The surgical management of Scheuermann's disease

Thirty patients of a group of 39 patients with Scheuermann's kyphosis who underwent posterior spine fusion using large-diameter Harrington compression instrumentation were reviewed with a mean follow-up of 71.8 months. The mean curve before surgery was 71.5, and at follow-up, 37.7. The mean loss of correction at review was 6. This procedure was effective in adults with a fixed deformity as long as no anterior bony bridging existed. The authors believe that posterior Harrington instrumentation and spine fusion offer excellent correction of deformity at long-term follow-up without the added morbidity of a second procedure.

Familial Scheuermann disease: a genetic and linkage study

Scheuermann juvenile kyphosis or Scheuermann disease is the most frequent cause of kyphosis in adolescence. However, the natural history and genetic basis is still unknown. Reports of identical radiological changes in monozygotic twins, sib recurrence, and transmission over three generations suggest underlying heritability. In this study, 12 probands were referred to us. Upon radiological examination of the proband's parents and sibs, seven were shown to have familial Scheuermann disease with an autosomal dominant pattern of inheritance. Of the remaining five probands, four had chromosomal anomalies. The three largest pedigrees were subjected to linkage analysis with three candidate genes: Duffy, COL1A1, and COL1A2. Linkage of Scheuermann disease was excluded with Duffy (lod score = -2.195 at theta = 0.10) and COL1A2 (lod score = -2.750 at theta = 0.05) in these families.

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.

[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.

[Evaluation and treatment of Scheuermann's disease]

Scheuermann's disease is considered a kyphoscoliotic process of specific segments of the vertebral column expanding on the original definition of thoracic hyperkyphosis. More important for prognosis than the description of anomalies of single vertebrae is the competent assessment of static imbalance. Because of lacking long-term results no strategies for treatment can be recommended today. Conservative as well as surgical therapies are laborious and their success often rather limited.

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.

Vertebral bone density in Scheuermann disease

The densities of the trabecular bone of two or three lumbar vertebral bodies in twenty adolescents, twelve to eighteen years old, who had Scheuermann disease were measured by quantitative computed tomography. These densities were then compared with those for the same vertebrae of twenty age, sex, and race-matched adolescents who were examined by computed tomography because of trauma. The same scanner and phantom were used in all examinations. Both the adolescents who had Scheuermann disease and the control patients were in good health before the quantitative computed-tomography examination and had not been taking any medications. The density of the trabecular bone density in the patients who had Scheuermann disease was not significantly different (p = 0.28) from that in the controls. There also were no significant differences between the patients and the controls with regard to height, weight, surface area, or body-mass index.

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.

Idiopathic scoliosis: foundation for physiological treatment

The three-dimensional nature of the idiopathic spinal deformity has been investigated in cadaveric specimens and patients with both idiopathic scoliosis and idiopathic kyphosis (Scheuermann's disease). In both scoliotic and kyphotic deformities the essential lesion lies in the sagittal plane with apical vertebral wedging. In idiopathic scoliosis there is an apical lordosis which being biomechanically unstable rotates to the side to produce a scoliotic deformity as a secondary component. In contradistinction the kyphotic wedging process of Scheuermann's disease is mechanically stable and any associated idiopathic type scoliosis occurs above and below the region of kyphosis. When an asymmetric lordosis is created in the growing New Zealand white rabbit, a progressive lordoscoliosis is readily produced and when the thoracic kyphosis is restored the scoliotic deformity shows evidence of regression and this forms the basis of physiological treatment. In 25 patients with idiopathic thoracic scoliosis the thoracic kyphosis has been restored and this leads to enhanced correction of the deformity in all three planes.

Spondylolysis in Scheuermann's disease

Increased lumbar lordosis places increased stress on the pars interarticularis. Fatigue fractures of the pars can result in spondylolysis. There was a 50% incidence of asymptomatic spondylolysis in 18 patients who had Scheuermann's kyphosis and an increased lumbar lordosis. This significant increase further confirms the pathogenesis of spondylolysis. Patients with Scheuermann's disease with low-back pain should be evaluated with oblique radiographs of the lumbar spine to rule out spondylolysis.

