Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individuals

We reviewed magnetic resonance imaging studies of the thoracic spines of ninety asymptomatic individuals to determine the prevalence of abnormal anatomical findings. This group included sixty individuals who had no history of any thoracic or lumbar pain and thirty individuals who had a history of low-back pain only. In addition, we reviewed imaging studies of eighteen patients who had an operatively proved herniation of a thoracic disc and studies of thirty-one patients who had been seen with thoracic pain. Sagittal T1-weighted spin-echo and axial multiplanar gradient refocused images at each disc level were interpreted by us (two neuroradiologists and two orthopaedic spine surgeons); we had no clinical information about the patients. Sixty-six (73 percent) of the ninety asymptomatic individuals had positive anatomical findings at one level or more. These findings included herniation of a disc in thirty-three subjects (37 percent), bulging of a disc in forty-eight (53 percent), an annular tear in fifty-two (58 percent), deformation of the spinal cord in twenty-six (29 percent), and Scheuermann end-plate irregularities or kyphosis in thirty-four (38 percent). This study documents the high prevalence of anatomical irregularities, including herniation of a disc and deformation of the spinal cord, on the magnetic resonance images of the thoracic spine in asymptomatic individuals. We emphasize that these findings represent roentgenographic abnormalities only, and any clinical decisions concerning the treatment of pain in the thoracic spine usually require additional studies.

Vertebral alterations in Scheuermann's kyphosis

In a cadaver-derived skeletal collection of 1,384 thoracolumbar spinal columns, 103 (7.4%) individuals with vertebral changes of Scheuermann's kyphosis were identified. Anterior extension of the vertebral specimens was noted in 94% of affected specimens. No evidence of osteoporosis was noted by single-photon absorptiometric analysis in the affected sample compared with a normal control group. Biopsy specimens from two immature patients obtained at surgery suggested disorganized endochondral ossification similar to that noted in Blount's disease. It was concluded that increased pressure on the anterior margin of the centrum is responsible for histologic and morphologic changes of Scheurermann's kyphosis.

The aetiology of spinal deformities

There are two types of spinal deformity, lordosis and kyphosis, and they are mutually exclusive at the same site. Lordosis is rotationally unstable and buckles to the side with growth and spinal flexion, producing scoliosis and changes in transverse plane geometry as secondary phenomena. Kyphosis is a uniplanar deformity arising behind the axis of spinal column rotation and it does not buckle. Spinal balance in the sagittal plane is delicate and in the normal child during adolescence both idiopathic scoliosis and idiopathic kyphosis can easily develop. The development and progression of spinal deformities can be explained in biological and mechanical terms. Any condition in which the critical load to the spine is reduced will favour the production and progression of a spinal deformity. Neuromuscular factors in idiopathic scoliosis are additive and not causative.

Disk degenerative disease in childhood: Scheuermann's disease, Schmorl's nodes, and the limbus vertebra: MRI findings in 12 patients

Twelve pediatric patients were studied with MRI. All had various disk problems including Scheuermann's disease, Schmorl's nodes and limbus vertebrae. All patients shared loss of disk height, altered disk hydration and variable herniation of nuclear material.

Combined idiopathic kyphosis and scoliosis. An analysis of the lateral spinal curvatures associated with Scheuermann's disease

A radiological study of 50 patients with thoracic Scheuermann's disease revealed two types of lateral spinal curvature. A total of 43 lateral curves was present in 35 of the patients. Thirteen were apical at the same level as the Scheuermann's kyphosis and were due to vertebral-body wedging in the coronal plane; these curves had a mean Cobb angle of 15 degrees, occurred with equal prevalence in boys and girls and were directed equally to right and left. Thirty curves occurred in regions of compensatory lordosis (mean 5.6 degrees) situated above or, more commonly, below the Scheuermann's kyphosis. These scolioses had a mean Cobb angle of 16 degrees, were more often convex to the right than to the left and were significantly more prevalent in girls than in boys. The presence of these kyphoses and scolioses in the same spine, separated by only a few vertebrae, emphasises the importance of the sagittal plane in idiopathic spinal deformities and strongly suggests that idiopathic scoliosis and Scheuermann's disease share a common pathological process.

