Scheuermann's Kyphosis

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Original Editors - Liza De Dobbeleer

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

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.  (LoE: 3A)
 It is a rigid kyphosis of the thoracic or thoracolumbar spine occurring in adolescence. (LoE 3A)  (LoE: 2B)
 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.(LoE: 3A)
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.  (LoE: 3A)

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.(LoE 1A)  
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.
(LoE:1A)

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.
(LoE:3A)(
LoE:3B)
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.(LoE : 2B) (LoE : 3A)
• There also could be a correlation between disc generation, reduced intradisc distance and abnormal configurations of the vertebral bodies.(LoE : 2B) 
• 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. (LoE : 3A)
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. (LoE : 3A)
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.  (LoE : 3A)
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.(LoE : 2B)
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.  (LoE: 2B)
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. (LoE: 2B)

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. (LoE : 2B)(LoE : 2A)(LoE : 2B)
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. (LoE: 5)(LoE : 2B) (LoE : 2A)(LoE : 2A)(LoE : 2B)
Palpation in this region can be tender. (LoE : 2B)
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.(LoE : 2B)
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. (LoE : 2B)(LoE : 2A)(LoE : 2A)(LoE: 3A
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.(LoE: 5)

Differential Diagnosis

Differential diagnosis is important to be able to separate Scheuermann’s disease from curved back or postural kyphosis. The difference is that a person with Scheuermann’s disease will have a latter which is affable and it is possible to correct it voluntarily by asking the patient to extent the trunk. A patient with postural kyphosis is flexible, symmetrical and has a more rounded shape (mostly below 60 degrees) back when bending forward. It also cannot be seen on radiological images on the contrary with Scheuermann’s disease, which has its own characteristics visible (Figure 2). (LoE: 3A)
Other pathologies that must be excluded are idiopathic kyphosis, specific or not spondylitis osteochondral dystrophies, spondyloepiphyseal dysplasia, congenital scoliosis, congenital kyphosis and kyphosis secondary to fractures, endocrinopathies, tumors, and vertebral infections.(LoE: 2B)

Diagnostic Procedures

A first type of test is radiography. The radiographs include anteroposterior and lateral standing on long films. The entire thoracolumbar spine had to be on one film. The patient had to stand in neutral position with his hips and knees fully extended. Also side- and backward bending x-rays are recommended to understand the flexibility of the spine. If we see three adjoining vertebral bodies with an anterior wedging of 5 degrees on the lateral radiographs, Scheuermann's disease is confirmed. This is measured with the Cobb technique. Also secondary changes such as irregular vertebral endplates, Schmorl nodes and disk space narrowing should be noted.
As said earlier, scoliosis and spondylolisthesis is associated with Scheuermann’s disease. These pathologies can be documented on plain radiographs. It has to be treated as separate entities.(LoE: 3A)(LoE: 2B)(LoE: 2B)(LoE: 3A)
If the patient has leg pain or symptoms of neurological dysfunction, an MRI is taken.(LoE: 3A)

Outcome Measures

The diagnosis of Scheuermann’s disease is based on radiological criteria reported by Sorensen which means that there are at least 3 consecutive vertebral bodies with a minimum of 5° of wedging. (LoE: 3A)(LoE: 2B)
Other criteria include endplate irregularity, thoracic kyphosis greater than 35° or 45°. (LoE: 3A)(LoE: 2B)
On the lateral radiographs, there are four spinal parameters. The first parameter defines the sagittal vertebral axis as a linear horizontal distance between the C7 plumb line (originating in the centre of the vertebral body) and the posterior corner of the S1 endplate. If the C7 plumb line is anterior to the S1 posterior corner, the sagittal vertebral axis is defined as positive. (LoE: 3A)
The thoracic kyphosis Th4-Th12 is the angle measured between the proximal endplate of Th4 and the distal endplate of Th12. This angle is measured using the Cobb method.Between the proximal endplate of the Th11 vertebrae and the distal endplate of L1 vertebrae the Th11-L1 angle is measured. If the Cobb method is negative, lumbar lordosis is indicated. (LoE: 3A)(LoE: 4B)(LoE: 2B)(LoE: 2B)
The lumbar lordosis L1-S1 is defined as the angle between the proximal endplate of the L1 vertebrae and endplate of S1 is measured with the Cobb method. Also three pelvic parameters can be measured. The pelvic incidence was defined as the angle between the line joining the centre of the bicoxofemoral axis and the centre of the S1 endplate and the line orthogonal to the S1 endplate. The angle between the line joining the centre of the bicoxofemoral axis and the centre of the S1 endplate and vertical line is the Pelvic tilt. If the midpoint of the S1 endplate was anterior to the centre of the bicoxofemoral, the value is negative. The angle between the line parallel to the S1 endplate and the reference horizontal line is the sacral slope (Figure 3). (LoE: 3A)(LoE: 3A)(LoE: 4B)(LoE: 2B)(LoE: 2B)

