A Novel Surgical Indication for Scheuermann's Kyphosis

Scheuermann kyphosis can be treated surgically to restore proper sagittal alignment. Thoracic curves >70° are typically indicated for surgical intervention. However, patients who have reached their natural limit of compensatory lumbar hyperlordosis are at risk of accelerated degeneration. This can be determined by comparing lumbar lordosis on standing neutral radiographs and supine extension radiographs. Minimal additional lordosis in extension compared with neutral, abutment of the spinous processes, or greater lumbar lordosis standing than with attempted extension suggest the patient is maximally compensated. We present a case of an adolescent boy with Scheuermann kyphosis who had reached the limit of his hyperlordosis compensation reserve. He subsequently underwent a T4 to L2 posterior spinal fusion with T7 to T11 Ponte Smith-Petersen grade two osteotomies. He tolerated the procedure well with no intraoperative complications or neuromonitoring changes. The patient has continued to do well and progressed to normal activity at 5-month follow-up.

How to determine the optimal proximal fusion level for Scheuermann kyphosis

OBJECTIVE

To determine optimal proximal fusion levels for instrumented spinal fusion for Scheuermann kyphosis.

METHODS

We reviewed 86 patients (33 women) who underwent corrective instrumented spinal fusion for Scheuermann kyphosis. All patients had long-cassette upright lateral radiographs taken preoperatively, postoperatively, and at 2 years and the last follow-up. Demographic, radiographic, and surgical parameters were compared between patients with and without PJK.

RESULTS

PJK occurred in 28 patients (32%). The mean maximum Cobb angle was 85.8° ± 11.7° preoperatively, 54.8° ± 14.2° postoperatively, and 59.7° ± 16.8° at the last follow-up. Age and sex did not differ between the PJK and non-PJK groups (P > 0.05). The preoperative curve characteristics, fusion levels, and corrective ratio were similar in both groups (P > 0.05). The maximal Cobb angle at 2 years and the last follow-up significantly differed between the 2 groups (P < 0.05). The proportion of patients with the uppermost instrumented vertebra (UIV) at or above the proximal end vertebra (PEV) was similar in both groups (P > 0.05). The proportion of patients with UIV at or above T2 was significantly greater in the non-PJK group (P < 0.05). PJK was significantly associated with a C7 plumb line (C7PL)-sacrum distance ≥ 50 mm (P < 0.05).

CONCLUSION

PJK is the main cause of postoperative correction loss. Proper fusion-level selection can reduce PJK occurrence. We recommend having the UIV at T2 or above, especially when the C7PL-sacrum distance ≥ 50 mm.

Selecting the Vertebra above Sagittal Stable Vertebra as the Distal Fusion Level in Scheuermann's Kyphosis: A Prospective Study with a Minimum of 2-Year Follow-Up

OBJECTIVE

The proper selection of the lower instrumented vertebra (LIV) remains controversial in the surgical treatment of Scheuermann's disease and there is a paucity of studies investigating the clinical outcomes of fusion surgery when selecting the vertebra one level proximal to the sagittal stable vertebra (SSV-1) as LIV. The purpose of this study is to investigate whether SSV-1 could be a valid LIV for Scheuermann kyphosis (SK) patients with different curve patterns.

METHODS

This was a prospective study on consecutive SK patients treated with posterior surgery between January 2018 and September 2020, in which the distal fusion level ended at SSV-1. The LIV was selected at SSV-1 only in patients with Risser >2 and with LIV translation less than 40 mm. All of the patients had a minimum of 2-year follow-up. Patients were further grouped based on the sagittal curve pattern as thoracic kyphosis (TK, n = 23) and thoracolumbar kyphosis (TLK, n = 13). Radiographic parameters including global kyphosis (GK), lumbar lordosis (LL), sagittal vertical axis (SVA), LIV translation, pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were measured preoperatively, postoperatively, and at the latest follow-up. The intraoperative and postoperative complications were recorded. The Scoliosis Research Society (SRS)-22 scores were performed to evaluate clinical outcomes.

