Ovid: 5-Minute Sports Medicine Consult, The

Mark E. Lavallee
Christopher Johnson
  • 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
  • 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.
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
  • 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
  • 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
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].
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.
  • 737.10 Kyphosis, acquired, postural
  • 737.30 Kyphoscoliosis, idiopathic
  • 756.19 Kyphosis, congenital

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