Hi, today we saw a very interesting case in rheumatology course, he was a 15 years old boy who's suffering from kyphosis....
The disease has MANY names:
Adolescent kyphosis, adolescent round back, aseptic osteochondrosis, type Scheuermann, epiphyseal osteochondritis syndrome, juvenile dorsal kyphosis, juvenile kyphosis, kyphosis dorsalis adolescentium, kyphosis dorsalis juvenilis, kyphosis of adolescence, malum epiphyseonecrotium vertebrale, osteochondritis deformans dorsi, spinal epiphysitis, spinal osteochondrosis, vertebral osteochondritis, vertebral osteochondrosis
What is Scheuermann's disease or Scheuermann's kyphosis?
Scheuermann's Kyphosis means an increase in the normal kyphosis or the roundback that all of us have to some extent. Most people with Scheuermann's disease will have an increased roundback, but no other particular problem. Those folks who have a profound roundback or if the Scheuermann's Disease affects the lower thoracic or lumbar spine are more likely to have discomfort as they age.
Hyperkyphosis may be associated with increased pain in adult years. Growing patients who have an increased kyphosis are frequently treated with bracing which has been shown to have a good outcome in kyphosis, probably better than in scoliosis cases. For adults the treatment is observation, or anti-inflammatory drugs or reconstructive surgery depending on the severity of the symptoms. Exercises for spine extension and hamstring stretching are usually prescribed. However, exercises are unlikely to correct the deformity for an adult. Exercises used for flexible kyphosis are hyperextension isometric exercises and hamstring stretches. If the deformity and pain are severe enough, a few people are treated with surgery to reduce the kyphosis and fuse the spine.
The kyphosis from Scheuermann's syndrome is different from the kyphosis produced from osteoporotic compression fractures in older women, although the two groups can overlap.
The cause of Scheuermann's kyphosis is unknown, but is thought to be due to a growth abnormality of the vertebral body. Diagnostic criteria varies with different experts. Typically patients have a rigid hyperkyphosis with wedging of the apical vertebral segments.
Radiology:
Initial radiographs for kyphosis should include standing anteroposterior (AP) and lateral views of the spine—lower cervical to sacrum. Postural roundback rarely exceeds 60° while Scheuermann’s typically does. The interobserver error is slightly higher for kyphosis than for scoliosis, so the prudent orthopaedic surgeon will insist upon measuring radiographs personally rather than relying upon the radiology report. Radiographic examination should generally take place every 4-6 months in the growing child to look for evidence of curve progression. The radiographic confirmation of Scheuermann’s disease requires anterior vertebral wedging of > 5° in at least three contiguous vertebrae. Secondary radiographic findings include irregular apical vertebral end-plates, anterior narrowing of disc spaces, and subchondral lucencies (Schmorl’s nodes). Presence of these findings with kyphosis of > 50° warrants orthopaedic referral. These radiographic features are absent in postural roundback.
Scheuermann’s kyphosis usually exceeds 60°, and may be measured with the cobb angle as shown. Anterior vertebral wedging must be present in > 3 continuous vertebrae to substantiate the diagnosis.
MRI showing Shmorl's nodes (but not in Sheuermann's syndrom)
Treatment of Scheuermann’s
Indications for treatment include pain, progression of deformity, neuropathy, and (rarely) cosmesis. Methods of reducing pain include non-steroidal and non-narcotic analgesics as well as postural and flexibility exercises.
More severe kyphotic deformity may require brace treatment or surgical fusion.
Bracing
The Milwaukee brace, a CTLSO designed in 1945, has been the mainstay of treatment for Scheuermann’s of moderate severity. Plastic body jackets (TLSO’s) have been used more recently to enhance patient acceptance, but such braces are not useful for kyphosis with an apex cephalad to T7. Braces are helpful for Scheuermann’s measuring 50-74°, provided the patient still has significant growth remaining. Extension braces are usually recommended at least 20 hours per day until growth diminishes, with the goal of preventing significant curve progression. While unlikely in idiopathic scoliosis, brace treatment often results in some permanent reduction of spinal deformity in Scheuermann’s kyphosis.
Spinal Fusion
The indications for surgical treatment of Scheuermann’s are controversial. Still, some reasonable criteria for spine fusion may include pain, poor cosmesis, neuropathy, brace failure, or significant kyphosis exceeding 75°.
Contemporary surgical treatment of Scheuermann’s typically involves anterior or posterior spinal fusion, or both, with segmental instrumentation. Surgical treatment usually results in complete correction of deformity.
After surgery, patients typically do not require a brace, but strenuous activities must be curtailed for 9-12 months to avoid loosening of the rods. Failure of spine fusion (pseudarthrosis) and wound infection each occur with about 1% incidence. Routine hardware removal is not required, but rods can be removed if they become prominent, loose, or infected. To check for late complications, patients are usually followed with radiographs 1-2 times per year until skeletal maturity.
