Spinal posture during pubertal growth

Scheuermann's disease in patients 15-40 years old: A study to determine its prevalence and its relationship with age and sex using chest radiographs as screening tool

BACKGROUND

There is insufficient knowledge of the epidemiology of Scheuermann's disease. The data available comes from estimations from young adults with obvious deformity, from studies evaluating children who may not have developed the deformity yet, or from older populations who can develop vertebral wedging secondary to other causes. We aimed to determine the prevalence of Scheuermann's disease in patients 15-40 years old using plain chest radiographs as a screening tool.

METHODS

We evaluated 454 patients aged 15-40 years old studied using standing plain chest radiographs. We measured thoracic kyphosis from T5 to T12; using the intraclass correlation coefficient (ICC), we determined inter- and intra-observer agreement. To determine the prevalence of Scheuermann's disease we used the Sorensen criteria. We performed a correlation analysis of thoracic kyphosis and age, and a linear regression to determine the impact of age and sex on the kyphosis angle.

RESULTS

The prevalence of Scheuermann's disease was 2.2% (0.9-3.5%). The prevalence was not different in females (1.4%) and males (2.8%), p = 0.36. Inter-and intra-observer agreements were excellent: ICC = 0.93 (0.84-0.97) and 0.97 (0.95-0.98). There was a small positive correlation of kyphosis angle with age (r = 0.110; p = 0.019). Linear regression revealed that age (ß = 0.138; p = 0.019) was an independent predictor of kyphosis angle, but sex was not (ß-coefficient = 0.007; p = 0.994).

CONCLUSION

We found a prevalence of Scheuermann's disease of 2.2%, without significant differences between males and females. Age independently influenced the kyphosis angle; sex did not. This study allows a better understanding of the epidemiology of Scheuermann's disease.

Sexual Dimorphism and the Origins of Human Spinal Health

Recent observations indicate that the cross-sectional area (CSA) of vertebral bodies is on average 10% smaller in healthy newborn girls than in newborn boys, a striking difference that increases during infancy and puberty and is greatest by the time of sexual and skeletal maturity. The smaller CSA of female vertebrae is associated with greater spinal flexibility and could represent the human adaptation to fetal load in bipedal posture. Unfortunately, it also imparts a mechanical disadvantage that increases stress within the vertebrae for all physical activities. This review summarizes the potential endocrine, genetic, and environmental determinants of vertebral cross-sectional growth and current knowledge of the association between the small female vertebrae and greater risk for a broad array of spinal conditions across the lifespan.

Vertebral cross-sectional growth: A predictor of vertebral wedging in the immature skeleton

The degree of vertebral wedging, a key structural characteristic of spinal curvatures, has recently been found to be negatively related to vertebral cross-sectional area (CSA). The purpose of this longitudinal study was to examine the relation between vertebral cross-sectional growth and vertebral wedging progression within the immature lumbar spine. Using magnetic resonance imaging (MRI), we analyzed the potential association between increases in lumbar vertebral CSA and changes in L5 vertebral wedging in 27 healthy adolescent girls (ages 9–13 years) twice within a two-year period. Vertebral CSA growth was negatively associated with changes in posteroanterior vertebral wedging (r = -0.61; p = 0.001). Multiple regression analysis showed that this relation was independent of gains in age, height, and weight. When compared to the 14 girls whose vertebral wedging progressed, the 13 subjects whose vertebral wedging decreased had significantly greater vertebral cross-sectional growth (0.39 ± 0.25 vs. 0.75 ± 0.23 cm²; p = 0.001); in contrast, there were no significant differences in increases in age, height, or weight between the two groups. Changes in posteroanterior vertebral wedging and the degree of lumbar lordosis (LL) positively correlated (r = 0.56, p = 0.002)—an association that persisted even after adjusting for gains in age, height, and weight. We concluded that in the immature skeleton, vertebral cross-sectional growth is an important determinant of the plasticity of the vertebral body; regression of L5 vertebral wedging is associated with greater lumbar vertebral cross-sectional growth, while progression is the consequence of lesser cross-sectional growth.