Pathogenesis of osteochondrosis juvenilis Scheuermann

In osteochondrosis juvenilis Scheuermann, foci of various sizes in the cartilaginous end plates of the vertebral bodies display a loosening or complete interruption of the collagen fibers. These findings, together with an alteration and occasional absence of the growth zone, may result in the typical deformation of the vertebral bodies. Electron micrographs of the areas with optically absent collagen fibers reveal collagen fibrils. They are arranged in an irregular pattern. We conclude that a disturbance of collagen or ground substance biosynthesis is of importance in the pathogenesis of juvenile osteochondrosis.

The reliability and diagnostic value of radiographic criteria in sagittal spine deformities: comparison of the vertebral wedge ratio to the segmental cobb angle

STUDY DESIGN

A prospective, radiographic cohort study.

OBJECTIVES

This study assessed the radiographic reliability and diagnostic value of the vertebral wedge ratio (WR) to the more segmental Cobb angle (CA) regarding sagittal spine deformities.

SUMMARY OF BACKGROUND DATA

The use of the CA has been used to assist in the radiographic diagnosis of various sagittal spine deformities. However, the reliability and diagnostic aptitude of the CA remains speculative and may not be as receptive to individual variations of vertebral integrity in sagittal spine deformities.

METHODS

Sixty patients (age range, 8-21 years) who were diagnosed with Scheuermann's kyphosis (Group 1; n = 16), with postural roundback (Group 2; n = 23), or who were regarded normal (Group 3; n = 21) were radiographically evaluated to assess the reliability and diagnostic potential of the vertebral WR (apex of the curve and 2 adjacent vertebrae) and segmental CA. Radiographic assessment was conducted by 3 independent blinded observers on 3 separate occasions.

RESULTS

Very strong intraobserver (WR a = 0.85-0.99; CA a = 0.97-0.99) and interobserver (WR a = 0.79-0.89; CA a = 0.95) reliabilities were noted. A greater degree of WR reliability was noted in Group 1, whereas CA reliability remained consistent in all Groups. A statistically significant difference was found between all Groups in relation to vertebral WR and segmental CA (P < 0.05). Based on relative risk ratio analyses, an apex wedge ratio of < or = 0.80 and/or a segmental Cobb angle of > or = 20 degrees is highly and significantly associated with Scheuermann's kyphosis.

CONCLUSION

The segmental CA exhibited a higher degree of reliability than the vertebral WR. The apex vertebral WR exhibited the greatest amount of wedging in the Scheuermann's patients; whereas in the other groups it remained largely consistent with the adjacent vertebral WRs. An apex vertebral WR < or = 0.80 and/or a segmental CA of > or = 20 degrees are highly associated with the clinical diagnosis of Scheuermann's kyphosis. If the segmental CA cannot be ascertained, the apex vertebral WR is a relatively strong reliable alternative, primarily with regards to Scheuermann's kyphosis. In addition, the type of deformity may potentially dictate the ideal measuring method.

The practical use of surface topography: following up patients with Scheuermann's disease

PURPOSE

The purpose of this study was to answer the question of whether a course of in-patient rehabilitation of 4-6 weeks results in a significant postural improvement in patients with a structural kyphosis. Since all clinical measuring parameters are liable to high margins of error and measuring the surface with the formetric system has shown high reliability in previous studies, this system has been used to evaluate the results of rehabilitation in patients with Scheuermann's disease.

MATERIALS AND METHOD

A pre-/post-interventional study was undertaken including only patients (n = 136) with Scheuermann's kyphosis and a thoracic curve pattern. 62 female patients with an average age of 19 years and 74 male patients of average age 20 years were diagnosed with the Formetric system before an in-patient rehabilitation programme of 4-6 weeks. For this study, the maximal kyphotic angle was evaluated.

