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.

Back pain in children

Children and adolescents occasionally have back symptoms, but rarely come to a physician's office for more severe back pain. When a child or adolescent appears in the clinic with complaints of back pain, a careful detailed evaluation is appropriate. The incidence of findings in children with significant back pain is high; therefore, a detailed history, physical examination, and evaluation are needed. It is also legitimate to continue monitoring children even if no obvious cause is initially identified because often a diagnosis subsequently will be made.

Scheuermann's disease

Scheuermann's disease is the most common cause of structural kyphosis in adolescence. The mode of inheritance is likely autosomal dominant and the etiology remains largely unknown. Indications for treatment remain controversial because the true natural history of the disease has not been clearly defined. Brace treatment appears to be very effective if the diagnosis is made early. Surgical treatment is rarely indicated for severe kyphosis (> 75 degrees ) with curve progression, refractory pain, or neurologic deficit.

Scheuermann's kyphosis

Scheuermann's disease is a kyphotic deformity of the spine that develops in early adolescence. This condition has been reported to occur in 0.4% to 8% of the general population, with an equal distribution between sexes. Diagnosis of Scheuermann's disease is suggested on clinical examination; however, parents of children affected often confuse it with poor posture. Radiographs are the standard imaging modality used to confirm the diagnosis of Scheuermann's disease. Classic signs include vertebral end plate irregularity, disk space narrowing, and anterior wedging of involved vertebral bodies. Other diagnostic tools such as CT scans or magnetic resonance imaging may also be of value in the evaluation of Scheuermann's disease. The mode of treatment for this condition depends upon the severity of the deformity, remaining growth, and presence or absence of symptoms. Early treatment may be limited to observation and exercises, whereas patients who have kyphosis of up to 75 degrees and how have growth remaining may benefit from bracing. Surgical correction is reserved for severe cases that are symptomatic and refractory to conservative management.

[Differential diagnosis of erosive osteochondrosis and bacterial spondylitis: magnetic resonance tomography (MRT)]

PURPOSE

To evaluate retrospectively criteria in the differential diagnosis of erosive osteochondrosis (EO) and infectious spondylitis (IS) on the basis of MRI.

METHODS

T1-weighted sagittal images before and after Gd-DTPA application, T2-weighted TSE or T-STIR images of 23 patients with proven 15 and 41 patients with EO were evaluated. Criteria for this evaluation were morphology and extension of bone marrow edema, visibility of the low-intensity vertebral endplate, contrast enhancement and signal intensity in the disc space on T2-weighted and T-STIR images.

RESULTS

Bone marrow edema was more extensive in IS than in EO. The mean rated value for bone marrow edema on a four-level scale (0-3) was for IS 2.91 (+/- 0.29), for EO 1.32 (+/- 0.76, p < 0.001). In 37/41 cases of EO and in 22/23 cases of IS Gd-DTPA enhancement was found in the disc space (n.s.). In EO the low intensity endplate was visible in all parts in 36/41 cases (87.8%) on T1-weighted images, in IS not in a single case (0%). On T2-weighted or STIR images signal intensity of the discs was decreased in 82.1% of EO, 82.6% of segments in IS had water-equivalent signal intensity (p < 0.001).

CONCLUSION

If all the criteria are taken into consideration differential diagnosis of EO and IS on the basis of MRI findings is possible.

[3-dimensional surface measurement of spinal deformities with video rasterstereography]

QUESTION

Video rasterstereography is a method for back surface measurement comprising automatic back surface reconstruction and shape analysis. Aim of this prospective study was to determine the accuracy of this method in comparison to the conventional frontal and lateral standing radiographs.

METHOD

95 patients with idiopathic scoliosis or scoliotic postural abnormalities and 18 patients with thoracic hyperkyphosis and Scheuermann's disease were investigated. The Cobb angles, the sagittal profile and apical vertebral rotation as well as pelvic obliquity and trunk decompensation were measured. The analysis was carried out by two independent observers.

RESULTS

The root mean square (r.m.s.) deviation of the Cobb angle in the cases of idiopathic scoliosis ranged between 7 degrees and 8 degrees. In video rasterstereography there were no false negative results and two false positive results concerning differentiation between structural scoliosis and scoliotic postural abnormality. The r.m.s. deviation of apical vertebral rotation averaged 7.9 degrees and for pelvic obliquity respectively trunk imbalance 0.65 cm respectively 1.07 cm. The thoracic hyperkyphosis in Scheuermann's disease showed a r.m.s. deviation of 5.6 degrees.

CONCLUSIONS

Video rasterstereography is a reliable method in the three-dimensional evaluation of spinal deformities and constitutes a valuable additional tool to the clinical examination and can reduce the number of radiographs.