Association Between Vertebral Cross-sectional Area and Vertebral Wedging in Children and Adolescents: A Cross-sectional Analysis

A small vertebral cross-sectional area (CSA) imparts a mechanical disadvantage that escalates the risk for vertebral fractures in elderly populations. We examined whether a small vertebral CSA is also associated with a greater degree of vertebral wedging in children. Measurements of vertebral CSA, lumbar lordosis (LL) or thoracic scoliosis angle, and vertebral wedging were obtained in 100 healthy adolescents (50 boys and 50 girls) and 25 girls with adolescent idiopathic scoliosis (AIS) using magnetic resonance imaging. Vertebral CSA of the lumbar vertebrae negatively correlated to the degree of posteroanterior vertebral wedging at L₅ (r = -0.49; p < 0.0001); this was true whether all subjects were analyzed together or boys and girls independently. In contrast, we found a positive correlation between the degree of LL and vertebral wedging (r = 0.57; p < 0.0001). Multiple regression analysis showed that the association between vertebral CSA and wedging was independent of age and body mass index. In girls with AIS, vertebral CSA negatively correlated to the degree of lateral thoracic vertebral wedging (r = -0.66; p = 0.0004), an association that persisted even after accounting for age and body mass index. Additionally, Cobb angle positively correlated to lateral thoracic vertebral wedging (r = 0.46; p = 0.021). Our cross-sectional results support the hypothesis that smaller vertebral CSA is associated with greater vertebral deformity during growth, as in adulthood. © 2017 American Society for Bone and Mineral Research.

Familial lumbar Scheuermann disease with idiopathic scoliosis in China: First case report

RATIONALE

Given that Scheuermann disease rarely occurs in the lumbar region and that the co-occurrence of Scheuermann disease and idiopathic scoliosis (IS) has not been reported-the etiology of Scheuermann disease and IS is not clear. In this case report, we present familaiar lumbar Scheuermann disease with IS, in a Chinese proband, who was successfully treated with surgery.

PATIENT CONCERNS

A 16-year-old boy presented at the Second XiangYa Hospital of Central South University with a chief complaint of kyphotic deformity in the lower back for 4 years and obvious lower back pain. In addition, he complained of limited lumbar activity. And The proband's family history was obtained by routine inquiring. In this Chinese family with 17 members over 3 generations. The 3 patients (proband, proband's sister and father) shared the characteristics of vertebral wedging from L1 to L3 and a kyphosis Cobb angle of 37°, 70°, or 73°, respectively. The main deformity of the proband's mother was at T7-L1 with a Cobb angle of 102° in the coronal plane at T7-L1, thoracic kyphosis of 73°, and lumbar lordosis of 62°.

DIAGNOSES

Scheuermann's disease.

INTERVENTIONS

Clinical history, physical examination, laboratory tests, and radiographs of those in the pedigree were recorded, and the related literature was reviewed. The proband accepted osteotomy and orthopedic surgery for treatment.

OUTCOMES

After 3 months of treatment, postoperative lateral radiographs showed a significantly improved sagittal vertical axis (SVA). The other patients were continued to be seen in follow-up visits.

LESSONS

This series of lumbar Scheuermann patients with IS in a pedigree support the genetic contribution to Scheuermann disease. Therefore, this study provides some insight into the genetic etiology of Scheuermann disease with IS.

