Kyphosis

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:

• aging and associated degeneration of intervertebral disks, atrophy, and osteoporotic collapse of the vertebrae
• endocrine disorders, such as hyperparathyroidism and Cushing's disease
• prolonged steroid therapy
• other conditions, such as arthritis, Paget's disease, polio, compression fracture of the thoracic vertebrae, metastatic tumor, plasma cell myeloma, or tuberculosis.

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 Kyphosis

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.

Diagnosis information

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.

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Complications

• Disabling back pain
• Neurological symptoms including leg weakness or paralysis
• Decreased lung capacity
• Round back deformity

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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:

• Teach the patient with adolescent kyphosis caused by poor posture alone the prescribed therapeutic exercises and the fundamentals of good posture. Suggest bed rest when pain is severe. Encourage use of a firm mattress, preferably with a bed board. If the patient needs a brace, explain its purpose and teach her how and when to wear it.
• Teach good skin care. Tell the patient not to use lotions, ointments, or powders where the brace contacts the skin. Warn her that only the physician or orthotist should adjust the brace.
• If corrective surgery is needed. explain all preoperative tests thoroughly as well as the need for postoperative traction or casting. if applicable. After surgery. check neurovascular status every 2 to 4 hours for the first 48 hours. and report any changes immediately. Turn the patient often by logrolling and teach the patient how to logroll herself.
• Offer pain medication every 3 or 4 hours for the first 48 hours. Institute blood product replacement, if ordered, Accurately measure fluid intake and output. including urine specific gravity. Insert a nasogastric tube and an indwelling urinary catheter, if ordered; a rectal tube may also be necessary if paralytic ileus causes abdominal distention.
• Provide meticulous skin care. Check the skin at the cast edges several times per day; use heel and elbow protectors, to prevent skin breakdown. Remove antiembolism stockings. if ordered. at least three times per day for at least 30 minutes.
• Provide emotional support. The adolescent patient is likely to exhibit mood changes and periods of depression. Maintain communication. and offer frequent encouragement and reassurance.
• Assist during removal of sutures and application of a new cast (usually about 10 days after surgery). Encourage gradual ambulation (usually with the use of a tilt table in the physical therapy department).
• At discharge. provide detailed. written cast care instructions. Tell the patient to immediately report pain. burning. skin breakdown. loss of feeling. tingling, numbness, or cast odor. Advise her to drink plenty of liquids to avoid constipation, and to report any illness (especially abdominal pain or vomiting) immediately. Arrange for home visits by a social worker and a home care nurse.