The duPont kyphosis brace for the treatment of adolescent Scheuermann kyphosis

The purpose of this study was to evaluate the effectiveness of a newly designed brace in the treatment of adolescent Scheuermann thoracic kyphosis. Twenty-two children who met the roentgenographic criteria of Scheuermann kyphosis and were compliant with treatment were followed until skeletal maturity. Sixteen patients (73%) showed nonprogression of their kyphosis (nine patients demonstrated an improvement, seven patients remained unchanged), and had a mean improvement of 9 degrees (64 degrees to 55 degrees). Six patients (27%) demonstrated progression of the kyphosis and had a mean increase in their kyphosis of 9 degrees (59 degrees to 68 degrees). One patient underwent posterior spinal fusion for progressive thoracic kyphosis despite bracing. It was recommended that this brace be worn until skeletal maturity; in this study this time period was determined to be at least 16 months to induce improvement or halt progression of this disease. Flexible curves are a positive predictor of a successful outcome of bracing with the kyphosis brace. These results are comparable to previous reports in the literature describing the effectiveness of the modified Milwaukee brace in the treatment of Scheuermann thoracic kyphosis prior to skeletal maturity, and the kyphosis brace has the advantage of concealability under normal attire.

Effect of intensive rehabilitation on pain in patients with Scheuermann's disease

In our rehabilitation centre, the treatment of Scheuermann's disease consists of a daily postural education, lasting several hours. As for pain therapy, we mainly apply physiotherapeutic methods with osteopathy, manual therapy, Mc Kenzie and Brügger. In addition, we offer psychological help for pain relief. In case of severe chronic pain, we additionally treat it with acupuncture. Pain therapy with medication is only performed in rare cases. The aim of the present study was to find out if such an intensive rehabilitation programme had any effect on pain level in patients with Scheuermann's disease. An Intervention study (pre-/post-design) was undertaken including the following material: 351 patients suffering from Scheuermann's disease reported their pain level before and after an inpatient treatment. For this aim, we used a visual analog scale (VAS), a numerical scale (NS), a standardised adjective scale (VRS) and a pain frequency scale. In our group, there were 61 female patients with a thoracolumbar Scheuermann's disease, 121 female patients with a thoracic Scheuermann's disease, 92 male patients with a thoracolumbar Scheuermann's disease and 77 male patients with a thoracic Scheuermann's disease. The average age was 17 to 21 years old with an average kyphotic angle varying in the individual groups between 53 and 64 degrees. In the case of the numerical pain severity scale, pain severity was for example 2,9 in female patients with thoracolumbar Scheuermann's disease. In female patients with thoracic Scheuermann's disease, pain severity was also at 2.9. In male patients with thoracolumbar Scheuermann's disease, it was at 2.0 and in male patients with thoracic Scheuermann's disease, it was at 1.9. This numerical pain scale showed highly significant changes in pain severity: 2.1 in female patients with thoracolumbar Scheuermann's disease, 1.9 in female patients with thoracic Scheuermann's disease, 1.4 in male patients with thoracolumbar Scheuermann's disease and 1.8 in male patients with thoracic Scheuermann's disease. There was also a significant decrease in pain frequency. Seen as a whole, each scale showed a pain reduction between 16 and 32%, which is significant in all the cases and even highly significant in some cases. The in patient rehabilitation seems to have a positive effect on pain level in patients with Scheuermann's disease. In case of Scheuermann's disease in adult age, treatment is only indicated when patients suffer from pain. For those reasons, an in-patient intensive program of rehabilitation in a clinic with adequate quality structure should be considered.

Segregation analysis of Scheuermann disease in ninety families from Siberia

Scheuermann disease [OMIM number 181440] is the most common cause of structural kyphosis in adolescence. Segregation analysis using a model with gender effects was applied to 90 pedigrees from Barnaul (West Siberia, Russia) ascertained through a proband with Scheuermann disease. The transmission probability model was used to detect major gene effect. A significant contribution of a major gene to the control of the pathology was established. Inheritance of the disease can be described within the framework of a dominant major gene diallele model. According to this model, Scheuermann disease should never occur in the absence of the mutant allele. All male carriers of the mutant allele develop the disease, while only a half of female carriers manifest it. We found a high frequency of idiopathic scoliosis in the families with Scheuermann disease (0.08 vs. 0.01-0.02 in general population). We also observed a succession of idiopathic scoliosis and Scheuermann disease in consecutive generations. The familial aggregation of these two spinal pathologies in the present sample may indicate a genetic unity of Scheuermann disease and idiopathic scoliosis.