RESULTS

A total of 36 patients were recruited in this study, with 23 in the TK group and 13 in the TLK group. In TK group, the GK was significantly decreased from 80.8° ± 10.1° to 45.4° ± 7.7° after surgery, and was maintained at 45.3° ± 8.6° at the final follow-up. While in the TLK group, GK was significantly decreased from 70.7° ± 9.2° to 39.1° ± 5.4° after surgery (p < 0.001) and to 39.3° ± 4.5° at the final follow-up. Meanwhile, despite presenting with different sagittal alignment, significant improvement was observed in LL, SVA, and LIV translation for both TK and TLK groups (p < 0.05). Self-reported scores of pain and self-image in TK group and scores of self-image and function in TLK group showed significant improvement at the final follow-up (all p < 0.05). Distal junctional kyphosis (DJK) was observed in two patients (8.7%) in TK group, and one patient (7.7%) in TLK group. No revision surgery was performed.

CONCLUSION

Selecting SSV-1 as LIV can achieve satisfactory radiographic and clinical outcomes for SK patients with different curve patterns without increasing the risk of DJK. This selection strategy could be a favorable option for SK patients with Risser sign >2 and LIV translation less than 40 mm.

Scheuermann's Disease

Scheuermann's disease is a rigid progressive kyphosis occurring in late childhood to adolescence. It is the most common cause of sagittal imbalance and angular progressive kyphosis in adolescents associated with back pain. The exact etiology of the disease is unclear, but it is characterized by defective growth of the end plate that may result from excessive mechanical stress on a weakened end plate during spinal growth. Several other theories have been proposed, and it is thought to be a multifactorial disease occurring as a result of the interplay of multiple factors. The radiographic features consist of anterior vertebral body wedging, irregular end plates, Schmorl's nodes, and intervertebral disk degeneration. The natural history and evolution of this disease is also unknown. Conservative management with physiotherapy, rehabilitation, and bracing is the first line of treatment. Mechanical bracing helps prevent further progression of the kyphotic deformity. Surgery is mostly indicated in patients with failure of conservative management, with neurologic compromise, and for cosmetic reasons.

Effect of the type of brace on head to pelvis sagittal alignment of adolescents with Scheuermann's kyphosis

The aim of this study was to determine the effects of the Milwaukee brace and thoracolumbosacral orthosis (TLSO) on head to pelvis sagittal alignment in adolescents with Scheuermann's kyphosis (SK). A total of 52 adolescents with SK who were under brace treatment were studied. They underwent biplanar radiography of the head to pelvis (EOS Imaging, Paris, France) before and 6 months after the beginning of bracing. We measured T1 slope, neck tilt (NT), cervical sagittal vertical axis (cSVA), thoracic inlet angle (TIA), C0-C2 lordosis, C2-C7 lordosis, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sagittal vertical axis (SVA) and T1 spinopelvic inclination (T1SPi). There were no significant differences in baseline values of TIA, PT, SS, PI, SVA, TK, cSVA, NT and T1 slope between the two groups (p > 0.05). There were significant differences between the baseline and final measurements of T1 slope, cSVA, TK, LL, T1SPi and TIA in both groups (p < 0.05). The results imply that brace treatment can significantly affect head to pelvis sagittal parameters of adolescents with SK. However, there are no significant differences in the values of head to pelvis sagittal parameters when comparing short-term effect of TLSO and the Milwaukee brace.

Long-term outcome after brace treatment of Scheuermann's kyphosis: an observational controlled cohort study

BACKGROUND

In the literature, there are several papers on Scheuermann's kyphosis. It is a structural deformity of the spine that is characterized by anterior wedging of 5° or more of 3 adjacent thoracic vertebral bodies with kyphosis measuring greater than 45° between T5 and T12. Bracing treatment is able to obtain, during skeletal growth, remodeling of the deformed vertebrae.

AIM

The aim of this study was to evaluate the effectiveness of conservative treatment in Scheuermann's kyphosis at a minimum follow-up of 10 years.

DESIGN

This is an observational controlled cohort study nested in a prospective clinical on-going database in patients with Scheuermann kyphosis.

SETTING

Inpatients and outpatients in Rome.

METHODS

From a consecutive series of patients included in a prospective database, we selected 158 patients with thoracic Scheuermann's kyphosis who were treated using an anti-gravity brace: 93 males and 65 females. The mean age at the beginning of the treatment was 14 years. The time bracing prescribed was a max of 20 hours daily and a min of 16 hours daily. Weaning was started when a full recovery of vertebral geometry was seen on a lateral radiograph view or when growing was ended. Radiographical measurements were performed on radiographs from a lateral projection at baseline (t1), at the end of the treatment (t2) and at 10 years of minimum follow-up (t3). To avoid the great variance in the range of curve angles in thoracic kyphosis (TK) that rely on the radiological position, X-rays were performed observing the following position: standing with head straight, arms bent at 45° and hands lightly placed on a support. The anterior wedging angle (Alpha) of the apex vertebra and the degrees of the curve (Cobb methods) were analyzed using statistical analysis.