Two hereditary spinal diseases producing kyphosis during adolescence

Familial accumulation of spinal osteochondrosis (Scheuermann's disease) and hereditary juvenile anterior fusion of the vertebral bodies in the thoraco-lumbal area are reported for the first time in the same family. Radiological examination of the spine in 2 planes of 73 persons formed the basis for the study. Nine cases of spinal osteochondrosis and 5 cases of hereditary juvenile anterior fusion were found. Proliferation and increased height of the anterior surface of the body of the vertebrae and pronounced reduction in the anterior aspect of the intervertebral spaces were characteristic during the early stages of the latter condition, similarly fewer back symptoms and a better prognosis were observed in these patients than was the case of patients with Scheuermann's disease.

Scheuermann kyphosis. Follow-up of Milwaukee-brace treatment

From 1960 through 1978, a total of 274 patients who had a diagnosis of Scheuermann kyphosis were treated with a Milwaukee brace at the Twin Cities Scoliosis Center. We analyzed the long-term results in 120 patients who had used the Milwaukee brace and had been followed for at least five years after the completion of treatment. The average age of the patients at the initiation of treatment was twelve years and five months, the average age at the completion of treatment was sixteen years and one month, and the average age at the last follow-up examination was twenty-four years. Of the patients who wore the brace consistently, seventy-six showed improvement in the kyphosis between the initial evaluation and the evaluation at final follow-up, while twenty-four showed worsening and ten were unchanged. Seven of the twenty-four patients who were worse had had surgery before the review for this study. The indication for surgery was a kyphosis of more than 60 degrees that was increasing and was not controlled by the brace. Ten patients were inconsistent in their use of the brace. Two of the ten patients had improvement and eight had worsening of the kyphosis; three of the latter eight had a spinal fusion. This study showed that the Milwaukee brace is usually an effective method of treatment for patients who have Scheuermann kyphosis; however, four of fourteen patients who had an initial kyphosis of more than 74 degrees required a spinal fusion.

Dorsolumbar kyphosis or Scheuermann's disease

Confusion over dorsolumbar kyphosis and Sheuermann's disease has existed in the literature since the first recorded episodes in 1921. The present article delineates an etiology of back pain that is frequently seen in the adolescent population and is not to be confused with the painless fixed kyphotic deformity so frequently mentioned in the scoliosis literature. These patients with a painful dorsolumbar Sheuermann's disease may well have a traumatic herniation of the disk into the bony vertebral body. This type of x-ray and clinical finding should become familiar to all clinicians dealing with an adolescent population.

Lumbar posterior marginal intra-osseous cartilaginous node

This report concerns 12 patients, eight young adults and four adolescents, presenting with lumbar or sciatic pain. This was associated with an unusual defect of the inferior and posterior edges of the vertebral bodies of L4 or L5, together with a small bony ridge protruding into the spinal canal. We found 11 similar cases in the literature, all involving adolescents except for one young adult. It has been considered to be the result of a fracture of the posterior ring apophysis in association with a herniated disc. In our cases, in the absence of any known previous trauma, the radiological features and surgical results and the similarity and frequent association with typical lesions of Scheuermann disease, all suggest a posterior marginal cartilaginous node. The inferior lumbar location and frequent association with herniated disc and sciatic nerve root compression in young patients are discussed.

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.

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.

Back pain and vertebral changes simulating Scheuermann's disease

Nineteen adolescent patients who presented with mechanical-type back pain and vertebral changes consisting of intravertebral disc herniation, disc space narrowing, and minimal wedge deformity are described. The symptoms and signs were primarily located at the dorsolumbar junction. A specific strenuous activity or traumatic event was clearly associated with the onset of symptoms in 16 of the 19 patients. Spondylolysis or spondylolisthesis (grade I or II) at L5-S1 was also found in 32% of the patients. Most patients responded well to a program of rest, exercises, salicylates, and temporary avoidance of the particular activity involved. Some required orthoses to obtain relief. No patient had a progressive kyphotic deformity during the follow-up period. The relationship of this condition to increased stresses applied to the immature spine, particularly in a preflexed posture, is emphasized.

