Scheuermann’s Kyphosis (Osteochondrosis)
Scheuermann's Kyphosis: Definition
Scheuermann's Kyphosis, or Scheuermann's disease, is a form of juvenile Osteochondrosis of the spine, characterized by an extreme rounding of the spine in the thoracic or upper part of the back (called Kyphosis). Most people who have Scheuermann's Kyphosis do not have pain associated with their condition.
In Scheuermann's Kyphosis, the end plates of the vertebrae and the disc space undergo changes during development that lead to the distortion of the thoracic portion of the spine.
Scheuermann's Kyphosis has also been used to describe changes that can happen in the lower spine that causes pain to occur in the low back, but that condition is known as Juvenile Disc Disorder. It is, at times, confused with Scheuermann's Kyphosis, being referred to as Lumbar Scheuermann's disease. In an attempt to avoid misunderstanding, the correct terminology has been changed. The two conditions are now referred to as:
- Scheuermann's Disease or Scheuermann's Kyphosis: the condition of adolescent Kyphosis
- Juvenile Disc Disorder or Juvenile Discogenic Disorder: the condition of Adolescent Degenerative Disc Disease
Additional reading: "33 Vertebrae or I love my Osteochondrosis"
Prevalence
Scheuermann's Kyphosis occurs more frequently in boys and usually is diagnosed in early to mid-adolescence. It occurs in approximately 4-8% of the population.
Patients with Scheuermann's Disease, for the most part, are diagnosed around 13-16 years of age. Patients are commonly also are taller than peers, and have progressed skeletal frames versus their chronologic age. Some children have disproportionated limb lengths.
Studies have shown that between 20 to 30% of patients with Scheuermann's Disease also have Scoliosis. In more serious cases, the mix is more frequently known as Kyphoscoliosis.
Reasons
Scheuermann, the man credited with discovering this Kyphotic disorder, believed it was caused by insufficient blood flow to the cartilage surrounding the vertebral body, and he thought this was responsible for the wedging of the vertebrae. This theory has been disproved, but it is still unknown what lies at the root of the disorder.
There is evidence to suggest that the wedging comes about as a result of problems that occur during growth and development. When the body grows, normal processes occur that change cartilage completely into bone tissue. If cartilage doesn't totally transform into bone, or if it occurs unevenly, one portion of the vertebra may develop more quickly. When the entire bone has developed, one side of the vertebra is taller. This accounts for the wedge-shaped vertebrae that are present in abnormal Kyphotic conditions. There are other ideas that try to explain how Scheuermann's Kyphosis begins. These theories include childhood Osteoporosis, genetic factors, and mechanical reasons.
Genetics
Studies have suggested the possibility that Scheuermann's Kyphosis is a disease condition that is inherited. Research has shown many families that have passed the condition through specific types of genes. The genetic link is not common but is still being investigated.
Childhood Osteoporosis
One medical research study showed the presence of mild Osteoporosis in some people who had Scheuermann's Kyphosis, even though the patients were not very old. Other research did not reach the same conclusion. More studies are needed to find out whether or not Osteoporosis plays a role in the development of this disease.
Mechanical Reasons
Mechanical factors include strains caused by poor posture, heavy lifting, and bending. This theory seems likely as the use of back braces to treat the condition have been successful. If a brace can work to straighten a kyphotic back, then it would seem reasonable to expect mechanical forces could also cause increased deformities that naturally occur in the spine. Some spine experts believe that tension in the hamstring muscles contributes to spinal deformity by pulling on the pelvis.
Researchers are not sure that the disease is caused by mechanical stress, but rather that mechanical factors worsen the condition after it already exists. In many cases, it is difficult to determine which occurred first: the deformity which resulted in mechanical changes taking place, or the mechanical changes that resulted in anatomical deformity.
Other Reasons
Other theories discussed to help explain the cause of Scheuermann's Kyphosis include changes in collagen due to biochemical factors affecting bone growth, an increased level of growth hormone and an alteration in disc height.
Complications
Complications of Scheuermann's Disease are optional conditions, symptoms, or different issues that are caused by Scheuermann's Disease. Most of the time, the qualification between symptoms of Scheuermann's Disease and complications of Scheuermann's Disease is unclear and unpredictable.
Complications are uncommon, however, it can incorporate disease, loss of rectification, spinal cord damage or other neurological issues. In few cases, another surgical method might be required.
