High Yield Topics

Kyphosis

By admin



Ovid: 5-Minute Sports Medicine Consult, The


Kyphosis
Mark E. Lavallee
Christopher Johnson
Basics
Description
  • Kyphosis is a fixed exaggerated convex anteroposterior (AP) curvature of the thoracic spine.
  • Scoliosis is a fixed lateral curvature of the spine (>10 degrees by Cobb angle) and vertebral rotation.
  • Lordosis is a fixed concave exaggerated AP curvature of the lumbar spine.
  • Kyphoscoliosis is a combination of lateral and AP curvatures of the spine.
  • Scheuermann's juvenile kyphosis is osteochondrosis of the secondary ossification center of a vertebrae causing thoracic kyphosis.
  • Synonym(s): Curvature of the spine; Hunchback; Dowager's hump; Postural roundback
Epidemiology
  • Most commonly seen in postmenopausal women who have osteoporosis. Rare occurrence in skeletally maturing patients; occasionally seen in adolescents as they transition through their secondary growth spurt.
  • Females > Males
  • Kyphosis has an incidence of 1 in 1,000, while scoliosis is about 2 in 100.
  • Scheuermann's juvenile kyphosis occurs in 0.4–0.8% in the U.S.
  • Idiopathic scoliosis occurs in 2–4% of school-aged children (1).
Risk Factors
  • Female gender and remaining growth potential
  • Family history is the primary risk. Inheritance patterns are still being actively elucidated.
  • Myelodysplasia, Marfan syndrome, Ehlers-Danlos syndrome, and achondroplasia have all been associated with kyphosis and/or scoliosis.
Genetics
In 2007, CHD7 was identified as the 1st gene with polymorphisms associated with susceptibility to scoliosis. No consistent genetic loci has been associated purely with kyphosis (2).
Commonly Associated Conditions
  • Osteoporosis
  • Vertebral fracture
  • Scoliosis
  • Scheuermann's juvenile kyphosis
  • Marfan syndrome
  • Ehlers-Danlos syndrome
Diagnosis
History
  • Upper back curvature, often painless
  • Often noticed by an observer, such as a parent, partner, or spouse
  • Cases of nonpainful, nontraumatic kyphosis are often discovered in school-based screenings, preparticipation examinations, or general wellness exams.
  • A family history of kyphosis, scoliosis, connective tissue disorder, or neurological disorder should be sought.
Physical Exam
  • Subtle findings, such as noticeable “hump” on back
  • Pain is not often a feature for idiopathic kyphosis, but if present, other causes of kyphosis need to be ruled out.
  • Check posture, leg length discrepancy, muscle tone, and abdominal reflexes.
  • A complete neuro-orthopedic exam (ie, cavus feet seen in Charcot-Marie-Tooth syndrome)
  • Assess patient's ability to “correct” deformity with attempted thoracic hyperextension. Postural roundback will improve, whereas true kyphosis will have minimal improvement.
  • Marfanoid body habitus, hypermobile joints, or hyperextensible skin (ie, Marfan or Ehlers-Danlos syndrome)
  • Café-au-lait spots (ie, neurofibromatosis)