RESULTS

The results from our study showed that in 158 patients with TK curves, the mean Cobb angle was 57.6±6.3 SD at baseline, 43.3±7.8 SD at the end of treatment and 44.49±7.4 SD at ten years of follow-up. The alpha angle was 14.43±2.535 SD at baseline and 8.571±3.589 SD at the end of treatment, and after ten years of follow-up, it was 8.654±3.57 SD. The mean duration of treatment was 28.42±12.07 months, and the mean follow-up was 128.3±11.07 months. The difference between baseline and end of treatment, tested with the one-way ANOVA comparisons test, was significant (P<0.0001) for both Cobb angle and alpha; instead, the difference between the end of treatment and follow-up was not significant (P=0.3277).

CONCLUSIONS

The results confirm that conservative treatment in Scheuermann's kyphosis during skeletal growth is effective. Bracing treatment can remodel the deformed vertebrae.

CLINICAL REHABILITATION IMPACT

At the 10-year follow-up after bracing, kyphosis curve correction was stable over time.

OUP accepted manuscript

Pectus carinatum may rarely be associated with kyphosis. However, the correlation between both conditions is not well reported. Therefore, there are no reports for combined correction of both deformities in the same patient. Moreover, studies estimating the kyphosis prevalence in patients with pectus carinatum are lacking. To our knowledge, this is the first paper to present such a case. We report an 18-year-old boy with both pectus carinatum and kyphosis that were surgically corrected in a combined procedure. The indication of surgery is cosmetic, and the postoperative recovery included pneumothorax but was otherwise uneventful and satisfactory.

Postoperative sagittal alignment of congenital thoracolumbar to lumbar kyphosis or kyphoscoliosis: a minimum 10-year follow-up study

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To elucidate the postoperative course of sagittal alignment in patients with congenital thoracolumbar to lumbar kyphosis or kyphoscoliosis. Acquisition of acceptable sagittal alignment is essential to treat spinal deformity. Little evidence exists regarding long-term surgical outcomes on sagittal alignment in congenital kyphosis or kyphoscoliosis.

METHODS

Sixteen consecutive patients (mean age 10.5 ± 3.5 years) with congenital kyphosis or kyphoscoliosis who underwent vertebra resection and osteotomy with instrumentation by single posterior or combined anterior and posterior approach were included. Preoperative radiographs identified kyphosis in 3 patients and kyphoscoliosis in 13 patients. All patients had clinical and radiologic follow-up for > 10 years (mean 16.3 ± 4.0 years).

RESULTS

Segmental kyphosis was significantly improved from 33.9° ± 20.1° to 14.9° ± 17.6° by surgery and was finally maintained at 16.8° ± 22.2° and sagittal vertical axis (SVA) of 13.1 ± 33.7 mm at preoperation and 18.3 ± 22.1 mm at postoperation significantly increased to 26.8  ±  45.7 mm during follow-up. Of the 16 patients, 5 (31%) were identified as those with SVA > 40 mm, and SVA increases > 30 mm during follow-up. In patients with sagittal malalignment, radiographs demonstrated decreased lumbar lordosis at the lower foundation from 28.8° ± 39.0° to 17.0° ± 17.6°, significant increased pelvic tilt from 25.8° ± 5.4° to 37.4° ± 7.4° during follow-up (p < 0.05), and larger residual segmental kyphosis than those in the 11 patients without sagittal malalignment with statistical significance. Of the five cases, progression of local kyphosis (one case) and sagittal decompensation, including decreased lumbar lordosis with disc degeneration (four cases), increased pelvic tilt (three cases), or proximal junctional kyphosis (two cases), were observed.

CONCLUSION

Based on this > 10-year follow-up study, residual kyphosis and sagittal decompensation are revealed to be risk factors for postoperative sagittal malalignment in patients with congenital thoracolumbar to lumbar kyphosis or kyphoscoliosis.

LEVEL OF EVIDENCE

Level IV, case series.

Sternoclavicular dislocation as a possible complication for surgical Scheuermann's deformity correction: a case report

OBJECTIVE

We present a sternoclavicular dislocation as a non-reported complication after spinal kyphotic deformity surgical correction.