Some of the possible complications of Scheuermann's Disease or Scheuermann's Kyphosis are:
- Recurring serious back pain
- Deformity
- Neurological issues
- Cardiopulmonary diseases
Scheuermann's Kyphosis: Symptoms
A rounded back or hunched over posture is usually one of the Scheuermann's Kyphosis symptoms in young children that alert their parents or their teachers of their need to be evaluated by a physician. Young children do not usually have pain or other Scheuermann's Kyphosis symptoms.
In older children and adolescents who are approaching puberty and have curvature in the lower part of their thoracic spine, pain is often one of the primary Scheuermann's Kyphosis symptoms. This occurs most frequently in young males who are active. Physicians think this unique type of the disease may occur because the condition is not noticed during childhood, and so treatment is delayed.
When adults live with an abnormal, hunched spine for several years, they may experience worsening discomfort and pain. The pain is most often what prompts them to seek medical attention. They may also be distressed by the physical deformity that eventually develops. The pain or the physical deformity is usually what causes adults to seek medical care.
In addition to having the abnormal curvature, most patients with Scheuermann's Kyphosis symptoms experience back stiffness, loss of flexibility and pain. The lower back and the neck attempt to compensate for the thoracic spine by increasing the natural curves in these areas. Since the patient cannot straighten the thoracic curve, the lumbar and cervical spines increase their curvatures to try to accommodate for the rounded back. All of these abnormal changes in the posture are usually accompanied by tight muscles in the legs, shoulders, and hips.
Degenerative Spondylosis is also likely to occur as part of the history in middle-aged patients with Scheuermann's Kyphosis symptoms. Degenerative changes in the spine due to aging can cause the formation of bone spurs around the joints of the spine. The spinal column begins to narrow in a condition known as Spondylosis which further contributes to the stiffness and pain.
People of all ages who have pain due to abnormal Scheuermann's Kyphosis symptoms typically report their pain is located slightly beneath the abnormal curve, along with the sides of the vertebrae.
Scheuermann's Kyphosis symptoms can cause increased lordosis, which is a curving inward of the lower back. This puts additional stress on the lumbar spine. Over time, this added strain may cause lower back pain. This typically occurs in adults who have additional lumbar lordosis following years of untreated exaggerated Kyphosis.
Rarely, the spinal cord can be affected. Extreme Kyphosis can stretch the spinal cord over the top portion of the curve, injuring it. In addition, patients with Scheuermann's Kyphosis symptoms have an increased risk of developing a herniated disc in the thoracic area. This is a condition in which the material from inside the intervertebral disc leaks out and compresses the spinal cord or its nerves. Spinal cord symptoms include numbness or feelings of pins and needles. Leg muscles may feel weak. Severe symptoms may include changes in bladder and bowel function.
Diagnostic procedures
History
When you go to the doctor, the more information you are able to provide, the easier your problem will be to diagnose. Many times, patients are asked to fill out a form that asks questions about their medical problems.
The history of your Kyphosis is important to your doctor because it helps to understand when the problem began and how it has progressed. The doctor will ask if you have pain if you have been injured, questions about your lifestyle and any family history of Kyphosis. The doctor may also ask questions about other medical conditions you have that are unrelated to your spine.
Physical Examination
The doctor will perform a physical examination after obtaining your medical history. This examination will help the physician rule out other possible causes of your condition.
- X-rays: Spinal curvatures are visible and can be measured on x-rays. If the curvature is due to a problem with the posture, no other abnormalities are likely to be revealed on an x-ray. If your Kyphosis is due to Scheuermann's Disease, at least three vertebrae in a row will be wedged together, and the X-ray will also be able to show if there are small herniations on the ends of the vertebrae, known as Schmorl's nodes. If you are older, degenerative changes that are common in Arthritis may show up on X-rays. These changes are common with an increase in pain.
- Computed Tomography: (CT scan) Your physician may recommend this test if more detailed images are needed.
- Myelography: In this test, a dye is injected into the spinal canal followed by special X-rays. If the doctor is concerned about your spinal cord being affected by your disease, this test may be recommended.
- Magnetic resonance imaging: An MRI uses strong magnetic waves instead of x-rays to show images of the body's soft tissues. This test is non-invasive, meaning it does not require the use of needles or any special dye.