RESULTS

The average kyphotic angle as measured by the surface topography system before inpatient rehabilitation was 60.7 degrees (SD 11.2) and after 54.9 degrees (SD 12.1) for the whole sample of 136 patients. The improvements where highly significant in the t-test. In the cases of the female patients, the maximal kyphotic angle decreased from 62 degrees to nearly 54 degrees; in the cases of the male patients it had decreased from 60 degrees to nearly 55 degrees by the end of the programme.

DISCUSSION

After the in-patient treatment, the kyphotic angle decreased very significantly. The range of change was far greater than the margin of error and, thus, the following conclusion may be reached: In-patient rehabilitation with an intensive programme of treatment may result in a correction of structural kyphoses in which there are clear signs of Scheuermann's disease. Consequently in-patient rehabilitation is recommended for adolescents in cases of Scheuermann's kyphoses.

Progressive non-infectious anterior vertebral fusion

Four cases of progressive non-infectious anterior vertebral fusion are described. Three cases remain relatively asymptomatic, but one has developed spinal cord compression secondary to an acute angled kyphosis. The clinical, radiological, and pathological features are reviewed and some comparisons with the spinal changes in thalidomide embryopathy are made.

Juvenile and idiopathic kyphosis. Long-term follow-up of 20 cases

Twelve patients with juvenile kyphosis and eight patients with idiopathic kyphosis were reviewed at an average follow-up of 19 years. The average age of the patients at follow-up was 33 years (range 26-45 years). All the patients but one, who had a posterior fusion of the dorsal spine, had been treated with a plaster cast jacket followed by a plastic brace. At the end of treatment there had been an improvement of about 30% on the original curves in both juvenile and idiopathic kyphosis. At follow-up, however, all the patients had lost the correction obtained and the curves had become worse than originally, those in idiopathic kyphosis more so than those in juvenile kyphosis. Despite the increase in their angular deformity, all the patients managed fairly well and only two complained of distressing back pain.

Identification of human remains lacking skull and teeth. A case report with some methodological considerations

This report deals with a case in Denmark in which close cooperation among the local police, the Central Missing and Wanted Persons Search Squad, and the Institute of Forensic Medicine resulted in the positive identification of human remains (part of a skeleton), although the deceased's skull was missing, he had no teeth (but a dental prostheses), and an attempt at blood typing produced a false result. When the remains were found, there was no idea who the deceased might be. The initial forensic examination provided a general description (age, height, and sex), and reconstruction of the vertebral column showed extensive changes caused by arthrosis and changes typical for Scheurmann's disease. The description made on this basis was sent to police stations throughout the country and, far from where the remains were found, a police officer had received the report of a missing person who could have been the deceased. Further investigation was based mainly on the medical history of this missing person and the tracing of the effects found with the remains, and emphasized radiographic comparison.

Radiological signs of Scheuermann disease and low back pain: retrospective categorization of 188 hospital staff members with 6-year follow-up

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To investigate the relationship between radiological signs of Scheuermann disease (SD) and low back pain (LBP) in a local population using lumbar magnetic resonance (MR) images.

SUMMARY OF BACKGROUND DATA

SD is a spinal disorder, and both its classic and atypical (lumbar) forms are associated with LBP. However, radiological signs of SD are present in 18% to 40% of the general population, in whom the clinical significance of "SD-like" spine remains largely unknown.

METHODS

This retrospective cohort study included 188 staff members from a single hospital. Participants' lumbar MR images and self-administered questionnaires concerning demographic information, LBP status, consequences, and functional limitations were collected. Participants were classified into 2 groups according to whether lumbar MR images met SD diagnostic criteria, and LBP status, consequences, and functional limitation were compared. Follow-up interviews were conducted after 6 years to compare LBP progression.

RESULTS

Thirty-four participants (18.1%) had SD-like spine. Rates of lifetime, previous 1-year, and point LBP did not significantly differ between groups. However, among participants who had ever had LBP, SD-like spine was associated with higher rates of work absence (42.1% vs. 9.5%, χ = 9.620, P = 0.002) and seeking medical care (68.4% vs. 39.2%, χ = 5.216, P = 0.022) due to LBP, as well as significantly greater intensity of the most severe LBP episode in the past 2 years (6.4 ± 2.5 vs. 4.1 ± 2.5, t = 3.564, P = 0.001). Among the 159 participants who completed the 6-year follow-up, a significantly higher proportion of people with SD-like spine reported aggravated LBP during the follow-up.