BACKGROUND

The sternocostal complex seems to have an important role in the pathology of Scheuermann's kyphotic deformity. A role for the sternoclavicular complex has never been reported in association with Scheuermann's disease pathology but could explain anterior sternoclavicular dislocation after spinal kyphotic deformity correction.

METHODS

A 19-year-old male patient underwent surgery for a 74° thoracic kyphosis associated with a 35° thoracic and a 50° lumbar scoliotic curve. In the early post-operative period, the patient developed pain over the left sternoclavicular joint articulation, with a very obvious lump. An X-ray disclosed an anterior sternoclavicular dislocation. After surgical treatment failed, the dislocation was repaired in a second surgical procedure with a flexion and lengthening osteotomy of the middle third of the clavicle followed by capsular repair reinforced with sternocleidomastoid fascia.

RESULTS

At an 8-year follow-up after his spine procedure and 6 years after his clavicular surgery, the patient had full shoulder range of motion and no joint pain, despite the presence of a new sternoclavicular anterior dislocation.

CONCLUSION

Sternoclavicular dislocation after spine kyphotic deformity correction is presented for the first time; however, it is not possible to establish a causative association. Additional studies are necessary to delineate the role of the sternoclavicular complex in Scheuermann's disease.

Reciprocal Changes in Sagittal Alignment With Operative Treatment of Adolescent Scheuermann Kyphosis-Prospective Evaluation of 96 Patients

INTRODUCTION

Sagittal alignment abnormalities in Scheuermann kyphosis (SK) strongly correlate with quality of life measures. The changes in spinopelvic parameters after posterior spinal fusion have not been adequately studied. This study is to evaluate the reciprocal changes in spinopelvic parameters following surgical correction for SK.

METHODS

Ninety-six operative SK patients (65% male; age 16 years) with minimum 2-year follow-up were identified in the prospective multicenter study. Changes in spinopelvic parameters and the incidence of proximal (PJK) and distal (DJK) junctional kyphosis were assessed as were changes in Scoliosis Research Society-22 (SRS-22) questionnaire scores.

RESULTS

Maximum kyphosis improved from 74.4° to 46.1° (p < .0001), and lumbar lordosis was reduced by 10° (-63.3° to -53.3°; p < .0001) at 2-year postoperation. Pelvic tilt, sacral slope, and sagittal vertical axis remained unchanged. PJK and DJK incidence were 24.2% and 0%, respectively. In patients with PI <45°, patients who developed PJK had greater postoperative T2-T12 (54.8° vs. 44.2°, p = .0019), and postoperative maximum kyphosis (56.4° vs. 44.6°, p = .0005) than those without PJK. In patients with PI ≥45°, patients with PJK had less postoperative T5-T12 than those without (23.6° vs. 32.9°, p = .019). Thoracic and lumbar apices migrated closer to the gravity line after surgery (-10.06 to -4.87 mm, p < .0001, and 2.28 to 2.10 mm, p = .001, respectively). Apex location was normalized to between T5-T8 in 68.5% of patients with a preoperative apex caudal to T8, whereas 90% of patients with a preoperative apex between T5 and T8 remained unchanged. Changes in thoracic apex location and lumbar apex translation were associated with improvements in the SRS function domain.

CONCLUSION

PJK occurred in 1 in 4 patients, a lower incidence than previously reported perhaps because of improved techniques and planning. Both thoracic and lumbar apices migrated closer to the gravity line, and preoperative apices caudal to T8 normalized in more than two-thirds of patients, resulting in improved postoperative function. Individualizing kyphosis correction to prevent kyphosis and PI mismatch may be protective against PJK.

Severe rigid Scheuermann kyphosis in adult patients; correction with posterior-only approach

PURPOSE

Scheuermann kyphosis is the most common structural kyphosis among adolescence and young people. Surgical treatment may be performed through combined anterior and posterior or posterior-only approaches; to our knowledge, the efficacy of posterior-only approach as less invasive procedure is not well studied in case of severe rigid Scheuermann kyphosis.

MATERIALS AND METHODS

Eighteen patients with severe rigid Scheuermann kyphosis operated through only posterior approach from 2013 to 2016 were evaluated. All information regarding demographic data, curve size before and after the surgery, surgical time, amount of blood loss, correction loss during follow-up and also complications was collected.