Association between vertebral cross-sectional area and lumbar lordosis angle in adolescents

Lumbar lordosis (LL) is more prominent in women than in men, but the mechanisms responsible for this discrepancy are poorly defined. A recent study indicates that newborn girls have smaller vertebral cross-sectional area (CSA) when compared to boys-a difference that persists throughout life and is independent of body size. We determined the relations between vertebral cross-sectional area (CSA) and LL angle and whether sex differences in lumbar lordosis are related to sex differences in vertebral CSA. Using multi-planar magnetic resonance imaging (MRI), we measured vertebral cross-sectional area (CSA) and vertebral height of the spine of 40 healthy boys and 40 girls, ages 9-13 years. Measures of the CSA of the lumbar vertebrae significantly differed between sexes (9.38 ± 1.46 vs. 7.93 ± 0.69 in boys and girls, respectively; P < 0.0001), while the degree of LL was significantly greater in girls than in boys (23.7 ± 6.1 vs. 27.6 ± 8.0 in boys and girls, respectively; P = 0.02). When all subjects were analyzed together, values for LL angle were negatively correlated to vertebral CSA (r = -0.47; P < 0.0001); this was also true when boys and girls were analyzed separately. Multivariate regression analysis indicated that vertebral CSA was independently associated with LL, even after accounting for sex, age, height or vertebral height, and weight. Similar negative relations were present when thoracic vertebrae were analyzed (Model P < 0.0001, R2 = 0.37, thoracic vertebral CSA slope P < 0.0001), suggesting that deficient vertebral cross-sectional dimensions are not merely the consequence of the anterior lumbar curvature. We conclude that vertebral CSA is negatively associated with LL, and that the greater degree of LL in females could, at least in part, be due to smaller vertebral cross-sectional dimensions. Studies are needed to examine the potential relations between vertebral CSA and spinal conditions known to be associated with increased LL, such as spondylolysis and spondylolisthesis.

Sacral orientation and Scheuermann's kyphosis

To examine whether the association between spinal alignment and sacral anatomical orientation (SAO) can be detected in skeletal populations, by comparing SAO values in individuals with a typical SD to individuals with normal spinal alignment. 2025 skeletons were screened for Scheuermann's disease. Scheuermann's kyphosis was established by the presence of apophyseal abnormalities associated with more than 5° of anterior wedging in each of three adjacent vertebrae. SAO was measured as the angle created between the intersection of a line running parallel to the superior surface of the sacrum and a line running between the anterior superior iliac spine and the anterior-superior edge of the symphysis pubis (PUBIS). SAO was measured on 185 individuals with normal spines and 183 individuals with Scheuermann's kyphosis. Out of 2025 skeletons, 183 (9 %) were diagnosed with Scheuermann's kyphosis. The sacrum was significantly more horizontally oriented in individuals with Scheuermann's kyphosis compared with the control (SAO: 44.44 ± 9.7° vs. 50 ± 9.9°, p < 0.001). Alteration in spinal biomechanics due to a horizontally orientated sacrum may be an important contributing factor for the development of Scheuermann's kyphosis.

Scheuermann disease: evaluation of radiological criteria and population prevalence

STUDY DESIGN

Observational population-based study.

OBJECTIVE

To determine the prevalence of radiographical Scheuermann disease in a Dutch population and evaluate the consistency of diagnostic criteria.

SUMMARY OF BACKGROUND DATA

Scheuermann disease is a form of osteochondrosis characterized by increased posterior rounding of the thoracic spine with structural vertebral deformity. Different expert opinion-based radiological criteria exist, yet these have not been validated. The prevalence in the general population reported ranged from 1% to 10%.

METHODS

Lateral spine radiographs of 2753 Rotterdam Study participants (aged 45-89 yr) were assessed for Scheuermann disease using Sørensen and Sachs' radiographical criteria in 2 phases. Cohen κ statistics were calculated for interrater agreement. Prevalence estimates were calculated and sex differences were tested with Pearson χ test. We evaluated whether varying the kyphosis angle criterion would change the prevalence estimate.