Also Schmorl nodes will be seen.(LoE: 2B)

Examination

Scheuermann’s disease can be seen during examination as a well-defined, angular, thoracic hyperkyphosis and as a compensatory effect the therapist will also see a cervical and lumber hyperlordosis. This happens as a result of the balancing attempts of the column. These curves of compensation can also become a source of pain. (LoE: 3A)
The head and neck will be seen in an anterior position called “gooseneck deformity”. In some cases the shoulders can also follow the same anterior protrusion. (LoE: 3A)
These symptoms can be seen during flexion of the trunk as an angular and sharp hump on the thoracic or thoracolumbar region. This deformity is considered to be relatively fixed and is not corrected with spinal hyperextension (Figure 4). (LoE: 3A)
Other findings of examination are the presence of contractures of the pectoral muscles, hamstrings and the hip flexors. (LoE: 3A)
Almost one third of the patients also have mild or moderate scoliosis. (LoE: 3A)
The therapist will observe the patient in different types of views: frontal, lateral and back. However, there are some components which are assessed during a static examination: feet equilibrium, lower limb alignment, sagittal and frontal pelvic balance, hip asymmetry, abdomen, spine, morphological disharmony of the chest, shoulders, neck and head. By measuring the distances from the plumb line we can discover deformities of the sagittal posture (Figure 5). LoE : 2A
When the patient is evaluated during movement, it will give information about the level of coordination and balance which will later influence the therapeutic choices.
Other aggravating factors should also be assessed such as visual/psychological disorders which may require a mulit-disciplinar approach during the therapy.LoE : 2A

Medical Management

The treatment of Scheuermann’s Disease depends on the patient’s age, degree of angulation, and estimated remaining growth.(LoE : 2B)

Non-operative treatment

If the thoracic kyphosis exceeds 40-45° during the growth period and if there are radiological sings of Scheuermann’s disease, non-operative treatment is indicated. This consists of bracing, casting and exercises. 
The initial management of patients with Scheuermann’s disease includes documentation and assessment of the degree of deformity and/or pain, as well as an overall “gestalt” of the negative impact of the deformity on the patient’s life. Physical therapy for postural improvement exercises focusing on the trunk and hamstring extensor strengthening is often recommended. A physical therapist can also evaluate whether there is any tendency toward increased hip flexion contracture and may work on associated lumbar lordosis (LoE 2A).

Until now, there is no scientific evidence that exercise improves the kyphosis. (LoE 2A)
Only patients with mobile kyphotic deformity and with at least one year of remaining growth will experience improvement of bracing and casting (LoE 2A). (LoE: 2A)

Results of brace treatment for relieving pain have not been published because bracing has been used primarily for the treatment of deformity (LoE 2A).

The prerequisites for the bracing treatment in patients with Scheuermann’s disease include that the patient has at least a 45°-curve and that patients with a kyphosis of up to 65° may be successfully managed by bracing. There is a higher failure rate in patients with curves of greater than 74°. As mentioned before, it’s necessary to have some flexibility in the curve and the patient needs to be skeletally immature (LoE 2A). (LoE: 2A)

A modified Milwaukee brace (Figure 6) that has posterior pads attached to the uprights pushing anteriorly on the kyphosis, with both the neck and pelvis controlled by the upper and lower segment of the brace is a classic treatment. It’s ideally to wear the brace 23 hours a day for 1 to 2 years. The brace is adjusted monthly (LoE 2A).

If the patient’s Risser sing is 4 or 5, bracing and casting is known to become ineffective.
According to some authors, cast treatment has a successful outcome in patients with rigid Scheuermann’s disease. 
The Bradford series with the Milwaukee brace treatment remains the largest series of conservative treatment. Patients following this treatment had stabilization or a small improvement of deformity.
Also other braces like the modified Boston, Lyon brace and the Maguelone brace are effective (Figure 6) 
The Boston lumbar brace is recommended for flexible curves below 70° with an apex at or below T7. The Lyon brace is a bivalve rigid brace with a posterior shell usually T7-S3 and an anterior shell with a manubrial thrust reinforced by a metallic bar.
The Maguelone brace is highly effective and very dedicated to the most frequent pure thoracic hyperkyphosis with apex from T5-6 to T8-9. With this brace, the patient can do specific in-brace exercises.
Braces must be carried a minimum of 18 months to have an effect on vertebral wedging.
As patients grow older, they feel increasing ashamed of their body. They are more concerned about the future effect of the deformity on their body.
Patients, whose bracing time increases, have more probability to get low back pain. So girls have a higher probability to get low back pain than boys. Patients with larger spinal curves have more difficulties in bending and increased incidence of back pain than patients with smaller curves.
Low compliance in adolescence with spinal deformities treated with body orthosis is mostly caused by psychological reasons mainly associated with relations at school and back pain. Therefore it’s recommended to give these patients careful instructions and psychological support   

