Scheuermann's Kyphosis

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Original Editors - Liza De Dobbeleer

Top Contributors - Nicolas D'Hondt, Leen Meylemans, Liza De Dobbeleer, Lucinda hampton, Rachael Lowe, Kim Jackson, Admin, Fasuba Ayobami, WikiSysop, Aminat Abolade, 127.0.0.1, Elaine Lonnemann, Uchechukwu Chukwuemeka, Claire Knott, Meaghan Rieke and Anna Fuhrmann  

Search Strategy

We used databases such as Pubmed and ResearchGate to find scientific articles.
Our keywords consisted of “Scheuermann’s disease”, “Scheuermann’s kyphosis”, “Juvenile kyphosis” whether or not combined with “description”, “symptoms”, “diagnosis”, “treatment”, “measurement”, “examination”, “physical therapy” and so on.
We only used articles of which the full text was available.

Definition/Description

Scheuermann’s disease or Scheuermann’s kyphosis is a form of osteochondritis of the spine. 1( 
LoE: 3A) It is a rigid kyphosis of the thoracic or thoracolumbar spine occurring in adolescence. 32 Scheuermann’s disease is characterized by an increased posterior rounding of the thoracic spine in association with structural deformity of the vertebral elements. It’s the most prevalent in pediatric population and it’s the most common cause of structural hyperkyphosis. There are two types: the typical thoracic pattern, the more common, with non-structural hyperlordosis of the cervical and lumber spine and the atypical thoracolumbar pattern that is thought to be more likely to progress in adulthood. Until now the cause of Scheuermann’s disease remains unknown.1
By radiographic techniques the disease can be defined as three adjacent wedged vertebrae angled by at least 5 degrees. This definition can be altered according to different authors, as some of them consider the disease to be present if there is one vertebra wedged and associated with irregular vertebral endplates.

Clinically Relevant Anatomy

The upper and middle-back is called the thoracic spine. It joins the cervical spine and extends down about five inches past the bottom of the shoulder blades, where it connects with the lumbar spine. This region has a gentle convex curve.
The thoracic spine consists of 12 thoracic vertebrae, labelled T1-T12.These vertebrae are larger and thicker than the cervical vertebrae, but smaller than the lumbar vertebrae. They provide the stability which is very important to hold the body upright and to provide protection for the vital organs in the chest.
There is a limited flexibility in the thoracic spine because planar joints connect the ribs to it. Each thoracic vertebra supports a pair of ribs and contains a pair of smooth, concave joint-forming processes known as facets on its sides.
T1 is unique because it supports two pairs of ribs through a pair of facets and a pair of demi-facets.
T1-T9 have a pair of demi-facets, where a facet is split between two adjacent vertebral bodies.
T1 and T10-T12 contain a pair of full facets on their vertebral bodies to support ribs.
Also the intervertebral discs distinguish from the cervical and lumbar intervertebral discs because they are thinner. The spinal canal is most narrow in the thoracic spine, which makes the spinal cord much vulnerable. 6 7
The lumbar spine refers to the lower back. It connects to the thoracic spine and has a gentle concave curvature. Each vertebra is connected by an intervertebral disk made of tough fibrocartilage with a jelly-like centre. The inner layer, nucleus pulposus, acts as a shock absorber. The outer layer, annulus fibrosus, holds the vertebrae together and provides strength and flexibility to the back during movement. The lumbar vertebrae are larger and heavier than the cervical or thoracic vertebrae. The vertebral body of the lumbar vertebrae has to bear most of the body weight. That’s why the vertebral body makes up the majority of the lumbar vertebrae’s mass. The body is posteriorly connected to a thin ring of bone known as the arch. It surrounds the hollow vertebral foramen and connects the body to the bony processes on the posterior of the vertebra.6 7 8

Epidemiology /Etiology

The disease mostly develops during puberty and is seen equally in both sexes. Depending on which criteria are used, 5 to 40% of the population has this anomaly. In the United States the disease occurs in 0,4 to 8 percent of the general population.10 31 32
Many theories have been proposed for the etiology of Scheuermann's disease, but the real cause is still unclear. Here are some of these theories:

• The skeleton of a newborn consists mainly of cartilage, which in childhood is transformed into bone5. Schmorl found that the lumbar Scheuermann’s disease could be related to defects of ossification process. The defect is often located at the anterior of the lumbar vertebrae, more precisely at the endplates. This results in an anterior wedging of the vertebrae and thus an increased kyphosis.
• Ferguson suggested that the anterior wedging is caused by the persistence of the anterior vascular groove. It creates a weak point in the vertebrae, which can lead to the collapse of the vertebral body. But these findings have not been observed in other studies.
• There could be mechanical factors contributing to the disease. Partial reversal of the anterior wedging has been noted in patients who wore a brace during the active of the disease, suggesting that mechanical factors play a role in the development of the deformity.
• Osteoporosis could also be responsible for the development of Scheuermann's disease.
• Mostly, the patients have a greater lordosis in the lumbar spine than people without this pathology.11 12
• There also could be a correlation between disc generation, reduced intradisc distance and abnormal configurations of the vertebral bodies.11 31
• Ascani et al. found that patients who had Scheuermann's disease were taller than average and that their skeletal age was ahead of their chronological age. They also found increased levels of growth hormone in these patients.
  

Nowadays scientific literature considers Scheuermann’s disease to be hereditary but the methods of transmission is still undefined.
Other important factors are biomechanical factors, most importantly hamstring contracture that prevents a normal pelvic inclination when flexing the trunk. When this movement is repeated it can cause a progressive anterior wedging of the vertebrae.13
Findings of a research by Ogden et al. states that the appearance of an asymmetric biomechanical stress on the vertebral bodies will result in changes in the remodelling process. In this case kyphosis would be a result of the imbalance of the load supported between the anterior and the posterior parts of the spine.13
Other factors such as elevated growth hormone levels, idiopathic juvenile osteoporosis, deficiency of vitamin D, dural cysts, spondylolysis, infections, spinal deformities and other disease are also implicated in the development of Scheuermanns disease. The disease can also be a result of several of these factors acting simultaniously. 13
According to a study by G. Armbrecht et.al about the prevalence of Scheuermann’s disease in Europe both men and women aged 50 and over, the prevalence of the disease is 8% in both sexes but it variated a lot between centres of Europe.38
Highest prevalence of the disease is seen in Germany and a bit lower prevalence in the United Kingdom, the Netherlands and Russia. In these high prevalence countries was Scheuermann’s disease the most common cause of hyperkyphosis in adolescence which will have an effect for a lifetime of the patient. 38
Central European centres such as Slovakia and Hungary had much lower prevalences but the reason behind these findings remain unclear because there has been no data collected which could prove that these differences have a genetic or an environmental background.38

Characteristics/Clinical Presentation

Most patients with Scheuermann's disease are presented with a history of deformity. The most common cause is structural kyphosis in adolescence. 14 15 35
If the Scheuermann’s disease is located in the upper thoracic region, there will be a kyphotic deformity that will be best demonstrated in the forward flexed position. The normal curvature of the thoracic spine is between 20 and 45 degrees. If the patient has a curvature of more than 50 degrees, where the spine has three contiguous vertebral bodies that have wedging of five degrees or more, scheuermann’s disease is included. 8 14 15 16 17
Palpation in this region can be tender. 35
In the lumbar spine, hyperlordosis can occur and there is a strong correlation between Scheuermann’s disease and scoliosis.
Hamstring tightness may be present in these patients.35
As the disease progresses, there will be more complaints such as back pain. The pain is located just distal to the apex of the deformity and then radiates laterally in a paraspinal pattern. The pain also is activity related and often abates with rest) and fatigue, muscle stiffness (especially at the end of the day) and neurological symptoms. In severe cases, heart and lung function can be impaired. Other secondary changes are Schmorl nodes, irregular vertebral endplates and disc space narrowing (Figure 1). Pain related to the pathology can be made worse by activity including sports that require a lot of twisting, forceful bending or arching backward such as gymnastics. Some studies have found Scheuermann’s disease to be more prevalent among boys than girls. Other studies have reported kyphosis to be more prominent in females than males. 15 14 16 36
After the puberty growth stops, the disease will also stop. Only some residual abnormalities will exist.
There’s no conclusive evidence that people with lumbar Scheuermann’s disease have a higher chance of low back pain compared with healthy people. More research is needed.8