RESULTS

A total of 677 (24.6%) individuals had endplate irregularities and 140 (5.1%) individuals had vertebral wedging. Abnormalities were significantly more prevalent among males (P < 0.05). The interrater agreement κ statistics were 78.8% for vertebral wedging and 79.4% for endplate irregularity. A total of 127 individuals had both criteria, of which 111 had a kyphosis angle greater than 45°, resulting in a prevalence of 4.0% (95% confidence interval [CI]: 3.3%-4.7%). The disease prevalence was 4.5% in males versus 3.6% in females, yet this difference was not statistically significant (P = 0.23). Adjustment of the kyphosis angle criterion from 45° to 40° or 35° increased the number of cases marginally, corresponding to prevalence estimates not significantly different from the estimates using original criteria (4.2% [95% CI: 3.3%-4.7%] and 4.4% [95% CI: 3.6%-5.2%]).

CONCLUSION

Our results revealed a prevalence of 4.0% of radiographical Scheuermann disease in Dutch individuals aged 45 years and older. Although there is no current "gold standard" for the radiographical definition, standardized scoring of independent features resulted in substantial interobserver agreement, and different applications of diagnostic criteria did not significantly alter the classification.

Spinal posture and pelvic position in three hundred forty-five elementary school children: a rasterstereographic pilot study

Children's posture has been of growing concern due to observations that it seems to be impaired compared to previous generations. So far there is no reference data for spinal posture and pelvic position in healthy children available. Purpose of this pilot study was to determine rasterstereographic posture values in children during their second growth phase. Three hundred and forty-five pupils were measured with a rasterstereographic device in a neutral standing position with hanging arms. To further analyse for changes in spinal posture during growth, the children were divided into 12-month age clusters. A mean kyphotic angle of 47.1°±7.5 and a mean lordotic angle of 42.1°±9.9 were measured. Trunk imbalance in girls (5.85 mm±0.74) and boys (7.48 mm± 0.83) varied only little between the age groups, with boys showing slightly higher values than girls. The trunk inclination did not show any significant differences between the age groups in boys or girls. Girls' inclination was 2.53°±1.96 with a tendency to decreasing angles by age, therefore slightly smaller compared to boys (2.98°±2.18). Lateral deviation (4.8 mm) and pelvic position (tilt: 2.75 mm; torsion: 1.53°; inclination: 19.8°±19.8) were comparable for all age groups and genders. This study provides the first systematic rasterstereographic analysis of spinal posture in children between 6 and 11 years. With the method of rasterstereography a reliable three-dimensional analysis of spinal posture and pelvic position is possible. Spinal posture and pelvic position does not change significantly with increasing age in this collective of children during the second growth phase.

Sagittal standing posture and its association with spinal pain: a school-based epidemiological study of 1196 Flemish adolescents before age at peak height velocity

STUDY DESIGN

Cross-sectional baseline data set on the sagittal standing posture of 1196 adolescents.

OBJECTIVE

To describe and quantify common variations in the sagittal standing alignment in boys and girls who are in the same phase of growth and to explore the association between habitual standing posture and measures for spinal pain.

SUMMARY OF BACKGROUND DATA

Data on postural characteristics and spinal pain measures in adolescence are sparse, especially when somatic and biological maturity status is to be considered. Our understanding of the relationship between standing posture in the sagittal plane and spinal pain is also deficient.

METHODS

A total of 639 boys (age [mean ± SD], 12.6 ± 0.54 yr) and 557 girls (10.6 ± 0.47 yr), with predicted years from peak height velocity (PHV) being 1.2 ± 0.71 and 1.2 ± 0.59 pre-PHV, respectively, were studied. Postural examination included the assessment of global alignment and local spinopelvic characteristics, using post hoc analyses of digital images and direct body measurements (palpation, digital inclinometry, and wheeled accelerometry). Spinal pain experience was assessed by questionnaire.

RESULTS

A wide interindividual variation in sagittal posture characteristics was observed. Logistic regression analyses yielded global alignment parameters to be associated with low back pain (lifetime prevalence), neck pain (lifetime prevalence, 1-mo prevalence, and doctor visit), and thoracic spine pain (doctor visit) outcome measures. None of the included local spinopelvic parameters could be identified as an associated factor with measures of spinal pain.