RESULT

There were six females and 12 males. Mean age of the patients was 22.4 years (range 17-38). Mean kyphosis angle before surgery was 87.2° (range 85-105), and that reduced to 47.4° (range 45-55) after the surgery. Mean curve size in hyperextension view was 73.8°. Mean postoperative Cobb angle was 50-55 percent of preoperative curves. Mean hospital admission duration was 3.5 days after the index surgery (range 3-5 days). Mean blood loss during the surgery was 250 ml. Mean surgical duration time was 150 min. Mean follow-up period was 9 months (range 8-48 months). No complication was found among the patients.

CONCLUSION

Posterior-only approach using advanced osteotomy techniques and posterior release is a safe and reliable approach for treatment of patients suffering from severe rigid Scheuermann kyphosis and provides acceptable deformity correction.

Progression of untreated mild thoracic Scheuermann's kyphosis - Radiographic and functional assessment after mean follow-up of 46 years

BACKGROUND

There is no data available on the radiographic development of the Scheuermann's deformity. Our purpose was to investigate radiographic deformity progression and the relation between kyphosis progression and clinical outcome in patients with untreated Scheuermann's kyphosis.

METHODS

Thoracic kyphosis (Th4-Th12) was measured from standing lateral radiographs in 19 patients at baseline and after mean 46-year follow-up. Mean age at baseline was 19.2 and at follow-up 64.7 years. At follow-up, height, weight, hand grip strength, and hamstring tightness were measured, and sit-to-stand and walking tests were performed. Additionally general health and quality of life questionnaires were administered.

RESULTS

The mean thoracic kyphosis increased from 46° (range 25°-78°) at baseline to 60° (34°-82°) (p < 0.001) at follow-up. Mean of the vertebrae wedge increased from 8.8° to 9.9° (p = 0.046). There was no correlation between extent of kyphosis progression and function at follow-up.

CONCLUSIONS

Among patients with Scheuermann's disease the degree of radiographic deformity progressed slightly during long-term follow-up. Progression did not predict symptoms.

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.

Spinal cord ischemia in Scheuermann disease: A report of three cases

BACKGROUND

Neurological complications in Scheuermann's disease are rare but serious.

CASE REPORTS

We report three cases of severe neurological deficit due to medullar ischemia attributable to the compression of a radiculomedullar artery by thoracic (two cases) and lumbar (one case) disc herniations associated with Scheuermann's disease. They were not treated surgically because of the absence of direct spinal cord compression or definitive spinal cord ischemia. Those young patients still have severe neurological damage. An earlier management could have prevented them.

CONCLUSION

When doubting about any compressive sign, MRI should be performed with diffusion weighted imaging (DWI) and apparent diffusion coefficient (ADC) sequences in emergency.

Paraspinal muscle volume in patients with Scheuermann's Kyphosis

To measure the cross-sectional area (CSA) of para-spinal muscles in Scheuermann's kyphosis patients. Preoperative MRI images of 16 Scheuermann's kyphosis patients were analysed and compared to 16 patients with normal MRI images (control group). The CSAs were measured at L3-4 and L4-5. Both groups showed similar demographics and patient characteristics. The multifidus muscles CSA were found to be significantly smaller at L3/4 level in Scheuermann's kyphosis patients (p = 0.022 on the left and p = 0.016 on the right side compared to control group). There was no significant change in multifidus CSA found at L4/5. The mean CSA of the extensor spinae muscles group were significantly smaller at all levels in Scheuermann's kyphosis patients : p = 0.001 bilaterally at L3/4 and p = 0.015 right side and p = 0.009 left side at L4/5 level. This study shows that patients with Scheuermann's kyphosis deformity have significantly smaller CSA of lumbar multifidus and extensor spinae muscles.

Vertebral Scheuermann's disease in Europe: prevalence, geographic variation and radiological correlates in men and women aged 50 and over

In 27 centres across Europe, the prevalence of deforming spinal Scheuermann's disease in age-stratified population-based samples of over 10,000 men and women aged 50+ averaged 8% in each sex, but was highly variable between centres. Low DXA BMD was un-associated with Scheuermann's, helping the differential diagnosis from osteoporosis.

INTRODUCTION

This study aims to assess the prevalence of Scheuermann's disease of the spine across Europe in men and women over 50 years of age, to quantitate its association with bone mineral density (BMD) and to assess its role as a confounder for the radiographic diagnosis of osteoporotic fracture.