CONCLUSION

Our results suggest that in the general population, lumbar MR images of many people meet SD diagnostic criteria, and having SD-like spine seemed to be associated with the severity and progressive nature of LBP. Our findings should inspire further research in this field.

LEVEL OF EVIDENCE

3.

Surface stereophotogrammetry of thoracic kyphosis

The thoracic kyphosis angles of 16 normal individuals, 10 patients with Scheuermann's disease and 11 with adolescent idiopathic scoliosis were measured both radiographically and from Integrated Shape Imaging System (ISIS) scans obtained by surface stereophotogrammetry. There was a high correlation between the two measures. The method of kyphosis measurement from ISIS scans was then used for 30 patients with adolescent idiopathic scoliosis who underwent corrective surgery. A significant reduction in thoracic kyphosis was observed postoperatively. In another group of 28 patients managed conservatively by bracing, some hypokyphosis developed after treatment. However, we found no association between hypokyphosis and curve progression.

Collagen stability and cross-linking in normal and kyphoscoliotic mouse intervertebral discs

Intervertebral discs of the cervical-thoracic region of the spine of BDL mice which are homozygous for the ky gene mutation undergo degeneration. Discs from these mice have a normal collagen content and undergo normal collagen cross linking prior to the appearance of degenerative changes. The major reducible collagen cross-link formed in discs of these mice and in normal CBA strain mice is hydroxylysino-5-ketonorleucine. These results and other previous results indicate that the discs in the ky mouse develop degenerative disease due to an extrinsic factor rather than to an intrinsic abnormality of their extracellular matrix. The extrinsic factor has been identified as spinal muscle atrophy.

Analysis of cervical sagittal alignment change following correction of thoracic and thoracolumbar Scheuermann's kyphosis

PURPOSE

To analyse pre-operative and post-operative changes of cervical sagittal alignment (CSA) in Scheuermann's kyphosis (SK) patients.

METHODS

64 SK and 33 control patients were retrospectively reviewed. Whole spine X-rays obtained at pre-op, 3 months post-op and at latest follow-up were reviewed and ten separate CSA radiological parameters were measured. Patients were divided in three groups: thoracic SK (TK group, apex T6-T9, n = 40), thoracolumbar SK (TLK group, apex T10-T12, n = 24), and controls.

RESULTS

Pre-operative C2-C7 lordosis was 21.1° ± 8.1°(TK), 6.1° ± 5.0°(TLK), and 11.4° ± 8.3° in control group and correlated significantly with T1 slope in both SK groups (r = 0.640, r = 0.772). Pre-operative T1 slope was dependent on deformity type, thoracic kyphosis (TK, β = 0.445), and lumbar lordosis (LL, β = -0.354). At final follow-up C2-C7 lordosis decreased to 15.7° ± 5.5° in TK, and increased to 12.1° ± 4.1° in TLK group. C2-C7 lordosis changes linearly correlated with T1 slope changes post-operatively (r = 0.721). Post-operative T1 slope showed linear correlation with post-operative changes in TK (β = 0.728) and pelvic tilt (PT, β = 0.539) in TK, and LL (β = -0.669), thoracolumbar kyphosis (TLK, β = -0.434), and PT (β = 0.760) in TLK group.

CONCLUSIONS

Our study suggests that SK is not a homogenous group of patients. Two patterns of pre- and post-operative CSA are demonstrated in TK and TLK groups. T1 slope is the most important parameter in determining pre-operative CSA and correlates with other regional anatomical parameters (TK and LL). Post-operative CSA adaptations also correlate with T1 slope post-operative changes. However, post-surgical T1 slope correlates with different parameters in the two SK groups (TK and PT in TK group; TLK, LL, and PT in TLK group).