[Results of operative treatment of Scheuermann disease]

Only rarely is a surgical intervention necessary for increased kyphosis in Scheuermann's disease. However, effective erection of fixed kyphoses is only possible with an incision of the anterior spinal ligament, removal of the discs at the vertex of the curvature, resection of the vertebral arch joints, narrowing of the considerably widened vertebral arches and stabilizing with Harrington's instrumentation. The present authors have treated 11 patients in this way. With this procedure it proved possible to erect the kyphosis on average by 53.4%. In the first postoperative year there was an average loss of correction of 1.7 degrees, though subsequent deterioration was only 0.7 degrees up to the time of the last follow-up examination. The residual correction gain was 50.4 per cent. The results in 4 other patients, in whom Schöllner's erector rods were implanted, were less favorable. The permanent correction was only 50.4 in these cases. The best postoperative results are likely to be obtained by a unilateral ventral and dorsal procedure.

Scheuermann's disease. Clinical and radiological survey of 17 and 18 year olds

This is a study of the incidence and possible predisposing stress factors of Scheuermann's disease (S.D.). 500, 17 and 18 year old, students from the local larger schools, from one country town school and from the local Teachers' Training College, took part. Each student filled in a questionnaire, underwent a simple spinal examination including a clinical assessment of the available passive hamstring stretch, and had a lateral X-ray of the dorsal and upper lumbar spine. 56.3% of the males and 30.3% of the females had X-ray evidence of previous S.D., in varying degrees of severity. Dynamic stress, such as playing sports involving a lot of potential compression stress, weight lifting, and heavy lifting work in spare time and holidays, seem to play little if any part in the pathogenesis of S.D. Tall males and males who had spent more than 2 weeks in bed, due to sickness or injury, were more prone to S.D. Hamstring tightness showed a significant relationship to X-ray evidence for males. In the absence of possible dynamic stress factors it is suggested that prolonged sitting may be an important factor in the pathogenesis of end plate breakdown and thus S.D.

[Evolution-linked, stress-related damage to the spine]

During physiological growth of the juvenile vertebral column, various stages of stability occur which are characterized by the condition of the marginal rim of the vertebral bodies. If the vertebral juvenile column is overstrained, these variations in stability result in a variety of damage to the vertebral bodies and vertebral disks. One of these lesions corresponds to Scheuermann's disease (osteochondrosis of vertebral epiphyses in juveniles). Damage of the vertebral column due to overstrain can occur only if the overstrain is applied in upright position. Since Man alone can damage his vertebral column in upright position (as a result of his evolutionary development), Scheuermann's thesis is confirmed that Scheuermann's disease is confined to Man. Spondylolysis/spondylolisthesis is also a damage caused by overstrain. Here, too, the damage can occur only if the load is exercised in upright position, with the exception of a slanted positioning of the intervertebral components.

[Backache and low back pain. Diagnosis and treatment]

In patients with back pain there is only a poor correlation between clinical and radiological symptoms. Therefore the interpretation of radiological findings is only possible with respect to the natural history of the disease. Indication for radiological examination is given for early diagnosis and treatment of malformation of the spine; diagnosis and treatment of functional disturbances of the spine with back- and low back pain and diagnosis and treatment of diseases which affect the stability of the vertebrae.

[Dysspondylis: a contribution to Scheuermann's disease]

Juvenile aberrations of the vertebral bodies and intervertebral discs are abnormalities of the chondral, periosteal and apophyseal ossification. Differentiation of clinically insignificant variations and potentially or manifestly pathogenic dysspondylies is suggested. The occurrence of abnormalities of bodies and discs is different in particular parts of the spine. The semiology of eight dysspondylies in individual segments of the spine is described. M. Scheuermann presents the most frequent dysspondyly.

[Differential diagnosis of early scoliosis in Scheuermann's disease and idiopathic scoliosis (author's transl)]

In order to avoid overtreatment or undertreatment of a beginning scoliosis early differentiation of the clinically unimportant concomitant scoliosis of Scheuermann's disease is essential as against early idiopathic scoliosis, spondyloepiphyseal dysplasia and the fixed round back deformity of adolescents. Scheuermann's scoliosis as opposed to idiopathic scoliosis is characterised by the almost complete lack of vertebral rotation (as with spondyloepiphyseal dysplasia), by a localized unilateral narrowing of the intervertebral space in the a.p. x-ray, as well as by a slight Z- or E-pattern, and a relative shortness of the curves. Simultaneous dorsal kyphosis may be absent. Indispensable is furthermore, the familiarity with the early x-ray signs of Scheuermann's disease in the lateral view as compared with the X-ray of the fixed roundback.