CONCLUSION

The orientation of gross body segments with respect to the gravity line seems superior to local spinopelvic features in terms of clinical importance, at least in the current pre-PHV cohort. Opportunities may exist for postural subgrouping strategies to begin with global alignment parameters in order to gain further insight into the relationship between sagittal alignment and the relative risk of developing spinal pain/seeking medical consultation for this pain.

Anatomical distribution of vertebral fractures: comparison of pediatric and adult spines

SUMMARY

We compared the distribution of vertebral fractures in adults and children and found that fractures occurred in different locations in the two age groups. This likely relates to the different shape of the immature spine.

INTRODUCTION

We hypothesized that the anatomical distribution of vertebral fractures (VF) would be different in children compared to adults.

METHODS

We compared the distribution of VF defined using the Genant semi-quantitative method (GSQ method) in adults (N = 221; 545 fractures) and in children early in the course of glucocorticoid therapy (N = 44; 94 fractures).

RESULTS

The average age in the adult cohort was 62.9 years (standard deviation (SD), 13.4 years), 26% was male, the mean lumbar spine Z-score was -1.0 (SD, 1.5), and the corresponding T-score was -2.4 (SD, 1.4). The pediatric cohort median age was 7.7 years (range, 2.1-16.6 years), the mean lumbar spine Z-score was -1.7 (SD, 1.5), 52% was male, and disease categories were acute lymphoblastic leukemia (66%), rheumatological conditions (21%), and nephrotic syndrome (14%). The VF distribution was biphasic in both populations, but the peaks differed in location. In adults, the peaks were at T7/T8 and at T12/L1. In children, the focus was higher in the thoracic spine, at T6/T7, and lower in the lumbar spine, at L1/L2. When children were assessed in two age-defined sub-groups, a biphasic VF distribution was seen in both, but the upward shift of the thoracic focus to T6 was observed only in the older group, with the highest rates of fracture present between ages 7 and 10 years.

CONCLUSIONS

These results suggest that the anatomical distribution of VF differs between children and adults, perhaps relating to the different shape of the immature spine, notably the changing ratio of kyphosis to lordosis.

Untreated Scheuermann's disease: a 37-year follow-up study

INTRODUCTION

There are only a few follow-up studies of untreated Scheuermann's disease. The aim of this study was to investigate the relationship between vertebral changes, back pain, and disability in patients with untreated Scheuermann's disease after a 37-year follow-up.

MATERIALS AND METHODS

Eighty patients responded to a postal questionnaire concerning back pain and disability and 49 of them had classic Scheuermann's disease. Degree of kyphosis, lordosis, scoliosis, the number of affected vertebrae, and mean and maximum wedge angles were measured from radiographs. Back pain and disability scores were compared to a sample of the general Finnish population (n = 3,835).

RESULTS

At follow-up, the patients were on average 59 (SD 8) years old (range 44-79 years), and the mean follow-up time was 37 (SD 7) years (26-54 years). The patients comprised more males than females (3.1:1). At follow-up, male patients were on average 3 cm taller than controls (p = 0.007). At age 20, female patients compared to controls were on average 6 kg heavier (p = 0.016) and had higher body mass index (BMI) (mean 23.9 kg/m(2) vs. 20.8 kg/m(2), p = 0.001). Scheuermann's patients had 2.5-fold [odds ratio (OR); 95% confidence interval (CI); 1.4-4.5, p = 0.003] increased risk for constant back pain compared to controls. The risk for disability because of back pain during the past 5 years (OR 2.6; 95% CI 1.4-4.7, p = 0.002), risk for back pain during the past 30 days (OR 3.7; 95% CI 1.9-7.0, p < 0.001) and risk for sciatic pain (OR 2.3; 95% CI 1.3-4.3, p = 0.005) were higher compared to controls. Scheuermann's patients had higher risk for difficulties in mounting stairs (OR 5.4; 95% CI 2.8-10.3, p < 0.001) and in carrying a 5 kg load for at least 100 m (OR 7.2; 95% CI 3.9-13.3, p < 0.001).