Scheuermann's disease in a juvenile male from the late Roman necropolis of Torrenueva (3rd-4th century CE, Granada, Spain)

This study details a severe case of Scheuermann's disease (SD) in a well-preserved skeleton of a juvenile male (designated TOR302), dated to 3rd-4th century CE, from the late Roman necropolis of Torrenueva (Granada, Spain). Individual TOR302 shows an evident kyphotic curve in the thoraco-lumbar spine, which is characterised by: (i) vertebral bodies of thoracic vertebra T2, thoracic segment T4-T9, and thoraco-lumbar segment T12-L2 wedged at >5°; (ii) slight anterior extensions of the epiphyseal ring; (iii) Schmorl's nodes on the superior and/or inferior plates; and (iv) a Cobb angle of 75°, derived from thoracic segments T4-T9. In addition, TOR302 shows other skeletal malformations as the secondary results of abnormal growth, due to altered biomechanical forces imposed by the spinal deformity, including: (i) lateral distortion of the spine that causes a slight secondary scoliotic curve; (ii) pelvic obliquity; and (iii) discrepancy in the length of the limbs. We argue that the secondary skeletal abnormalities allowed the individual to adapt to his spinal deformity meaning he was able to walk without the aid of a stick. Despite SD being a common modern clinical finding, few cases have been reported in ancient skeletal remains. This case therefore represents an important contribution to the palaeopathological literature.

Outcome of in-patient rehabilitation in patients with M. Scheuermann evaluated by surface topography

For the follow-up of patients with sagittal spinal deformities and postural disorders, we do not have well validated measuring systems at our disposal. All clinical measuring parameters are liable to a high margin of error. With a growing number of patients suffering from postural disorders and kyphoses, we have to look for other possibilities to monitor changes of the back, as well as in the short term, without the support of X-rays. As the measuring of the surface with the Formetric system showed a high measurement reliability in previous studies, we used this system to demonstrate the rehabilitation results of our patients with Scheuermann's disease. An intervention study (pre-/post-design) was undertaken including the following material.: 62 female patients with Scheuermann's disease and an average age of 19 years old and 74 male patients with Scheuermann's disease and an average age of 20 years old were measured with the Formetric system before an in-patient rehabilitation of four to six weeks. For this study, we evaluated the maximal kyphotic angle as shown by the system. In the case of female patients, the maximal kyphotic angle decreased highly significantly from sixty two to nearly fifty four degrees. In the case of the male patients, it decreased from sixty to nearly fifty five degrees at the end. It showed that the surface measuring system with the Formetric System is a reliable instrument for the follow-up of sagittal postural disorders and kyphoses for the present study, especially in the case of Scheuermann's disease. In praxis, the use of this measurement is very easy, we obtain the measurement results very quickly, so that the evaluation of data is not very time consuming. After the in patient treatment, the kyphotic angle decreased highly significantly. The changes range far above the margin of error, thus the following conclusions are justified. Firstly, the Formetric System is the appropriated instrument for the follow-up of postural disorder and kyphoses. Secondly, the in-patient rehabilitation with an intensive treatment program may result in a correction of also structural kyphoses with sure signs of Scheuermann's disease. Thus we recommend an in-patient rehabilitation in adolescent age in case of Scheuermann kyphoses with large curvatures and in case of Scheuermann kyphoses in adults suffering from pain.

Assessment of bone density in children with Scheuermann's disease

Twenty four children with Scheuermann's disease (11 girls and 13 boys) aged 9-18 years measured for bone mineral density. The total skeleton (TB BMD) and lumbar spine (L2-L4 BMD) mineral density were investigated by dual energy X-ray absorptiometry (DEXA). In nine patients with Scheuermann's disease and backache we found lower levels of TB BMD and L2-L4 BMD in comparison with reference population of Lunar database. Osteopenia in these children may be caused by decreased physical activity due to vertebral pain.