METHODS

In 27 centres participating in the population-based European Vertebral Osteoporosis Study (EVOS), standardised lateral radiographs of the lumbar and of the thoracic spine from T4 to L4 were assessed in all those of adequate quality. The presence of Scheuermann's disease, a confounder for prevalent fracture in later life, was defined by the presence of at least one Schmorl's node or irregular endplate together with kyphosis (sagittal Cobb angle >40° between T4 and T12) or a wedged-shaped vertebral body. Alternatively, the (rare) Edgren-Vaino sign was taken as diagnostic. The 6-point-per-vertebral-body (13 vertebrae) method was used to assess osteoporotic vertebral shape and fracture caseness. DXA BMD of the L2-L4 and femoral neck regions was measured in subsets. We also assessed the presence of Scheuermann's by alternative published algorithms when these used the radiographic signs we assessed.

RESULTS

Vertebral radiographic images from 4486 men and 5655 women passed all quality checks. Prevalence of Scheuermann's varied considerably between centres, and based on random effect modelling, the overall European prevalence using our method was 8% with no significant difference between sexes. The highest prevalences were seen in Germany, Sweden, the UK and France and low prevalences were seen in Hungary, Poland and Slovakia. Centre-level prevalences in men and women were highly correlated. Scheuermann's was not associated with BMD of the spine or hip.

CONCLUSIONS

Since most of the variation in population impact of Scheuermann's was unaccounted for by the radiological and anthropometric data, the search for new genetic and environmental determinants of this disease is encouraged.

Scheuermann's disease (dysostosis) of the spine

A 17-year-old adolescent boy presented with progressive lower back pain and fatigue.

Comparison between two types of "Scheuermann disease-like people": thoracolumbar disc herniation patients and healthy volunteers with radiological signs of Scheuermann's disease

BACKGROUND

Scheuermann's disease (SD) is a spinal disorder and includes both a classic form and an atypical form. Interestingly, its existence among the general population as well as the disc disease patients is common. One of our previous studies showed that about 18% of the hospital staff members meet the SD criteria. On the other hand, another study has demonstrated that 95.2% of the symptomatic thoracolumbar disc herniation (STLDH) patients meet the SD criteria, which suggests that STLDH is very likely a special form of SD. The purpose of this study was to discriminate the factors contributing to the development of STLDH by comparing STLDH patients with the healthy SD-like hospital staff members.

METHODS

This is a retrospective study including 33 STLDH patients who met the SD criteria and 30 SD-like hospital staff members. The STLDH group was chosen from a group of patients who underwent surgery after a diagnosis of STLDH (T10/11-L1/2) at our hospital between June 2007 and June 2010. SD-like hospital staff members were chosen from a database created in 2007, which contained a lumbar MR and low back pain (LBP) questionnaire of 188 hospital staff members. The demographic and radiologic characteristics were compared between groups.

RESULTS

There was no statistical difference in sex, age, and height between the two groups. The STLDH patients had higher body weight, boby mass index, and thoracolumbar kyphotic angle than SD-like hospital staff members. In addition, STLDH patients had more levels of Schmorl's nodes (3.5±1.7 vs. 2.0±1.9, t = 3.364, P = 0.001) and irregular endplateson (4.0±1.9 vs. 2.7±1.9, t = 2.667, P = 0.010) compared to the SD-like hospital staff members.

CONCLUSIONS

Higher body weight, higher body mass index, larger thoracolumbar kyphosis, and more Schmorl's nodes and irregular endplates on MR may be associated with the development of STLDH in "SD-like people."

Spina bifida occulta in high grade spondylolisthesis

A 14-year-old boy presented with symptomatic high-grade dysplastic type spondylolisthesis, with a presence of spina bifida occulta, not diagnosed by plain radiographs, but confirmed on preoperative CT and MR. Circumferential fusion with partial reduction of L5/S1 was performed. Awareness of the coexistence of spondylolisthesis and spina bifida by an accurate preoperative planning is paramount to avoid iatrogenic damage to neural elements during surgery.

Clinical validation of coronal and sagittal spinal curve measurements based on three-dimensional vertebra vector parameters

BACKGROUND CONTEXT

For many decades, visualization and evaluation of three-dimensional (3D) spinal deformities have only been possible by two-dimensional (2D) radiodiagnostic methods, and as a result, characterization and classification were based on 2D terminologies. Recent developments in medical digital imaging and 3D visualization techniques including surface 3D reconstructions opened a chance for a long-sought change in this field. Supported by a 3D Terminology on Spinal Deformities of the Scoliosis Research Society, an approach for 3D measurements and a new 3D classification of scoliosis yielded several compelling concepts on 3D visualization and new proposals for 3D classification in recent years. More recently, a new proposal for visualization and complete 3D evaluation of the spine by 3D vertebra vectors has been introduced by our workgroup, a concept, based on EOS 2D/3D, a groundbreaking new ultralow radiation dose integrated orthopedic imaging device with sterEOS 3D spine reconstruction software.