  • Adams' forward bending test (to look for associated scoliosis): Patient stands with legs locked, bends at the waist, arms toward feet. Examiner stands behind patient, lowers head and views across patient's back, looking for elevated and rotated vertebral segments.
  • A scoliometer may also be used to assess if patient has scoliosis. Measure the angle of trunk rotation (ATR). An ATR of 7 degrees or greater correlates (83% sensitivity, 86% specificity) to a clinically significant curve. The ATR multiplied by 3 estimates the curvature (Cobb angle).
Diagnostic Tests & Interpretation
Imaging
  • Kyphosis: AP/lateral chest x-ray is usually the 1st imaging test. Able to assess for degenerative joint disease, fractures, Schmorl's nodes, angle of kyphosis. Secondary or more complete view is a lateral standing radiograph of entire spine. Look for Schmorl's nodes (protrusions of intervertebral disc cartilage through vertebral body end plate of adjacent vertebra that are pathognomonic for Scheuermann's.
  • If scoliosis is associated with kyphosis: Standing posteroanterior and lateral radiographs of the entire spine. Pelvis is analyzed to determine Risser score.
  • In children and adolescents, make sure with radiographs to image the iliac crests, including the iliac apophyses to help with the Risser scoring.
  • Indications for MRI:
    • Age <10
    • Rapid progression of a curve
    • Abnormal neurologic examination
    • Atypical pain with inconclusive radiograph (1)[C]
Differential Diagnosis
  • Congenital kyphosis: Anomalies of vertebral segmentation and/or formation (Klippel-Feil syndrome, VACTERL syndrome).
  • Neuromuscular scoliosis: Upper motor neuron (Friedrich's ataxia, cerebral palsy, Charcot-Marie-Tooth syndrome, syringomyelia, muscular dystrophy) or lower motor neuron (poliomyelitis, spina bifida), spinal dysraphism (myelomeningocele)
  • Scheuermann's juvenile kyphosis: Pathognomonic Schmorl's nodes on at least 2 consecutive levels
  • Kyphosis secondary to bone demineralization (osteoporosis)
  • Vertebral fractures/trauma
  • Benign or malignant tumors (ie, Paget's disease of bone)
  • Parkinson's disease: “Stooping posture”
  • Spinal tuberculosis
  • Rickets
  • Marfan syndrome
  • Achondroplasia
  • Ehlers-Danlos syndrome, especially kyphoscoliotic type
  • Ankylosing spondylitis
Treatment
  • Management options include observation, bracing, physical therapy, oral medicine (osteoporosis), and surgical invention (in rare cases).
  • Idiopathic kyphosis in adolescence and Scheuermann kyphosis rarely need surgical intervention.
  • Treatment of painful kyphosis is 1st to determine cause.
  • <50 degrees in young adolescents without evidence of progression may be observed. Strengthening and stretching of abdominals, hamstrings, and paraspinal muscles are recommended to prevent excessive lordosis and hamstring contractures (1)[C].
  • Painful curves between 50 and 70 degrees or progressive deformity >65 degrees may be braced (many associated with Scheuermann's) (1)[C].