Hamstring tightness and Scheuermann's disease a pilot study

The lateral radiographs of the dorsal spines of 20 patients presenting with mainly low back pain are studied. These patients had clinically evident loss of flexion in the low dorsal spine and very tight hamstring muscles. 85% of them showed definite evidence of previous Scheuermann's Disease. The possibility that tight hamstrings may be an important factor in the aetiology of this disease is discussed, and a further large scale study is proposed.

[The treatment of Scheuermann's kyphosis with the Milwaukee brace (author's transl)]

The application of the Milwaukee brace during adolescence is indicated not only in scoliosis, but also in severe forms of Scheuermann's kyphosis. In Basel between 1970 and 1979, 55 patients with severe thoracic kyphosis were treated with the Milwaukee brace. 45 of these patients were followed for a longer period of time. The results of the measurements of the kyphotic angles and of the angles of the wedges vertebral bodies are presented in detail. In those children who were followed to adulthood an average curvature correction from 40 degrees to 32 degrees was found. This represents a correction exceeding 50%, if a physiological angle of 25 degrees is presumed. Also, measurements showed erection of the wedged vertebral bodies after completion of growth. Consequently, the use of the Milwaukee brace for rigid thoracic kyphosis of more than 35 degrees in adolescents is advised.

[Spinal lesions following modified exercises in adolescent high performance gymnasts]

20 high performance gymnasts between 14 and 22 years of age had an anamnestical, clinical and radiological checkup on the spine in order to assess news training-methods. Radiologically only 3 gymnasts were found to be without any pathological manifestation. 7 cases of M. Scheuermann were located. The other athletes showed degenerative findings of vertebral columns especially in the thoracic-lumbar transition. These degenerative signs, and the fact tht the gymnasts had no spondylosis, are the result of new exercises, which avoid extreme bending load in the lowest segment of the lumbar region. Anamnestical and radiological findings do not correlate. A critical medical screening is necessary before and during high performance training.

The relationship of juvenile lumbar disc disease and Scheuermann's disease

Between 1969 and 1979 five children were found to have lumbar disc disease and were evaluated for clinically unsuspected thoracic spine abnormalities. Of these five children, two had Scheuermann's disease and one had disc space narrowing associated with Schmorl's nodes. One other had narrowed disc spaces without bony defects, and one had a normal thoracic spine. A unitary concept of childhood lumbar disc disease, Schmorl's nodes and Scheuermann's disease is suggested.

Juvenile kyphosis (Scheuermann's disease): radiography, histology, and pathogenesis

In juvenile kyphosis (JK), the roentgenographic defects correspond to the sites of large translucent areas of the collagen-free tissue in the cartilaginous end plates of vertebral bodies. The extent of the roentgenographic lesions is proportional to the number and size of these translucent areas. The gradual transition of radiologic signs between the fully developed JK and the normal spine is paralleled by the decreasing intensity of these histologic change. This relationship can be traced from individual to individual, and within single vertebral columns. The growth zone is often narrow or even missing. The end plates are narrow and segmentally indented towards the vertebral body. These findings are manifestations of the pathogenetic process. Prolapses of disk tissue through gaps in the end plates are probably secondary to the loss of mechanical strength in these defective areas.

Bone scintigraphy in discitis and related disorders in children

Thirty-nine children with suspected pathology involving the vertebral column were investigated haematologically, radiographically, and by bone scintigraphy using technetium 99M pyrophosphate. Fifteen children were shown to have inflammatory disease of the vertebrae. A further six suffered from Scheuermann's disease, two from benign tumours, and the remainder from miscellaneous diseases not specifically involving bony pathology. The nuclide scan was abnormal in all cases of discitis and osteomyelitis, and in the two tumours. All of the other conditions were associated with a normal bone scan. This finding is of considerable diagnostic importance, and leads support to the theory that discitis is due to bacterial infection.