PURPOSE

Comparison of accuracy, correlation of measurement values, intraobserver and interrater reliability of methods by conventional manual 2D and vertebra vector-based 3D measurements in a routine clinical setting.

STUDY DESIGN

Retrospective, nonrandomized study of diagnostic X-ray images created as part of a routine clinical protocol of eligible patients examined at our clinic during a 30-month period between July 2007 and December 2009.

PATIENT SAMPLE

In total, 201 individuals (170 females, 31 males; mean age, 19.88 years) including 10 healthy athletes with normal spine and patients with adolescent idiopathic scoliosis (175 cases), adult degenerative scoliosis (11 cases), and Scheuermann hyperkyphosis (5 cases). Overall range of coronal curves was between 2.4 and 117.5°. Analysis of accuracy and reliability of measurements was carried out on a group of all patients and in subgroups based on coronal plane deviation: 0 to 10° (Group 1; n=36), 10 to 25° (Group 2; n=25), 25 to 50° (Group 3; n=69), 50 to 75° (Group 4; n=49), and above 75° (Group 5; n=22).

METHODS

All study subjects were examined by EOS 2D imaging, resulting in anteroposterior (AP) and lateral (LAT) full spine, orthogonal digital X-ray images, in standing position. Conventional coronal and sagittal curvature measurements including sagittal L5 vertebra wedges were determined by 3 experienced examiners, using traditional Cobb methods on EOS 2D AP and LAT images. Vertebra vector-based measurements were performed as published earlier, based on computer-assisted calculations of corresponding spinal curvature. Vertebra vectors were generated by dedicated software from sterEOS 3D spine models reconstructed from EOS 2D images by the same three examiners. Manual measurements were performed by each examiner, thrice for sterEOS 3D reconstructions and twice for vertebra vector-based measurements. Means comparison t test, Pearson bivariate correlation analysis, reliability analysis by intraclass correlation coefficients for intraobserver reproducibility and interrater reliability were performed using SPSS v16.0 software.

RESULTS

In comparison with manual 2D methods, only small and nonsignificant differences were detectable in vertebra vector-based curvature data for coronal curves and thoracic kyphosis, whereas the found difference in L1-L5 lordosis values was shown to be strongly related to the magnitude of corresponding L5 wedge. Intraobserver reliability was excellent for both methods, and interrater reproducibility was consistently higher for vertebra vector-based methods that was also found to be unaffected by the magnitude of coronal curves or sagittal plane deviations.

CONCLUSIONS

Vertebra vector-based angulation measurements could fully substitute conventional manual 2D measurements, with similar accuracy and higher intraobserver reliability and interrater reproducibility. Vertebra vectors represent a truly 3D solution for clear and comprehensible 3D visualization of spinal deformities while preserving crucial parametric information for vertebral size, 3D position, orientation, and rotation. The concept of vertebra vectors may serve as a starting point to a valid and clinically useful alternative for a new 3D classification of scoliosis.

Scheuermann's Kyphosis: an update

A review of the current literature demonstrates considerable debate regarding the pathogenesis, natural history and treatment of Scheuermann's kyphosis. Most of the views and recommendations provided in various reports are weakly supported by levels of evidence. In addition, prospective studies using validated questionnaire instruments and long-term follow-ups to assess clinical outcomes in patients treated conservatively or surgically versus those untreated that would document the natural history of the condition are still unavailable. This systematic review summarizes the current knowledge on Scheuermann's kyphosis and attempts to present a rational approach in the evaluation and management of this group of patients.

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

STUDY DESIGN

A prospective, radiographic cohort study.

OBJECTIVES

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Do anterior interbody cages have a potential value in comparison to autogenous rib graft in the surgical management of Scheuermann's kyphosis?

BACKGROUND CONTEXT

Previous studies have analyzed the outcome following posterior correction and combined anterior-posterior correction for Scheuermann's kyphosis. Traditionally interbody fusion has been obtained using morselized rib graft. Recently the use of titanium anterior cages has been suggested for interbody use. There are no long-term studies comparing these two techniques.

PURPOSE

To investigate the potential value of titanium anterior interbody cages compared with morselized rib graft for anterior interbody fusion in combination with posterior instrumentation, correction, and fusion for Scheuermann's kyphosis.