    • P.349


  • Literature supports surgical correction indicated at >75 degrees with Scheuermann's kyphosis and 60 degrees for congenital kyphosis.
  • Observation:
    • Juveniles/adolescents with moderate curves of <60 degrees: Manage by following with serial radiographs every 4–6 mos, depending on skeletal maturity (Risser score; see scoliosis chapter)
    • Skeletally mature with curves <40: Follow with history, physical, and occasional radiograph.
    • Check bone densitometry (dual energy x-ray absorptiometry) on patient with vertebral fracture, nontraumatic, and those with osteoporosis. Treatment of osteoporosis with bisphosphonates has been shown to improve kyphosis-related back pain.
    • Standing lateral radiographs of whole spine every 6 mos
  • Brace:
    • Immature with curve >60 degrees or in those who progresses >10 degrees during observation to a curve >40
    • Bracing options include:
      • Preliminary hyperextension plaster cast
      • Milwaukee brace (for curves above T7)
      • May use an underarm rigid brace (if curve is below T7)
    • Once the curve is supported, the patient should use 20 hr/day. The brace use may be tapered to nighttime use once the progression of the curve is controlled.
    • Goal is to delay/prevent curve progression until skeletally mature
    • Contraindication to bracing: Curves >80 degrees, extreme thoracic hypokyphosis, high thoracic or cervical curves
    • Standing radiograph images every 6 mos (or 4 mos if progressing and skeletally immature)
  • Surgery:
    • Wedge osteotomies of the posterior aspect of the vertebrae have been done to correct those with severe kyphosis in skeletally mature patients without osteoporosis.
    • Vertebroplasty and balloon kyphoplasty are procedures available to patients who develop kyphosis related to osteoporosis or trauma-related collapse of thoracic vertebral body.
    • Once a curve reaches 80 degrees, it is assumed it is not controlled by bracing; operative correction with posterior instrumentation/fusion is recommended. Upper thoracic kyphosis with curves >100 cause significant restrictive lung disease.
  • Some clinicians advocate following juvenile patients with exaggerated kyphotic curves of >40 degrees at 4–6-mo intervals until iliac crest growth plates close.
Additional Treatment
Additional Therapies
  • Postural roundback, not true kyphosis, has been shown to improve with physical therapy focused on postural control and core/shoulder girdle strengthening.
  • Bracing in juvenile/adolescent patients should be continued as long as there is no progression of curvature and vertical growth is still occurring. In young women, this means a Risser stage of at least 3; in young men, a Risser stage of 4.
Ongoing Care
Follow-Up Recommendations
  • Refer to orthopedic/spine specialist when there is a:
    • Nonbraceable curve of the thoracic spine (apex of curve higher than T6)
    • Worsening curvature despite bracing
    • Curvature in the newborn and infant; any children under 10 yrs old
    • Curvature associated with severe trauma/vertebral fracture
    • Curvature-associated malignancy
  • Juvenile/adolescent kyphosis is often diagnosed or progresses during a sensitive time of life. Studies have demonstrated a negative effect on body image, self-esteem, and attitude with treatment. This may affect compliance. Treatment is time-consuming, confining, and can be uncomfortable. The adolescent is faced with many lifestyle changes. Providers should be aware of the possible psychological impact from new demands on the patient and family. Discussions about patient's thoughts/feelings on treatment as well as support groups should be considered (3)[C].
References
1. Schiller JR, Eberson CP. Spinal deformity and athletics. Sports Med Arthrosc. 2008;16:26–31.
2. Gao X, Gordon D, Zhang D, et al. CHD7 gene polymorphisms are associated with susceptibility to idiopathic scoliosis. Am J Hum Genet. 2007;80:957–965.
3. Reichel D, Schanz J. Developmental psychological aspects of scoliosis treatment. Pediatr Rehabil. 2003;6:221–225.
4. Wood KB. Spinal deformity in the adolescent athlete. Clin Sports Med. 2002;21:77–92.
Additional Reading
Dobbs MB, Weinstein SL. Infantile and juvenile scoliosis. Orthop Clin North Am. 1999;30:331–341, vii.
Miller NH. Cause and natural history of adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30:343–352, vii.
Roach JW. Adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30:353–365, vii–viii.
Staheli LT, Song K. Practice of pediatric orthopaedics, 2nd ed. Lippincott, Williams & Wilkins; 2006:220–224.
Codes
ICD9
  • 737.10 Kyphosis, acquired, postural
  • 737.30 Kyphoscoliosis, idiopathic
  • 756.19 Kyphosis, congenital
Clinical Pearls
  • Sports and athletic activity is allowed and encouraged for all patients with nonpainful kyphosis in nonoperative treatment. Those with painful causes of their kyphosis should consult with their doctor prior to starting an exercise program. Postoperative patients' return to play is at the discretion of the surgeon. Level/extent of fusion, time from surgery, and type of sport usually dictates the decision (4)[C].
  • Braces are used to prevent progression and are not intended to correct the curve. Compliance is essential to treatment success.
  • Most studies support results with brace wear of 18–20 hr per day. Night-only braces have also been shown to have success (4)[A].
  • Braces for juvenile/adolescent patients should be worn until the Risser score is 4 (closed growth plates).
  • Further studies are still needed to elucidate the effect of exercises. Favorable effects have been shown, however, on strength, postural stability, and balance. This may be valuable as an adjunct to treatment. Exercise has been shown to help postural roundback.
  • Manipulation therapy has not been proven to help correct curvature of the spine. Few articles such as case studies advocate the role on manipulation, but more data and controlled studies are needed to support their use in curve correction.


Continue Reading
You might also like More from author

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More