The disease has MANY names:
Adolescent kyphosis, adolescent round back, aseptic osteochondrosis, type Scheuermann, epiphyseal osteochondritis syndrome, juvenile dorsal kyphosis, juvenile kyphosis, kyphosis dorsalis adolescentium, kyphosis dorsalis juvenilis, kyphosis of adolescence, malum epiphyseonecrotium vertebrale, osteochondritis deformans dorsi, spinal epiphysitis, spinal osteochondrosis, vertebral osteochondritis, vertebral osteochondrosis
What is Scheuermann's disease or Scheuermann's kyphosis?
Scheuermann's Kyphosis means an increase in the normal kyphosis or the roundback that all of us have to some extent. Most people with Scheuermann's disease will have an increased roundback, but no other particular problem. Those folks who have a profound roundback or if the Scheuermann's Disease affects the lower thoracic or lumbar spine are more likely to have discomfort as they age.
Hyperkyphosis may be associated with increased pain in adult years. Growing patients who have an increased kyphosis are frequently treated with bracing which has been shown to have a good outcome in kyphosis, probably better than in scoliosis cases. For adults the treatment is observation, or anti-inflammatory drugs or reconstructive surgery depending on the severity of the symptoms. Exercises for spine extension and hamstring stretching are usually prescribed. However, exercises are unlikely to correct the deformity for an adult. Exercises used for flexible kyphosis are hyperextension isometric exercises and hamstring stretches. If the deformity and pain are severe enough, a few people are treated with surgery to reduce the kyphosis and fuse the spine.
The kyphosis from Scheuermann's syndrome is different from the kyphosis produced from osteoporotic compression fractures in older women, although the two groups can overlap.
The cause of Scheuermann's kyphosis is unknown, but is thought to be due to a growth abnormality of the vertebral body. Diagnostic criteria varies with different experts. Typically patients have a rigid hyperkyphosis with wedging of the apical vertebral segments.
Radiology:
Initial radiographs for kyphosis should include standing anteroposterior (AP) and lateral views of the spine—lower cervical to sacrum. Postural roundback rarely exceeds 60° while Scheuermann’s typically does. The interobserver error is slightly higher for kyphosis than for scoliosis, so the prudent orthopaedic surgeon will insist upon measuring radiographs personally rather than relying upon the radiology report. Radiographic examination should generally take place every 4-6 months in the growing child to look for evidence of curve progression. The radiographic confirmation of Scheuermann’s disease requires anterior vertebral wedging of > 5° in at least three contiguous vertebrae. Secondary radiographic findings include irregular apical vertebral end-plates, anterior narrowing of disc spaces, and subchondral lucencies (Schmorl’s nodes). Presence of these findings with kyphosis of > 50° warrants orthopaedic referral. These radiographic features are absent in postural roundback.
Scheuermann’s kyphosis usually exceeds 60°, and may be measured with the cobb angle as shown. Anterior vertebral wedging must be present in > 3 continuous vertebrae to substantiate the diagnosis.
MRI showing Shmorl's nodes (but not in Sheuermann's syndrom)
Treatment of Scheuermann’s
Indications for treatment include pain, progression of deformity, neuropathy, and (rarely) cosmesis. Methods of reducing pain include non-steroidal and non-narcotic analgesics as well as postural and flexibility exercises.
More severe kyphotic deformity may require brace treatment or surgical fusion.
Bracing
The Milwaukee brace, a CTLSO designed in 1945, has been the mainstay of treatment for Scheuermann’s of moderate severity. Plastic body jackets (TLSO’s) have been used more recently to enhance patient acceptance, but such braces are not useful for kyphosis with an apex cephalad to T7. Braces are helpful for Scheuermann’s measuring 50-74°, provided the patient still has significant growth remaining. Extension braces are usually recommended at least 20 hours per day until growth diminishes, with the goal of preventing significant curve progression. While unlikely in idiopathic scoliosis, brace treatment often results in some permanent reduction of spinal deformity in Scheuermann’s kyphosis.
Spinal Fusion
The indications for surgical treatment of Scheuermann’s are controversial. Still, some reasonable criteria for spine fusion may include pain, poor cosmesis, neuropathy, brace failure, or significant kyphosis exceeding 75°.
Contemporary surgical treatment of Scheuermann’s typically involves anterior or posterior spinal fusion, or both, with segmental instrumentation. Surgical treatment usually results in complete correction of deformity.
After surgery, patients typically do not require a brace, but strenuous activities must be curtailed for 9-12 months to avoid loosening of the rods. Failure of spine fusion (pseudarthrosis) and wound infection each occur with about 1% incidence. Routine hardware removal is not required, but rods can be removed if they become prominent, loose, or infected. To check for late complications, patients are usually followed with radiographs 1-2 times per year until skeletal maturity.
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