Scheuermann's Kyphosis: Treatment
Non-Surgical Treatment
When possible, Scheuermann's Kyphosis surgery is not needed. One non-surgical treatment is bracing or casting. The goal of this treatment is to attempt to guide the growth of the spine in order to straighten it. The brace or cast will only be successful in patients who are still growing. The brace is made to hold the spine in a more upright position. This is believed to remove pressure from the front portion of the vertebrae and allow the bone in the front to catch up with growth in the posterior portion.
Bracing may be used in patients who are no longer growing, but in these cases, it is only to relieve pain and to provide support. It will not change the curvature in these patients.
Many braces are available, but the Milwaukee is the most commonly used. The brace has lateral pads to position the shoulders and also a chin extension. The brace is thought to be effective in children and adolescents with a curvature of fewer than 75 degrees as measured by X-ray.
If patients wear the brace consistently, the deformity can be corrected within two years. The brace allows the spine to remodel and the growth of the spine to be corrected.
In most cases, the brace is worn from 16 to 24 hours daily the first year and then only at night for the second year. Physical therapy may be recommended, but it is rarely beneficial to patients with Scheuermann's Kyphosis but is needed for patient's who undergo Scheuermann's Kyphosis surgery.
Scheuermann's Kyphosis Surgery
Scheuermann's Kyphosis surgery is not usually needed. It may be recommended in cases of severe deformities or if there is neurological involvement. The goal of Scheuermann's Kyphosis surgery is to reduce the deformity. Some also think that surgery can relieve any pain that may be present. Scheuermann's Kyphosis surgery typically includes:
- Frontal Thoracotomy: In this Scheuermann's Kyphosis surgery procedure, tissues are released and the discs are removed. A bone graft is placed in the spaces to fuse the thoracic spine.
- Instrumentation is then completed using rods, wires, bars or screws to hold the spine in place during the process of fusion
- After the Scheuermann's Kyphosis surgery, if the fusion is successful, the spinal segments will fuse into one continuous piece of bone that will not progress into Kyphosis
Since Scheuermann's Kyphosis surgery typically occurs in the thoracic spine which has very little motion, a fusion in this area of the spine does not usually affect normal a and does not cause pain later in life. The most motion of the spine occurs in the lower back, and usually, it is not necessary to use this area. It's important to avoid over-stressing the other areas of the low back.
In a mature patient, Scheuermann's is not a progressive disease. This is not like adolescent scoliosis, which can continue to progress into adulthood. For adults who have Scheuermann's, the treatment usually consists of observation, anti-inflammatory medications or Scheuermann's Kyphosis surgery to reconstruct the spine, depending on how severe the symptoms are.
Pathological changes
The spine is shaped like an "S" when it is viewed from the side. This "S" shape allows weight be evenly distributed. The curve also helps the spine maintain its health under all kinds of various stress. The cervical spine normally curves slightly in toward the body, the thoracic spine curves slightly out, away from the body, and the lumbar spine curves slightly inward again to complete the "S." Even though the majority of the body's weight is carried in the lower part of the spine, each portion of the spine relies on the others to properly function.
Normally, the thoracic spinal curvature is between 20 and 40 degrees. A curve of a greater or lesser degree is considered abnormal. If the thoracic spine curves 45 degrees or greater, it is considered to be a type of problematic thoracic Kyphosis. In Scheuermann's Disease, the thoracic curve is typically between 45 and 75 degrees. In addition to this degree of curvature, there is also vertebral wedging of at least three vertebrae that lie next to one another, of greater than five degrees. These vertebrae look like triangular wedges and they fit tightly together, cutting down on the amount of space between the vertebrae.
In Scheuermann's Disease, there can also be additional abnormalities of the vertebrae that are affected. These deformities are called "Schmorl's nodes." These are places where the intervertebral discs between the vertebrae push through the bone at the top and bottom of each vertebra. This part of the vertebra is called the "endplate."
Many people with Scheuermann's Disease are noted to have an extra thickness in the ligament that runs along the front portion of the spine, called the anterior longitudinal ligament. Some specialists believe that the extra strength of this ligament may contribute to the deformity. The thickness of the ligament during childhood growth and development may lead to the growth of the posterior portion of the vertebrae and not enough growth on the front. This imbalance in growth may result in the wedged vertebra.
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