Surgical treatment of Scheuermann's disease with segmental compression instrumentation

Twenty-one patients with Scheuermann's kyphosis had surgery for progressive kyphotic deformity of 50 degrees or greater. There were six adolescents, with a mean age of 15.6 years (range, 13-17 years) and 15 young adults, with a mean age of 25.4 years (range, 18-40 years). All patients had posterior spine arthrodesis with segmental compression instrumentation. Seven patients with rigid kyphosis had combined anterior and posterior spine arthrodesis. One patient died of superior mesenteric artery syndrome. In the group of 13 patients with posterior arthrodesis only, followup was 4.5 years. The mean preoperative thoracic kyphotic curve of 68.5 degrees improved to 40 degrees at latest review, with an average loss of correction of 5.75 degrees. Junctional kyphosis occurred in two patients with a short arthrodesis: one at the cephalad end and one at the caudal end of the fused kyphotic curve. In the second group of seven patients with combined anterior and posterior arthrodesis, followup was 6 years. The mean preoperative thoracic kyphotic curve of 86.3 degrees improved to 46.4 degrees at latest review, with an average loss of correction of 4.4 degrees. Overall, there was no postoperative neurologic deficit and no pseudarthrosis. Thus, posterior arthrodesis and segmental compression instrumentation seems to be effective for correcting and stabilizing kyphotic deformity in Scheuermann's disease. Despite a long operating time, this technique provided significant correction, avoiding the development of any secondary deformity in most patients. Combined anterior and posterior spine arthrodesis is recommended for rigid, more severe kyphotic deformities.

Surgical correction of Scheuermann's kyphosis

This is a retrospective study of eight consecutive patients of mean age 19 (13-27) years with severe Scheuermann's kyphosis who underwent anterior and/or posterior fusion using the Cotrel-Dubousset (CD) instrumentation. In two an anterior release and fusion with rib grafts had been previously performed. The mean follow-up was 5 years. The preoperative hyperkyphosis averaged 86 degrees (71 degrees - 99 degrees), which was postoperatively 44 degrees (32 degrees - 58 degrees). The average loss of correction was 4.6 degrees (1 degrees - 12 degrees). The lumbar hyperlordosis spontaneously improved from -67 degrees to -48 degrees. Two patients, who had chronic back pain refractory to conservative treatment, improved considerably after surgery.

["Round back" in children and adolescents]

The hyper-kyphosis or "the postural round back" is one of the most common complaints in orthopedic practice. In the majority of cases, the thoracic kyphosis are painless and flexible. The vertebral bodies are normal on radiograms. This is "the kyphotic attitude" or postural round-back. A medical treatment is not the necessary rule. Life hygiene, sports and simple supervision are needed. Nevertheless, there are still pathological fixed kyphosis, induced in the majority of cases by Scheuermann's disease. The other possible etiologies (congenital, paralytic, post-traumatic, Pott's disease, postradiation, or metabolic origin) are a lot rare ones and will be excluded by clinical examination and imaging studies. The structural hyper-kyphosis require treatment. We will approach successively steps of the diagnosis and treatment of the hyper-kyphosis of the adolescent.

[Alkaline phosphatase level and bone density in Scheuermann's disease and in adolescent idiopathic scoliosis]

Authors made a comparison between 167 suffers from Scheuermann's disease (SD), 70 adolescence idiopathic scoliosis (AIS) and 132 age, sex, height, weight, pubertal developmental stages (Tanner stages) matched controls. The height percentile in 130 cases was also determined. The bone mineral density (BMD) was measured by pQCT on the non dominate sided radial bone. The alkaline phosphatase (AP) level increased at the beginning of puberty and in the puberty in SD. In SD the trabecular Z-score of BMD was significantly decreased in Tanner stage 1 to 4 in both boys and girls. It was not found any significance difference, however, in Tanner stage 5, while in AIS girl no significance decrease of BMD was found. In SD good correlation could be demonstrated between increase in AP and decrease in trabecular Z score r = 0.2, while did not correlate with height percentile. The AP level's increase, and radiomorphometric data of SD severity (intervertebral space narrowing and antero-posterior diameter increase of vertebral body) shows a significant correlation with decreased trabecular Z-score in the period of prepuberty.

Pyogenic spondylitis with Scheuermann's disease

We present the case of a teenager suffering from dorsal and lumbar pain. Imaging modalities diagnosed a lumbar retro-marginal anterior herniation and thoracic spondylitis. Such association has been reported twice in the literature.

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.

Painful adult thoracic Scheuermann's disease. Diagnosis by discography and treatment by combined arthrodesis

This is the case report of a 42-year-old woman with chronic thoracic pain, nonradicular and refractory to all nonoperative treatment. Radiographs showed the classic findings of Scheuermann's disease, but without abnormal kyphosis. Magnetic resonance imaging scans showed multilevel thoracic disc degeneration typical of long-term Scheuermann's disease. Thoracic discography revealed concordant pain at T6-7 and T7-8. Treatment consisted of an anterior fusion, T5-11, and posterior fusion of T3 through L1, with Cotrel-Dubousset instrumentation. At follow-up, she was pain free and able to work full time and had been able to return to golf, her favorite recreation. Discography of the thoracic spine, as of the lumbar spine, can reveal the true source of pain and thus lead to precise and effective treatment.

