Figure 1. Magnified image of wedged vertebrae in Scheuermann's kyphosis
Hyperkyphosis (forward bend of the thoracic [ribbed] vertebrae beyond normal limits) is classified as either postural or structural in origin.
Postural kyphosis is flexible and will correct when the patient is asked to stand up straight. Patients with postural kyphosis have no abnormalities in their vertebrae shape.
Structural kyphosis, known as Scheuermann's kyphosis, is defined as rigid. The front sections of the vertebrae grow slower than the back sections. The abnormal kyphosis is best viewed from the side in the forward-bending position where a sharp, angular abnormal kyphosis is clearly visible.
Instead of normal, rectangular vertebrae with ideal alignment, wedge-shaped vertebrae cause misalignment (Figures 1 and 2). This process occurs during a period of rapid bone growth (usually between the ages of 12 and 15 in males or a few years earlier in females). The kyphotic curve that develops with growth frequently remains mild and requires only periodic x-rays.
Patients often have poor posture and complaints of back pain, which is most common in early teenage years and less so as they approach adulthood. The pain rarely interferes with daily activity or professional careers. The kyphosis is more likely to be painful the apex (most angular section) is in the mid-to-low back instead of the upper back. In severe cases, adolescents may not be able to lie on their back without several pillows under their head.
Figure 2. A) Lateral x-ray of a patient with Scheuermann’s disease. B) Close-up x-ray demonstrating wedge-shaped vertebrae characteristic of Scheuermann’s disease.
Observation is typically recommended for:
- Postural hyperkyphosis (rounded back straightens with proper posture)
- Curves that are less than 60° in patients that are growing
- Curves 60° to 80° in patients that are finished growing
X-Rays and Exercise
Standing, long-cassette (scoliosis) x-rays are taken every six months as the child grows. If the child experiences pain, an exercise program is usually recommended.
Figure 3. On the left is a side-view of a patient with Scheuermann's kyphosis. On the right is the same x-ray after he was placed in a hyperextension brace.
When the curve is moderately severe (60° to 80°) and the patient is still growing, brace treatment in conjunction with an exercise program may be recommended. The brace fit must be regularly evaluated and adjusted to ensure optimal correction.
- Full-time use of a brace (20 hours/day) is usually required initially until maximum correction has been achieved.
- During the last year of treatment prior to skeletal maturity, part-time brace wear (12 to 14 hours/day) may be proposed.
- Brace wear must be continued for a minimum of 18 months in order to maintain a significant, permanent correction of the curve (Figure 3).