Alternative names :- Scheuermann's disease; Roundback; Hunchback; Postural kyphosis
The upper back or thoracic region is normally curved forward. If the curve exceeds 50 degrees, it's considered kyphotic. Kyphosis, also called round back or hunchback, is an exaggerated anteroposterior curving of the spine that causes a bowing of the back, commonly at the thoracic but sometimes at the thoracolumbar or sacral level. Kyphosis occurs in children and adults. Symptomatic adolescent kyphosis is more prevalent in girls than in boys and typically occurs between ages 12 and 16. It can worsen during adolescence or can result from compression of vertebrae that occurs with aging, particularly in women with osteoporosis.
What causes Kyphosis?
Congenital kyphosis is rare but usually severe, with resultant cosmetic deformity and reduced pulmonary function. Adolescent kyphosis (Scheuermann's disease, juvenile kyphosis, vertebral epiphysitis), the most common form of this disorder, 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, injuries (such as a car crash) 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.
Adult kyphosis (adult roundback) may result from:
In addition, kyphosis may also occur in children and adults with poor posture. Disk lesions called Schmorl's nodes may develop in anteroposterior curving of the spine and are localized protrusions of nuclear material that extend through the cartilage plates and into the spongy bone of the vertebral bodies. If the anterior portions of the cartilage are destroyed, they're replaced by fibrocartilage, which then ossifies, causing ankylosis.
Signs and symptoms of KyphosisDevelopment of adolescent kyphosis is usually insidious, commonly 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. Rarely, kyphosis may cause neurologic damage, such as spastic paraparesis secondary to spinal cord compression and herniated nucleus pulposus. In adolescent and adult forms of kyphosis that aren't due to poor posture alone, the spine won't straighten when the patient assumes a recumbent position.
Adult kyphosis produces a characteristic roundback appearance, possibly associated with pain, weakness of the back, and generalized fatigue. Unlike 'the adolescent form, adult kyphosis rarely produces local tenderness, except in osteoporosis with a recent compression fracture.
Physical examination reveals curvature of the thoracic spine in varying degrees of severity. X-rays of the spine can confirm diagnosis and identify its underlying cause by showing 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 rule out a diagnosis of kyphosis. Other sites of bone disease, primary sites of malignancy, and infection must be evaluated, possibly through vertebral biopsy. Magnetic resonance imaging or computed tomography scan can also assess lumbar anatomy.
Treatment of Kyphosis
Congenital defects usually have to be repaired surgically. The procedures are complicated and lengthy. Typically, hardware is surgically placed to stabilize the back bone.
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. A brace, however, is a treatment modality reserved only for adolescents. Corrective exercises include pelvic tilt to decrease lumbar lordosis, hamstring stretch to overcome muscle contractures, and thoracic hyperextension 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, after vertebral wedging has decreased, and after 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 both 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 inunobilization in plaster may be necessary when kyphosis produces a spinal curve greater than 70 degrees. Kyphosis caused by osteoporosis isn't treated except to prevent further bone softening.
Special considerations and Prevention
Effective management of kyphosis necessitates first-rate supportive care for patients in traction or a brace, skillful patient teaching, and sensitive emotional support:
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