Scheuermann's kyphosis in adolescents and adults: diagnosis and management

Scheuermann's thoracic kyphosis is a structural deformity classically characterized by anterior wedging of 5 degrees or more of three adjacent thoracic vertebral bodies. Secondary radiographic findings of Schmorl's nodes, endplate narrowing, and irregular endplates confirm the diagnosis. The etiology remains unclear. Adolescents typically present to medical attention because of cosmetic deformity; adults more commonly present because of increased pain. The indications for treatment are similar to those for other spinal deformities, namely, progression of the deformity, pain, neurologic compromise, and cosmesis. The adolescent with pain associated with Scheuermann's kyphosis usually responds to physical therapy and a short course of anti-inflammatory medications. Bracing has been shown to be effective in controlling a progressive curve in the adolescent patient. For the adult who presents with pain, the early mainstays of treatment are physical therapy, anti-inflammatory medications, and behavioral modification. In patients, either adolescent or adult, with a progressive deformity, refractory pain, or neurologic deficit, surgical correction of the deformity may be indicated. Surgical correction should not exceed 50% of the initial deformity. Distally, instrumentation should be extended beyond the end vertebral body to the first lordotic disk to prevent the development of distal junctional kyphosis.

[Back pain in children]

OBJECTIVE

The incidence of back pain in children in our country is unknown. Several causes can produce this symptom, but it is necessary to rule out pathologies that require specific treatments. The goal of this work was to study the incidence and the etiology of back pain in children in our country.

PATIENTS AND METHODS

We present a prospective study done in our Orthopedic Department during a period of 7 months. Twenty-two patients were referred with back pain of at least two months duration. The incidence was 2.9% compared to the total number of patients. The average age ranged from 7 to 17 years.

RESULTS

A careful history and a radiological examination diagnosed 50% (11 cases) of the causes of backache in the present study. An idiopathic etiology was the most frequent cause and represented 9 patients (41%). In the remaining 12 cases (59%) pathological causes that required special treatment were identified including 2 cases of Scheuermann disease, 4 cases of painful scoliosis, 3 spondylolysis with spondylolisthesis, 2 cases of discitis, 1 benign neoplasm and 1 psychogenic cause.

CONCLUSIONS

We recommend conservative management with the use of medication for relief of pain and physical therapy in the idiopathic cases. In the remaining cases, the specific treatment of the disease can improve the back 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.

Evaluating the child with back pain

The most common causes of serious low back pain in children include spondylolysis, Scheuermann disease and musculoligamentous injury. Questions should be asked about the mechanism of onset and exacerbating factors, and the frequency, duration and severity of the pain. The examination should check gait and alignment, flexibility, strength and reflexes, and localize and evaluate the pain. Warning signs of serious problems include constant pain in a child younger than 11 years of age that lasts for several weeks or occurs spontaneously at night, repeatedly interferes with school, play or sports, or is associated with marked stiffness and limitation of motion, fever or neurologic abnormalities. Pain at the lumbosacral junction may suggest spondylolysis or spondylolisthesis. Scheuermann disease is diagnosed by the observance of wedging, irregularity or growth disturbance of three successive vertebrae. Musculoligamentous pain may result from injury to or overuse of muscles or joints of the back. Rare causes include discitis, tuberculosis, bone or spinal cord tumor, pyelonephritis and retroperitoneal infection.

[Scheuermann disease as predisposition of later spinal disease and its effect on expert assessment in occupational disease examinations]

The Scheuermanns disease is an illness of which the fluoride stage is described as a disorder in growth of the vertebral-intervertebral disk borderline. This stage of the illness ends with the finish of bone growth. Depending on the advanced alterations of the spinal column segments or of the statics of the spinal column up to that point, in later stages of life there will be a higher rate of diskopathies of the lumbar vertebrae and later on of the cervical vertebrae where it often causes arthrosis of the swivel joints. I.e. Morbus Scheuermann is a predisposition for the beginning of diskopathies and has to be added to the differential diagnostic investigation considerations for the examination of causality of the occupation diseases subparagraph 2108 to 2110. We find it justified that the Scheuermanns disease has to be included into the accompanying leaflet as a relevant pre-illness. The thorakal as well as the lumbarthorakal or lumbar manifestation has to be a competitive cause of vocational connection brought under discussion. That is the reason why all the more a preference of the expected segments is required as far as an essential partial cause with a vocational influence with the judgement is discussed. The same also applies to the judgement in a sense of deterioration.

Spinal posture during pubertal growth

A cohort of children was followed-up annually from a mean age of 10.8-13.8 years to determine the development of their posture. Of the sample of 1060 children, 847 (79.9%) participated in the final examination. Thoracic kyphosis and lumbar lordosis were measured annually with a spinal pantograph. Those children whose thoracic kyphosis in pantography was more than 35 degrees at entry and 45 degrees or more at the final examination underwent a lateral standing radiograph. The 3-year incidence of Scheurermann's disease was 0.4%. The mean thoracic kyphosis increased and the mean lumbar lordosis decreased with age in both sexes, but these changes were not constant. Thoracic kyphosis was most pronounced at a mean age of 12.8 years and lumbar lordosis was least pronounced at a mean age of 13.8 years. In accordance with the literature, the wide individual variation found in this study for both thoracic kyphosis and lumbar lordosis during the pubertal growth period was mainly physiologic.

