms. In some cases, appearance is the main reason surgery is done. Spinal fusion is the most common surgical technique used for this condition. The authors present a detailed discussion of surgical approaches, techniques used, and fixation devices used (hardware such as screws, rods, metal plates).a
Like any spinal surgery, there are risks involved. Blood loss, infection, spinal cord or nerve damage, and failed back surgery (pain and loss of fusion) are the biggest potential post-operative complications patients face. Loss of correction is an additional concern for the adult group treated surgically. Second surgeries may be required for adults with these complications.
All-in-all, the authors say that improvements in surgical technique have helped reduce such problems. Better results with fewer problems, less blood loss, and lower costs (due to shorter surgical times) are reported.