CONCLUSION

Scheuermann's patients had a higher risk for back pain and disabilities during activities of daily living than controls. However, the degree of thoracic kyphosis among Scheuermann's patients was not related to back pain, quality of life, or general health.

Scheuermann's disease: focus on weight and height role

The aim of this cross-sectional case-control study is the comparison of the weight and height between a group of children with Scheuermann's disease (SD) and a comparable group of healthy ones and also the correlation of them with the degree and the morphology of the kyphotic curve. Following a school-screening program of 10,057 school students, aged between 11 and 17 years old, 175 adolescents with Scheuermann's disease were diagnosed. The mean height and weight of 175 adolescents diagnosed to have SD compared with this of a group of normal children taken randomly from the group of 9,882 healthy children screened. The control group was comparable with the study group concerning age (p = 0.605) and sex. The weight, height and body mass index (BMI) were significantly lower in the healthy (control) group (p < 0.001). However, there was no correlation between weight (r = -0.019, p = 0.804), height (r = 0.053, p = 0.484) and BMI (r = -0.177, p = 0.019) with the magnitude of kyphotic curve. There was also no correlation between weight (r = -0.27, p = 0.722), height (r = -0.025, p = 0.744) and BMI (r = -0.038, p = 0.619) with Voutsinas index as well. Scheuermann's disease is probably a multifactorial skeletal deformity. Weight and height do not seem to affect the magnitude and morphology of the main kyphotic curve in SD. It seems probably that this observation is not part of the pathogenetic mechanism of SD but a result of its cascade. The increased weight and height of these patients may be the secondary result of other disturbances (i.e. hormonal), which may play more crucial role in Scheuermann's disease pathogenesis.

Development of spinal posture in a cohort of children from the age of 11 to 22 years

Spinal posture and the resultant changes during the entire pubertal growth period have not been reported previously. No cohort study has focused on the development of spinal posture during both the ascending and the descending phase of peak growth of the spine. The growth and development of a population-based cohort of 1060 children was followed up for a period of 11 years. The children were examined 5 times, at the ages of 11, 12, 13, 14 and 22 years. A total of 430 subjects participated in the final examination. Sagittal spinal profiles were determined using spinal pantography by the same physician throughout the study. Thoracic kyphosis was more prominent in males at all examinations. The increasing tendency towards thoracic kyphosis continued in men, but not in women. The degree of lumbar lordosis was constant during puberty and young adulthood. Women were more lordotic at all ages. Thoracic hyperkyphosis of > or =45 degrees was as prevalent in boys as girls at 14 years, but significantly (P<0.0001) more prevalent in men (9.6%) than in women (0.9%) at 22 years. The degree of mean thoracic kyphosis and the prevalence of hyperkyphosis increased in men during the descending phase of peak growth of the spine, but decreased in women.

Predictors of neck pain: a cohort study of children followed up from the age of 11 to 22 years

Body height is an alleged risk factor for low back pain in adulthood, but its importance regarding non-specific neck pain is obscure during childhood and adolescence. We studied anthropometric measurements for their associations with the incidence of neck pain in a population study of 430 children who were examined five times: at the age 11-14 and 22 years. Body height and weight and the degrees of trunk asymmetry, thoracic kyphosis and lumbar lordosis were measured at every examination. The history of neck pain was obtained by a structured questionnaire at the final examination. The incidence of neck pain was defined as pain occurring in eight or more days during the past year. Short stature at 11 years of age predicted the incidence of neck pain. Adjusted for sex, the odds ratio (with 95% confidence interval) per an increment of one standard deviation of body height was 0.78 (0.62-0.97). At 22 years of age there was accordingly an inverse association between current body height and neck pain history, the odds ratio being 0.62 (0.45-0.86). Male sex was found to protect against neck pain; the odds ratio was 0.28 (0.18-0.44). Anthropometric measurements other than body height were not found to predict neck pain. The role of anthropometric factors in the development of neck pain at young adulthood seems only modest. Short stature may be a risk determinant of neck pain.