Scheuermann's juvenile kyphosis. A histologic study

The case histories and gross and microscopic findings of two adolescent patients with Scheuermann's kyphosis demonstrate that the anterior longitudinal ligament is bowstrung across the apex of the hyphosis. The microscopic findings include markedly irregular end plates and end plate disruption with protrusion of disk material into the vertebral body. The ring apophysis does not show avascular necrosis. The intervertebral disk is interpreted as normal both by routine histology and electron microscopy. It is postulated that Scheuermann's kyphosis may be secondary to vertebral osteoporosis occurring during the juvenile period rather than to an intrinsic abnormality in the intervertebral disk or ring apophysis.

Vertebral osteochondrosis (Scheuermann's kyphosis)

Scheuermann's juvenile kyphosis may be considered a form of vertebral osteochondrosis. Although the etiology remains unknown, the ultimate effect is a disorderliness of vertebral growth in the growth plate cartilage. The biomechanical effects of increased kyphosis on saggital plane deformity, especially in a growing child, serve to aggravate this deformity.

Transient kyphotic deformity of the thoracolumbar junction resulting from a large abdominal cyst: a case report

BACKGROUND CONTEXT

Pronounced kyphosis of the thoracolumbar junction is a common orthopedic problem in adolescents and may require prolonged bracing therapy or correction spondylodesis.

PURPOSE

To describe a case where a kyphotic deformity was related to gynecological instead of spine pathology.

STUDY DESIGN

Case report.

METHODS

A 17-year-old girl presented with a structural hyperkyphosis of the thoracolumbar spine and radiographic changes of the involved vertebral end plates.

RESULTS

The thoracolumbar hyperkyphosis appeared to have evolved from a massive intra-abdominal ovarian cyst. Endoscopic paracentesis of the cyst resulted in a complete regression of the hyperkyphosis.

CONCLUSIONS

A hyperkyphosis is not always related to spine pathology, and other potential causes must be excluded before bracing therapy is initiated.

The osteochondroses. A new pathological concept

In all histopathological studies of the osteochondroses, the one constant finding is a dysplastic change in the cartilaginous epiphysis and apophysis. This gives rise to disturbances of enchondral ossification, diminished mechanical resistance of the abnormal cartilage, and to ischaemic changes in the ossific nucleus. This has been demonstrated histologically only in Perthes disease and Köhler's disease and probably reflects vascular damage provoked by abnormal cartilaginous growth. Cartilage dysplasia could constitute the fundamental pathogenetic background common to all the osteochondroses.

[Low back pain among children and adolescents]

OBJECTIVES

We presented our experience with the diagnosis and treatment of low back pain in children.

METHODS

We retrospectively reviewed 29 children (15 girls, 14 boys; mean age 12 years; range 9 to 17 years) who were treated for low back pain and had appropriate follow-ups. Etiologic causes were sought by clinical evaluation, radiologic studies, and laboratory tests. Patients with unknown etiology underwent symptomatic treatment. The mean follow-up period was 42 months (range 12 to 96 months).

RESULTS

Etiology was determined in 26 patients (89%), which included spondylolysis/spondylolisthesis (n=8), Scheuermann's disease (n=6), neoplasia (n=5), discitis/vertebral osteomyelitis (n=4), and lumbar disc herniation (n=3). Spondylolysis was managed conservatively, except for one patient who had in situ spinal fusion for associated spondylolisthesis. Five patients with Scheuermann's disease were treated conservatively, while one patient required spinal fusion. Surgical treatment with biopsy, curettage, and bone grafting was performed for all neoplasias, but one which was followed-up conservatively. Two patients with discitis were managed with antibiotic treatment and two patients with vertebral osteomyelitis (Pott's abscess) underwent both medical treatment and surgical drainage and stabilization with strut graft. Lumbar disc herniation was treated conservatively in two patients, while one had surgical treatment with excision of disc fragments and limited laminectomy. Finally, all the patients became asymptomatic on final examinations.

CONCLUSION

Serious consideration should be given to persistent low back pain in children. Clinical, radiologic, and laboratory findings can be elaborated into etiologic diagnoses and complete relief can be achieved with appropriate treatment.