What is a vertebral fracture?

Vertebral deformities may be caused by a variety of conditions, such as osteoporosis, severe trauma, congenital deformities, Scheuermann's disease, osteoarthritis, and multiple myeloma. For the individual patient, the correct diagnosis of an osteoporotic fracture is a prerequisite for the choice of optimal treatment and will be ensured by careful differential diagnosis based on a spinal radiograph and additional diagnostic procedures. Evaluation of radiographs by experienced radiologists is crucial for the correct diagnosis of vertebral fractures. For clinical trials and epidemiological studies of osteoporosis, qualitative radiological evaluation of radiographs has proven to be insufficient, since results lack reproducibility. Therefore, objective morphometric methods based on vertebral height measurements have been developed for fracture identification and quantification in scientific settings. Satisfactory sensitivity of these methods is usually reached at the expense of specificity, leading to a high number of false positives. With some differences in methodology, most of the morphometric approaches are of comparable validity. However, none of the morphometric methods allows any subclassification of vertebral deformities with respect to etiology. A combined approach based on morphometry as well as standardized radiological evaluation by experts appears to be the most promising solution to the problem. Further efforts are needed to standardize radiological criteria to yield comparable results between individual readers and different studies. It has to be evaluated whether the combined approach (clinical reading and morphometry) is necessary during follow-up evaluation, as morphometry may be sufficient for monitoring once the diagnosis has been established at baseline.

Cord compression caused by multiple disc herniations and intraspinal cyst in Scheuermann's disease

STUDY DESIGN

The design for this article is a case report.

OBJECTIVES

Reported is the case of a patient with Scheuermann's disease who experienced spastic paraparesis caused by multilevel disc herniations and intraspinal meningeal cyst occurring together.

SUMMARY OF BACKGROUND DATA

Although Scheuermann's disease is associated with disc degeneration and calcification, multilevel disc herniations causing neurologic deficit is exceedingly rare.

METHODS

A patient diagnosed with Scheuermann's disease was evaluated by laboratory tests and radiographs because of paresthesin in bilateral lower extremities.

RESULTS

Evaluation revealed a "cyst" that was separated from the proper subarachnoid space and a disc herniation.

CONCLUSIONS

Intraspinal cyst and multilevel disc herniations could coexist in Scheuermann's disease. Both could contribute to cord compression. Drainage of the cyst, anterior decompression of the disc herniations, and interbody fusion to stabilize the diseased segments produced good results after 2 years.

[Back lumbar herniated discs and cauda equina syndrome as complications of Scheuermann's disease. A case report]

The author reports the case of a patient with spinal cord compression by a thoracic herniated disc without paraplegia as well as a cauda equina syndrome due to spondylotic and discal lesions, with small protrusions of the L4-L5 and L5-S1 discs associated with Scheuermann disease. There was complete recovery in six months with clinical treatment. The radiological evaluation using standard radiography, myelography, computed tomography, magnetic resonance imaging of the vertebral column, and electromyographic evaluation indicate a precise correlation between clinical picture and the distribution and course of lumbar spinal cord degenerations. Furthermore, a strong correlation was also found with hernias, roots and the bony sequalae of spinal cord dystrophy found in Scheuermann disease.

[Spastic paraparesis in Scheuermann disease: a case report]

A case of paraparesis due to Scheuermann's disease in a 17.5 years old boy suffering from a moderate dorsal kyphosis (Cobb angle 64 degrees) is reported. Etiologically, spastic paraparesis can be caused either by myelon compression due to extradural cysts, herniated dorsal discs, or direct myelon compression from the vertebral bodies. Radiologically, in addition an intraspinal lipom was suspected. Because of the neurological deficits surgical treatment was performed. Ventral release followed by an anterior spondylodesis was combined with a dorsal spondylodesis using the Harrington compression system. An intraspinal lipom could be excluded intraoperatively after laminectomy of the suspicious region. Three months postoperatively, no signs of any neurological deficits were observable. X-ray control demonstrated a solid spondylodesis with an Cobb angle of 38 degrees. Direct myelon compression or indirect myelon damage due to a reduced blood supply at the apex of kyphosis are supposed to be the pathophysiological pathway.

An analysis of sagittal curves and balance after Cotrel-Dubousset instrumentation for kyphosis secondary to Scheuermann's disease. A review of 32 patients

STUDY DESIGN

This study compared preoperative and postoperative saggittal curves and spinal balance in patients undergoing spinal fusion with Cotrel-Dubousset instrumentation for severe kyphosis secondary to Scheuermann's disease. Also determined was patient satisfaction regarding relief of pain and correction of the deformity. Thirty two patients with kyphosis > 75 degrees underwent spinal fusion with Cotrel-Dubousset instrumentation.