Operative treatment

Patients with Scheuermann’s disease rarely undergo surgery because the natural history of the disease is in most cases benign. Conservative treatment is usually not effective for large curves (above 75°) or in the adult. Spinal pain and unacceptable cosmetic appearance are the most common indications for surgery. It’s important to be careful in counselling these patients because these criteria are subjective. Because of this, there are also no evidence-based criteria for an indication of surgery. Other indications for surgery are exceptional complications like neurologic decompression through an anterior thoracotomy or posterolateral decompression. According to the literature, operative treatment should be considered in patients presenting with a kyphotic deformity over 75°, significant pain that has not responded to conservative measures associated with significant kyphosis (>65°) and/or respiratory problems due to severe kyphosis usually above 100° (LoE 2A).(LoE 2B)(LoE 2B)

The results of the surgical treatment can be considered relative to the two most common indications listed for surgery: relief of pain and correction of deformity (LoE 2A).(LoE 2B)

Before the operation there will be a clinical examination. The stiffness of the hamstrings, a popliteal angle of less than 30° and neurological findings will be tested. Stiff hamstrings can cause sagittal decompression. Radiographs will include long, scoliosis and the hyperkyphosis.
To rule out exceptional thoracic disc herniation, epidural cyst or possible spinal stenosis an MRI is recommended. Clinical photographs are mandatory because the operation is essentially cosmetic. Surgeons need to know: if the curve needs an anterior release, which levels must be included in the spine fusion, which correction technique they have to use and what the amount of correction is.
If the patient can’t make a thoracic curve less than 50°, anterior release is indicated.
Also the posterior shortening technique can help to reduce the curve. In this technique the superior and inferior facets at the apex are removed. Posterior fusion alone exposes the patient to loss of progression over time. The long-term result with pedicle screw instrumentation is not known but with an anterior fusion it will never be wrong. This because thoracoscopic procedures render the anterior release less morbid and may prevent loss of correction in the future.
For a classic Scheuermann’s disease, where the apex is at T8, one would release from T5-T6 down to T10-T11. It’s recommended to perform an anterior release of 5-6 levels around the apex of the curve and grafting the intervertebral disc spaces with pieces of autologous rib.
5-10% in patients with segmental posterior instrumentation has late operative-site pain. Even with a solid posterior fusion, removal of posterior instrumentation may lead to recurrence of the deformity. Therefore, an anterior fusion of large and stiff Scheuermann’s disease is considered safer for a long-lasting correction. The anterior release will be necessary in adult patients with anterior bridging (LoE 2A).

A major instrumention-related complication after surgical correction of Scheuermann Kyphosis is Distal junction kyphosis.

Physical Therapy Management

Treatment of Scheuermann's disease depends on the severity 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 exercise and get a prescription from the doctor for physiotherapy.

The methods of physical therapy include exercise programs to maintain flexibility of the back, correct lumbar lordosis, and strengthen the extensors of the back, electrostimulation and vertebral traction for increasing flexibility before a cast is applied. Although physical therapy has no role in correcting the underlying deformity. (LoE: 2B) Physical therapy is recommended in combination with bracing (LoE 3A).

According to Zaina et al. exercise programmes should always include patient awareness of spinal alignment and neutral and correct position of the vertebral column and awareness of and ergonomic position for work and study. Also mobilisation of the thoracic cage and muscular reinforcement and neuromotor integration are important. Another systematic review (Romano et al. 2013) indicates that there is lack of strong evidence for specific exercises and that higher quality research in this field is necessary.
Katharina Schroth developed a three-dimensional exercise therapy program. She divided the trunk into three parts: cervical, thoracic and lumbar body segments, which can be shifted against one another. This special program was designed to correct the relative position of the three blocks in sagittal plane together with self-elongation of the vertebral column, proprietary corrective breathing techniques and re-education of the neuromuscular system in order to improve postural perception. This method is based on kinaesthetic and sensorimotor principles (LoE 2A).

Spinal self-elongation is the initial force involved in every Schrotch exercise. It’s necessary to teach the patient how to strengthen the musculature surrounding the spine when they are in place associated with the newly formed posture. The patient learns an individual correction routine by using sensorimotor feedback mechanisms. Another type of feedback is the mirror monitoring. It allows synchronizing the corrective movement and postural perception. By using a mirror, the patient is able to see how the kyphotic posture changes into a more favourable one. Also the skeletal imbalance and how musculature gradually transforms into an upright position will be seen in the mirror (LoE 2A).