Anthropometric measurements and growth as predictors of low-back pain: a cohort study of children followed up from the age of 11 to 22 years

Body height is an alleged risk factor for low-back pain (LBP) in adulthood, but its importance is obscure during childhood and adolescence. We studied growth for its association with the incidence of LBP in a population study of 430 children who were examined five times: at the age 11,12,13,14 and 22 years. Body height and weight and the degrees of trunk asymmetry, thoracic kyphosis and lumbar lordosis were measured at every examination. The history of LBP was obtained by a structured questionnaire at the ages of 14 and 22 years. The incidence of LBP was defined as pain, which occurred on eight or more days during the past year among those 338 children who had been free from LBP until 14 years of age. Growth of body height between 11 years and 14 years of age predicted the incidence of LBP. Adjusted for sex, the odds ratio (with 95% confidence interval) per an increment of one SD (4.3 cm) was 1.32 (1.06--1.65), the P value for trend being 0.03. Growth after 14 years of age was inversely related to the incidence of LBP, but the association did not reach statistical significance (P for trend=0.06). Other anthropometric measurements or their changes were not found to predict LBP. Our results are not compatible with the old myth that spinal growth actually contributes to LBP. But abundant growth in early adolescence may be a risk factor for subsequent LBP.

Combined anterior–posterior fusion with laterally placed threaded interbody cages and pedicle screws for Scheuermann kyphosis

The authors report their preferred method for correcting Scheuermann disease via a combined anterior–posterior approach; their procedure is associated with a lower morbidity rate than the standard approach. Twenty-month follow-up examination demonstrated excellent maintenance of correction. The results satisfied the requirements to function without restriction in a vigorous military environment.

Kyphosis in a Turner syndrome population

OBJECTIVE

The purpose of this study was to determine the prevalence of kyphosis in a Turner syndrome (TS) population.

METHODS

Standing lateral thoracic spine and standing anterior-posterior (A-P) scoliosis radiographs were obtained on all girls with TS between the ages of 5 and 18 years seen in a TS clinic between July 2000 and March 2001. Medical histories were reviewed, and a pediatric orthopedic surgeon evaluated the radiographs of each patient (N = 25). Excessive kyphosis was defined as an A-P curvature >40 degrees, vertebral wedging as any A-P deformity >5 degrees at an individual vertebral body, and scoliosis as a lateral curvature >10 degrees.

RESULTS

Fifteen (60%) of 25 patients were found to have abnormal radiographic findings: 10 (40%) of 25 with excessive kyphosis, 10 (40%) of 25 with vertebral wedging, and 5 (20%) of 25 with scoliosis. Forty-eight percent of the girls had both excessive kyphosis and/or vertebral body wedging. Two girls had kyphosis > or =55 degrees, and 5 had scoliosis > or =25 degrees. Girls with excessive kyphosis and/or vertebral body wedging were older (13.6 +/- 3.9 years vs 10.6 +/- 2.8 years).

CONCLUSIONS

The prevalence of excessive kyphosis and vertebral body wedging seems to be increased in girls with TS and corresponds with advancing age. Routine radiologic surveillance may facilitate detection of developing deformities so that treatment with a brace can be considered to prevent or slow the process.