Differential Diagnosis

Most patients with Scheuermann's disease are presented with a history of deformity. The most common cause is structural kyphosis in adolescence. 14 15 35
If the Scheuermann’s disease is located in the upper thoracic region, there will be a kyphotic deformity that will be best demonstrated in the forward flexed position. The normal curvature of the thoracic spine is between 20 and 45 degrees. If the patient has a curvature of more than 50 degrees, where the spine has three contiguous vertebral bodies that have wedging of five degrees or more, scheuermann’s disease is included. 8 14 15 16 17
Palpation in this region can be tender. 35
In the lumbar spine, hyperlordosis can occur and there is a strong correlation between Scheuermann’s disease and scoliosis.
Hamstring tightness may be present in these patients.35
As the disease progresses, there will be more complaints such as back pain. The pain is located just distal to the apex of the deformity and then radiates laterally in a paraspinal pattern. The pain also is activity related and often abates with rest) and fatigue, muscle stiffness (especially at the end of the day) and neurological symptoms. In severe cases, heart and lung function can be impaired. Other secondary changes are Schmorl nodes, irregular vertebral endplates and disc space narrowing (Figure 1). Pain related to the pathology can be made worse by activity including sports that require a lot of twisting, forceful bending or arching backward such as gymnastics. Some studies have found Scheuermann’s disease to be more prevalent among boys than girls. Other studies have reported kyphosis to be more prominent in females than males. 15 14 16 36
After the puberty growth stops, the disease will also stop. Only some residual abnormalities will exist.
There’s no conclusive evidence that people with lumbar Scheuermann’s disease have a higher chance of low back pain compared with healthy people. More research is needed.8

Outcome Measures

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Examination

Patients with Scheuermann's disease normally have an angular thoracic or thoracolumbar kyphosis compensated by an hyperlordosis of the lumbar spine. Te kyphosis is fixed and stays apparant on hyperextension of the spine. The kyphosis is easier to see when seen from the side, when the patient bents forward.

Often de cervical lordosis is increased with a protrusion of the head. These abnormalities can be accompanied by a mild to moderate scoliosis.

Patients with Scheuermann's disease are well muscled compared to patients with postural kyphosis. 

Medical Management

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Physical Therapy Management

Treatment of the Scheuermann's disease depends on the severity of the disease or the progression of the disease, the presence or absence of pain and the age of the patient.

Patients with a mild form are suggested to move and get a prescription from the doctor for physiotherapy. This includes exercises to maintain flexibility from the back, correct lumbar lordosis, and strengthen the extensors from the back.. These exercise can be effective when the thoracic spine has not developed a relevant stiffness and when the sagittal curve is not too high (Cobb angles from 44° to 55°)

Patients with back pain should follow a postural and aerobic training program. These postural exercises are not only use full to fight the pain but also to manage the deformity in the spine.

Stretching exercises are also use full if there is tightness of the hamstring muscles.

Also in severe cases exercise will be designated to guarantee the muscle condition. The physiotherapist will also learn the patient how to keep the back in a correct position.
Depending on the severity and progression of the curve, patients should follow, in conjunction of the exercises, a brace therapy (e.g. a Milwaukee brace) for one or two years. The brace can influence the curve during growth by restoring height to the front of the vertebral body and sometimes can reduce pain if present. Many studies have proved that for patients who are already skeletally mature, bracing is not an effective treatment.
The patient must learn to move so the back is not under much stress. So is volleyball, sailing,… (static loads) not recommended, but swimming, ball games etc. (dynamic loads) are however recommended.
In severe cases, surgery can provide a solution.

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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