Changing the patient’s breathing pattern in order to decrease the risk of spinal deformity curve progression and to promote a more balanced posture is also an important part of the therapy.
Other components essential in the Schroth method are motivation and cooperation (LoE 2A).

Treatment objectives are stretching pectoral and hamstring muscles and passive and active reduction of the kyphotic curve. They learn to utilize active trunk muscle forces correctively and to maintain an erect posture. This correct posture is maintained in daily living activities. Particularly the “two stool” exercise and the “door frame” exercise show elements of muscle stretching and improvement of the thoracic kyphosis (LoE 2A).(LoE 3A)

Exercises include corrections in sitting and supine positions and correction against resistance in standing position.
The Schroth therapy may be effective in preventing impairment and reducing the thoracic curvature in Scheuermann’s patients. Further research is needed to implement this method in an evidence based clinical practice model  (LoE 2A).

Jaeger J et al found a significant reduction in kyphosis using the CBP protocol. Initially the therapy included full spine diversified spinal manipulation to the cervical, thoracic and lumbar regions. Also traction in the axial cervical spine/upper thoracic spine was performed with 20lbs for 10 minutes. To reduce pain and inflammation while mobilizing they put ice packings between the table top and the patient’s spine. Afterwards the patient started the CBP technique. This included mirror image postural adjusting using a drop table and with use of impulse handheld adjusting instrument. Each visit the patient did 3 sets of 15 repetitions of mirror image head retraction exercise while also pulling the pelvis posterior to the wall to extend the thoracic spine. Also thoraco-lumbar anterior and posterior core stability exercises on a Theraball were performed. They found a significant positive difference. 

Exercises (LoE 2B) (LoE 3B):

Bilateral external rotators associated with thoracic extension with elastic resistance: 3 x 20 rep (LoE 3B)

• ∗ Low rowing with elastic resistance. 3 x 20 rep (LoE 3B)
• the two stool exercise (LoE 3B):
• ∗ The door frame exercise (LoE 3B)
• ∗ Exercise on the wall bars

More Exercises:

• Movie 1: Heal Thoracic Kyphosis With Six Simple Exercises
• Movie 2: Improving Your Posture (kyphosis, rounded shoulders, forward neck) - Reece Tomlinson

Key Research

1. Zaina et al. Review of rehabilitation and orthopedic conservative approach to sagittal plane diseases during growth: hyperkyphosis, junctional kyphosis, and Scheuermann disease. EUR J PHYS REHABIL MED 2009;45:595-603. LoE : 2A
2. Bezalel T, Kalichman L, et al. Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment. Journal of Bodywork and Movement Therapies. April 2015,19(2):232-237 LoE: 2A
3. Wenger D R, Frick S L. Scheuermann Kyphosis. Spine. 1999,24(24):2630-2639 LoE: 2A
4. Arlet V, Schlenzka D. Scheuermann’s kyphosis: surgical management. European Spine Journal. 2005,14:817-827 LoE: 2A
5. Negrini S, Minozzi S, Bettany-Saltikov J, et al; Braces for idiopathic scoliosis in adolescents. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006850. LoE : 2A
   
   

Resources

1. http://cirrie.buffalo.edu/encyclopedia/en/article/125/
2. http://www.spine-health.com/conditions/spine-anatomy/lumbar-spine-anatomy-and-pain
3. http://emedicine.medscape.com/article/1899031-overview#a2
4. http://www.innerbody.com/anatomy/skeletal/thoracic-vertebrae-lateral 
5. www.eorthopod.com/content/scheuermanns-disease
   

Clinical Bottom Line

The management of SD depends upon the type of condition, the severity, the prognosis and the patient's tolerance for various interventions. Early diagnosis and intervention are beneficial.
Standing lateral and anteroposterior radiographs showing anterior wedging or consecutive thoracic vertebrae are the gold standard for diagnosis.
Conservative treatment with physical therapy and bracing is effective in limiting pain and fatigue until skeletal mature is reached for lesser degrees of kyphosis. If the kyphosis is more severe, surgery with spinal fusion is indicated to improve the deformity and symptoms. (LoE 2B)
The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 200527. These have recently been revised and their scientific quality has been increased. Their aim is to offer to all professionals and their patients an evidence-based updated review of the actual evidence on conservative treatment of Scheuermann's disease / idiopathic scoliosis.(LoE 2A)

Recent Related Research (from Pubmed)

1. http://www.ncbi.nlm.nih.gov/pubmed/?term=scheuermann's+disease
2. http://www.ncbi.nlm.nih.gov/pubmed/?term=scheuermann+kyphosis
3. http://www.ncbi.nlm.nih.gov/pubmed/?term=juvenile+kyphosis