Normally, the spine displays some convexity, but excessive thoracic kyphosis is pathologic. Kyphosis occurs in children and adults.
Causes
Congenital kyphosis is rare but usually severe, with resultant cosmetic deformity and reduced pulmonary function.
Adolescent kyphosis
Also called Scheuermann’s disease, juvenile kyphosis, and vertebral epiphysitis, adolescent kyphosis is the most common form of this disorder. It may result from growth retardation or a vascular disturbance in the vertebral epiphysis (usually at the thoracic level) during periods of rapid growth or from congenital deficiency in the thickness of the vertebral plates.
Adolescent kyphosis
Also called Scheuermann’s disease, juvenile kyphosis, and vertebral epiphysitis, adolescent kyphosis is the most common form of this disorder. It may result from growth retardation or a vascular disturbance in the vertebral epiphysis (usually at the thoracic level) during periods of rapid growth or from congenital deficiency in the thickness of the vertebral plates.
Other causes include infection, inflammation, aseptic necrosis, and disk degeneration. The subsequent stress of weight bearing on the compromised vertebrae may result in the thoracic hump commonly seen in adolescents with kyphosis. Symptomatic adolescent kyphosis is more prevalent in girls than in boys and usually occurs between ages 12 and 16.
Adult kyphosis
Also known as adult roundback, adult kyphosis may result from degeneration of intervertebral disks, atrophy, or osteoporotic collapse of the vertebrae that’s associated with aging; from an endocrine disorder, such as hyperparathyroidism or Cushing’s disease; or from prolonged steroid therapy.
Adult kyphosis may also result from conditions such as arthritis, Paget’s disease, polio, compression fracture of the thoracic vertebrae, metastatic tumor, plasma cell myeloma, or tuberculosis.
In children and adults, kyphosis may also result from poor posture.
Adult kyphosis
Also known as adult roundback, adult kyphosis may result from degeneration of intervertebral disks, atrophy, or osteoporotic collapse of the vertebrae that’s associated with aging; from an endocrine disorder, such as hyperparathyroidism or Cushing’s disease; or from prolonged steroid therapy.
Adult kyphosis may also result from conditions such as arthritis, Paget’s disease, polio, compression fracture of the thoracic vertebrae, metastatic tumor, plasma cell myeloma, or tuberculosis.
In children and adults, kyphosis may also result from poor posture.
Disk lesions called Schmorl’s nodes may develop in anteroposterior curving of the spine and are localized protrusions of nuclear material through the cartilage plates and into the spongy bone of the vertebral bodies. If the anterior portions of the cartilage are destroyed, bridges of new bone may transverse the intervertebral space, causing ankylosis.
Signs and symptoms
Signs and symptoms vary with the type of kyphosis.
Adolescent features
Development of adolescent kyphosis is usually insidious, typically occurring after a history of excessive sports activity, and may be asymptomatic except for the obvious curving of the back (sometimes more than 90 degrees). In some adolescents, kyphosis may produce mild pain at the apex of the curve (about 50% of patients), fatigue, tenderness or stiffness in the involved area or along the entire spine, and prominent vertebral spinous processes at the lower dorsal and upper lumbar levels, with compensatory increased lumbar lordosis and hamstring tightness.
In rare cases, kyphosis may induce neurologic damage: spastic paraparesis secondary to spinal cord compression or herniated nucleus pulposus. In adolescent and adult kyphosis not due to poor posture alone, the spine won’t straighten out when the patient assumes a recumbent position
Adult features
Adult kyphosis produces a characteristic roundback appearance and may be associated with pain, weakness of the back, or generalized fatigue. Unlike the adolescent form, adult kyphosis rarely produces local tenderness, except in patients with senile osteoporosis who have recently had a compression fracture.
Diagnosis
Physical examination reveals curvature of the thoracic spine with varying degrees of severity. X-rays may show vertebral wedging, Schmorl’s nodes, irregular end plates and, possibly, mild scoliosis of 10 to 20 degrees.
Adolescent kyphosis must be distinguished from tuberculosis and other inflammatory or neoplastic diseases that cause vertebral collapse; the severe pain, bone destruction, or systemic symptoms associated with these diseases help to rule out a diagnosis of kyphosis. Other sites of bone disease, primary sites of cancer, and infection must also be evaluated, possibly by a vertebral biopsy.
Treatment
For kyphosis caused by poor posture alone, treatment may consist of therapeutic exercises, bed rest on a firm mattress (with or without traction), and a brace to straighten the kyphotic curve until spinal growth is complete.
Signs and symptoms
Signs and symptoms vary with the type of kyphosis.
Adolescent features
Development of adolescent kyphosis is usually insidious, typically occurring after a history of excessive sports activity, and may be asymptomatic except for the obvious curving of the back (sometimes more than 90 degrees). In some adolescents, kyphosis may produce mild pain at the apex of the curve (about 50% of patients), fatigue, tenderness or stiffness in the involved area or along the entire spine, and prominent vertebral spinous processes at the lower dorsal and upper lumbar levels, with compensatory increased lumbar lordosis and hamstring tightness.
In rare cases, kyphosis may induce neurologic damage: spastic paraparesis secondary to spinal cord compression or herniated nucleus pulposus. In adolescent and adult kyphosis not due to poor posture alone, the spine won’t straighten out when the patient assumes a recumbent position
Adult features
Adult kyphosis produces a characteristic roundback appearance and may be associated with pain, weakness of the back, or generalized fatigue. Unlike the adolescent form, adult kyphosis rarely produces local tenderness, except in patients with senile osteoporosis who have recently had a compression fracture.
Diagnosis
Physical examination reveals curvature of the thoracic spine with varying degrees of severity. X-rays may show vertebral wedging, Schmorl’s nodes, irregular end plates and, possibly, mild scoliosis of 10 to 20 degrees.
Adolescent kyphosis must be distinguished from tuberculosis and other inflammatory or neoplastic diseases that cause vertebral collapse; the severe pain, bone destruction, or systemic symptoms associated with these diseases help to rule out a diagnosis of kyphosis. Other sites of bone disease, primary sites of cancer, and infection must also be evaluated, possibly by a vertebral biopsy.
Treatment
For kyphosis caused by poor posture alone, treatment may consist of therapeutic exercises, bed rest on a firm mattress (with or without traction), and a brace to straighten the kyphotic curve until spinal growth is complete.
Corrective exercises include pelvic tilts to decrease lumbar lordosis, hamstring stretches to overcome muscle contractures, and thoracic hyperextensions to flatten the kyphotic curve. These exercises may be performed in or out of the brace.
Lateral X-rays taken every 4 months evaluate correction. Gradual weaning from the brace can begin after maximum correction of the kyphotic curve, vertebral wedging has decreased, and the spine has reached full skeletal maturity. Loss of correction indicates that weaning from the brace has been too rapid, and time out of the brace is decreased accordingly.
Treatment for adolescent and adult kyphosis also includes appropriate measures for the underlying cause and, possibly, spinal arthrodesis for relief of symptoms. Although rarely necessary, surgery may be recommended when kyphosis causes neurologic damage, a spinal curve greater than 60 degrees, or intractable and disabling back pain in a patient with full skeletal maturity. Preoperative measures may include halo-femoral traction.
Corrective surgery includes a posterior spinal fusion with spinal instrumentation, iliac bone grafting, and plaster immobilization. Anterior spinal fusion followed by immobilization in plaster may be necessary when kyphosis produces a spinal curve greater than 70 degrees.
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