OBJECTIVES

To evaluate the initial and long-term correction of the primary kyphosis and changes in lumbar lordosis and sagittal balance, and to determine the incidence and etiology of junctional sagittal deformities.

SUMMARY OF BACKGROUND DATA

The average preoperative kyphosis was 85 degrees (range, 75 degrees to 105 degrees) with an average correction at final follow-up of 43 degrees (range, 26 degrees to 65 degrees). Preoperative lumbar lordosis averaged 75 degrees (range, 58 degrees to 100 degrees) and at final follow-up averaged 55 degrees (range, 23 degrees to 74 degrees). Most of the patients demonstrated negative sagittal balance and became slightly more negatively balanced postoperatively.

RESULTS

Maintenance of correction postoperatively was excellent, with only a 4 degree average loss of correction. There was spontaneous reduction in lumbar lordosis of varying degrees. Proximal junctional kyphosis was associated with over-correction (> 50%) of the kyphotic deformity or a fusion starting short of the proximal vertebra in the measured kyphosis. Distal junctional kyphosis developed in patients whose fusion ended short of the first lordotic segment.

CONCLUSIONS

This procedure appeared to yield good results when proper levels of fusion were selected and correction > 50% was not attempted.

Progressive cord compression secondary to thoracic disc lesions in Scheuermann's kyphosis managed by posterolateral decompression, interbody fusion and pedicular fixation. A new approach to management of a rare clinical entity

During a brief period of 21 months (November 1988 to August 1990) the neurospinal unit of our institution registered three cases of Scheuermann's kyphosis with herniation of the thoracic discs. Local and intercostal pain, progressive spasticity with gait disturbance and urinary hesitancy were the most common presenting symptoms. All of the patients were surgically managed by posterolateral decompression, interbody fusion (posterolateral approach) and pedicular screw plate fixation. The average length of follow-up was 25 months. Results were excellent in two patients and good in one. All patients had improvement in neurological status, were pain-free and demonstrated sound fusion within 5 months. A new approach to management of this rare clinical entity is documented.

Juvenile discogenic disease

This study was undertaken to document an association of degenerative lumbar disc disease in patients with thoracolumbar Scheuermann's disease. During a 3-month period, 9% of 1419 of the persons referred to our center for magnetic resonance imaging of the lumbar spine demonstrated changes of both thoracolumbar Scheuermann's disease and degenerative disc disease in the lower lumbar spine. The disease was less commonly detected on computed tomography (2% of 1522 patients). The patients were relatively young: 81% were younger than 40 years and 9% were younger than 21 years. We theorize that the thoracolumbar Scheuermann's disease and the associated degenerative disc disease of the lower lumbar spine are manifestations of an intrinsic defect of the discs and/or cartilaginous end plates, which results in inadequate nutrition and structural weakness or a combination of both, and early degeneration.

[Effect of spinal exercises on spinal parameters in Scheuermann disease]

Changes in the parameters of the spine (grade of kyphosis, total mobility of dorsolumbal spine, lumbal Schober's sign, finger-ground distance) within one year were studied in 103 Scheuermann-patients. In patients doing regular exercises the kyphosis did not increase and their finger-ground distance improved significantly; whilst in patients not doing regular exercises the kyphosis increased slightly though significantly, and their finger-ground distance did not improve. These result prove the beneficial effect of regular exercises.

Back pain in children and teenagers

Controversial opinions have been published concerning the frequency of LBP among children and adolescents. Studies from orthopaedics or neurosurgical departments have reported low figures for prevalence of specific LBP due to serious disorders. Field surveys, on the contrary, have shown that cumulative life prevalence of non-specific LBP in children and teenagers can be comparable to the prevalence data for adult populations. Some specific diagnoses are more common or characteristic of children complaining of LBP. Age, gender, sports activities and family history of LBP have been found to be significantly associated with an increased prevalence in non-specific LBP among children. Low back pain among children and teenagers is common and should be recognized. This chapter provides guidelines for a clinical approach and differential diagnoses. Most back pain in these age groups is benign and should be treated as such.

Spinal stenosis subsequent to juvenile lumbar osteochondrosis

This paper describes eight patients with spinal stenosis associated with marked osteochondrous changes in the vertebral bodies due to juvenile lumbar osteochondrosis (Scheuermann's disease). In no case was the midsagittal or interpedicular diameter of the spinal canal indicative of bony stenosis. On the other hand, in the myelograms the sagittal diameter of the dural sac was in all cases significantly narrowed, a diagnostic sign of central spinal stenosis. Therefore, myelography should always be contemplated when osteochondrous changes are present and spinal stenosis is suspected clinically regardless of whether the spinal canal diameters are normal in plain films.

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.