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.

Sacral osseous destruction in a female gymnast: unusual manifestation of Scheuermann's disease?

We describe a 14-year-old female gymnast whose complaint was that of chronic low back pain. Radiographs and computed tomograms showed both lumbar manifestations of Scheuermann's disease and an osseous destruction of the S1 vertebral body. We suggest that this is a sacral component of Scheuermann's disease.

[Physical measurement of the dorsal kyphosis in 14-17-year old patients with Scheuermann's disease and in matched healthy controls]

The modified use of the Debrunner-kyphometer (a special protractor to measure the dorsal kyphosis by an objective physical method) is presented. After proving the validity and reproducibility of the measuring method, the dorsal kyphosis of patients with Scheuermann's disease and of matched healthy controls was measured. The aim of the measurements was to assess the physiologic values of kyphosis and to investigate into the distribution of Scheuermann-patients regarding the grade of their dorsal sagittal curvature. In contrast with the everyday routine (subjective judgement of the sagittal curvatures or measuring on X-ray films), this method offers the advantage of an objective assessment without using X-rays. The presented simple method is recommended for screening school-children and for monitoring patients with Scheuermann's disease.

[Symptoms of spinal osteochondrosis]

Having screened 384 patients suffering from Scheuermann's disease and 2992 eleven-year-old children, the authors conclude that the early and salient symptoms of the disease are mobile thoracic kyphosis associated with the flexious contracture of the hip joint, and occasional anteflexious contracture of the shoulder joint together with a left-curved functional scoliosis. The authors analyse the nature and frequency of scoliosis, excluding other causes of the flexion contracture of the hip joint. Their findings are supported by data processed on computer.

[Scheuermann's disease]

Scheuermann's disease is most frequently diagnosed in patients between 13 and 17 years and is subdivided into high, long and low kyphoses. The symptoms consist of pain which may be aggravated by physical exertion. Pain is most frequent and most severe in the long and low kyphoses. The etiology and pathogenesis are not entirely elucidated but it is probable that there is a genetic component, that the condition is not unifactorial and that it may be due to weakness in the epiphyseal plates of the vertebrae. Radiography reveals irregularities of the end-plates of the vertebrae, frequently with Schmorl's impressions, narrowing of the intervertebral spaces, one or more wedge-shaped vertebral bodies and increased kyphosing. No effective symptomatic treatment is known but the patients should be advised about choice of career and work. In order to avoid hyperkyphosis and chronic pain, back and abdominal musculature must be strengthened and mobility in the spine improved. Gymnastics, swimming and cycling on stationary bicycles may be recommended but sports associated with jumping and marked stress for the spine must be warned against. In few and severe cases, treatment with a corset or operation may be necessary.

Disc degeneration in young gymnasts. A magnetic resonance imaging study

Magnetic resonance imaging (MRI) was performed on 35 young competitive gymnasts and 10 control subjects in order to detect the number of degenerated discs and other lumbar spinal disorders. Lumbar radiographs were obtained from all gymnasts who showed evidence of disc abnormality on MRI. Eleven gymnasts had suffered from episodes of low back pain during exercises and eight were found to have evidence of back trauma. Only 3 of the 35 gymnasts had MRI evidence of degenerated discs associated with Scheuermann's manifestations and spondylolysis. Lumbar radiographs confirmed the diagnosis in these three cases. The results indicate that despite the excessive range of motion and strong axial loading of the lumbar spine that are associated with gymnastic maneuvers, incurable primary damage to the intervertebral discs is uncommon in young gymnasts during growth.

Disc degeneration in Scheuermann disease

Comparison of the radiographic signs of Scheuermann disease and the corresponding disc degeneration on thoracolumbar magnetic resonance (MR) images was made in 21 young patients. Marginal sclerosis, Schmorl nodes and narrowed disc spaces, but not irregular or wedge-shaped end-plates, were significantly associated with disc degeneration. Fifty-five percent of the discs in the patients with Scheuermann disease were abnormal on MRI, compared with 10% in asymptomatic controls. Our study confirms that thoracolumbar disc degeneration is enhanced in 20-year-old patients with low back pain who have radiological evidence of Scheuermann disease.

Magnetic resonance study of disc degeneration in young low-back pain patients

The correlation of roentgenographic findings, clinical history, and incipient disc degeneration (DD), diagnosed with magnetic resonance imaging, was analyzed in young patients with low-back pain (LBP). One or more lumbar discs were abnormal in 57% of the 20-year-old LBP patients (n = 75) and in 35% of the asymptomatic controls (n = 34) in MRI. Narrowed disc spaces and alterations attributed to lumbar Scheuermann's disease, shown on the radiographs, were always associated with DD in MRI. Such a strong relationship was not observed with transitional vertebrae, spondylolisthesis, spina bifida, or postural abnormalities. However, an increased weight, a positive straight leg raising test, and a reduced lumbar mobility was consistent with an increase in frequency of DD. Magnetic resonance imaging is a safe and sensitive method for studying the presence and etiologic factors of DD.

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.