Effects of lifestyle and work-related physical activity on the degree of lumbar lordosis and chronic low back pain in a Middle East population

The relationship between the degree of lumbar lordosis and chronic low back pain (LBP) has long been speculated. It is postulated that prolonged sitting and sedentary lifestyle might change the degree of lumbar lordosis and cause LBP. The purpose of this study was to determine the effects of lifestyle, exercise, work setting, work intensity, and other demographic factors such as age, height, weight, and gender on the degree of lumbar lordosis and occurrence of LBP. Eight hundred forty subjects between ages 20 and 65 years were equally categorized into four groups: normal male, normal female, males with LBP, and females with LBP. A questionnaire was used to obtain information about the subject's lifestyle, work setting, level of exercise, and work-related physical activity. A flexible ruler was used to measure lumbar lordosis in all subjects. The average degree of lumbar lordosis for all subjects was 37 degrees +/- 13 degrees. Females had greater lumbar lordosis (42 degrees +/- 15 degrees ) than males did (32 degrees +/- 10 degrees ). There was no significant difference in the degree of lumbar lordosis in subjects with different lifestyle (p = 0.97), level of physical activity (p = 0.36), work setting (p = 0.5), and with or without LBP (p = 0.28). The degree of lumbar lordosis was positively related with the number of pregnancies (p = 0.04, r = 0.25), age (p = 0.02, r = 0.1) and height (p = 0.0001, r = 0.31) and negatively related with weight (p = 0.04, r = 0.06) of the subjects. The likelihood of developing LBP was significantly higher in the subjects who had high work-related physical activity (p = 0.03) and those who exercised less often (p = 0.008). We found no significant relationship between LBP occurrence and the degree of lumbar lordosis (p = 0.68), work setting (p = 0.15), height (p = 0.08), weight (p =0.06), and age (p = 0.67) of the subjects. The degree of lumbar lordosis was not different between normal subjects and those with LBP. Lumbar lordosis was not affected by lifestyle, level of physical activity, or type of work setting. Although these factors have not been found to affect the degree of lumbar lordosis, some affected the occurrence of LBP. This finding indicates that the effect of these factors on LBP involves mechanisms other than changing the degree of lumbar lordosis.

Development of trunk asymmetry in a cohort of children ages 11 to 22 years

STUDY DESIGN

A cohort study with a follow-up period of 11 years.

OBJECTIVES

To study the growth of the spine with a focus on the development of trunk asymmetry and scoliosis.

SUMMARY OF BACKGROUND DATA

Trunk asymmetry, a common phenomenon at adolescence, can be considered the clinical expression of scoliosis. The importance of the pubertal growth spurt has been stressed in the natural history of scoliosis. However, no cohort studies have focused on the ascending and descending phase of the spine's peak growth and the development of trunk asymmetry.

METHODS

The cohort consisted of all the fourth-grade school children in the Western school district of Helsinki, Finland, in the spring of 1986. These 1060 children (515 girls and 545 boys), from the average age of 11 to 14 years, were invited to undergo annual examinations. The 855 children (80.7%) who had participated in the study at the age of 14 years were invited to a reexamination at the age of 22 years. This invitation was accepted by 430 (208 women and 222 men; 54%) of those invited. The forward bending test, the spinal pantography, and the anthropometric measurements were carried out by the same author (M.N.) throughout this study.

RESULTS

At 22 years of age, 30% of the adults were found to be symmetric, with a hump less than 4 mm in the forward bending test, whereas 51% had a hump of 4 to 9 mm, and 19% had a hump 10 mm or larger (major asymmetry). The directional asymmetry of trunk surface, a skew to the right at the thoracic level and to the left at the lumbar level at puberty, remained constant at adult age. The prevalence of major trunk asymmetry at adult age was the same in both women and men, in contrast to the female predominance at puberty in this cohort. There were close correlations in the degrees of thoracic and lumbar asymmetry between puberty and adult ages.

CONCLUSIONS

The shape of the back develops mainly during the pubertal growth spurt at ages 12 to 14 years in girls and boys. Trunk asymmetry (and mild scoliosis) seems as prevalent in young adult women as in men, although at puberty idiopathic scoliosis was twice as prevalent among girls as among boys in this cohort.

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.