STUDY DESIGN

Nonrandomized comparison of two surgical techniques in matched subjects.

PATIENT SAMPLE

Fifteen patients with identical preoperative radiographic and physical variables (age, gender, height, weight, body mass index) were managed with combined anterior release, interbody fusion, posterior instrumentation, correction, and fusion. Group A (n=8) had morselized rib graft inserted into each intervertebral disc space. Group B (n=7) had titanium interbody cages packed with bone graft inserted at each level. The posterior instrumentation extended from T2 to L2 in both groups.

OUTCOME MEASURES

Preoperative and postoperative curve morphometry was studied on plain radiographs by two independent observers. The indices studied included Cobb angle, Ferguson's angle, Voutsinas index, sagittal vertical axis (SVA), sacral inclination (SI), and lumbar lordosis (LL). Interbody fusion was assessed at final follow-up. Each patient was reviewed at 3, 6, 12, 24, 48, and 60 months after surgery with standing radiographs.

METHODS

Both surgical groups were compared in terms of radiological parameters and complications. Wilcoxon-matched pairs test and Mann-Whitney test were used.

RESULTS

The average follow-up for Group A was 70 months and for Group B 66 months. For the whole group, the preoperative median Cobb angle for thoracic kyphosis was 86 degrees , the median Ferguson angle was 50 degrees , Voutsinas index was 28.7, SVA -3.5 centimeters, lumbar lordosis was 66 degrees , and the median sacral inclination angle was 40 degrees . The median postoperative Cobb angle was 42 degrees , Ferguson angle 28.4 degrees , Voutsinas index 13, SVA -4.0 centimeters, and the median sacral inclination angle was 34 degrees . There were significant differences between preoperative and postoperative measurements for all variables (p<.01), indicating that good correction was achieved. At 4-year follow-up, fusion criteria were satisfied in 12 of 15 cases (80%). Three patients had distal junctional kyphosis. There was no significant difference obtained in the final Cobb angle, Ferguson angle, and Voutsinas index when Group A (rib graft) was compared with Group B (titanium cage) Both Group A and B patients retained the postoperative correction achieved with respect to all the radiographic parameters studied.

CONCLUSION

We were unable to demonstrate any significant advantage for the use of anterior titanium interbody cages over the use of morselized rib graft in the surgical management of Scheuermann's kyphosis. Given the not inconsiderable cost and the need for posterior chevron osteotomies when interbody cages are used, we have now reverted to our previous practice of using morselized rib graft at each intervertebral level.

Predictable correction of the unfused lumbar lordosis after thoracic correction and fusion in Scheuermann kyphosis

STUDY DESIGN

A retrospective examination of preoperative and postoperative radiographs of the sagittal spine of 30 patients with Scheuermann kyphosis.

OBJECTIVES

To determine significant correlations between kyphosis and lordosis in Scheuermann kyphosis, determine predictability of spontaneous sagittal lordosis correction after thoracic correction and fusion, and understand better the biomechanics of the spine.

SUMMARY OF BACKGROUND DATA

Previous studies described relations between kyphosis and lordosis in healthy people. To our knowledge, no relationships, have been described between kyphosis and lordosis in Scheuermann kyphosis.

METHODS

On radiographs, maximum kyphosis, maximum lordosis, sacral slope and L5-S1 angle were measured in the preoperative and postoperative standing lateral radiographs of the spine, and correlations were calculated.

RESULTS

Preoperative significant correlations were present between kyphosis and lordosis (R = 0.421; P = 0.021), and between lordosis and sacral slope (R = 0.824; P < 0001). Postoperative correlations were stronger (R = 0.591; P = 0.001 and R = 0.844; P < 0.001). The percentage of correction of kyphosis was correlated with the percentage of spontaneous decrease of lordosis (R = 0.593; P < 0.001). A negative correlation between L5-S1 angle and upper lumbar segment of lordosis was found before and after surgery.

CONCLUSIONS

This study shows a significant correlation between kyphosis and lordosis before and after surgery. Surgical correction of thoracic hyperkyphosis gives a predictable spontaneous decrease of lumbar lordosis. Correction of lordosis occurs mainly in the upper segment of lumbar lordosis.

[Combined thoracoscopic anterior spinal release and posterior correction for Scheuermann's kyphosis]

OBJECTIVE

To evaluate the effectiveness of combined thoracoscopic anterior spinal release and posterior correction for Scheuermann's kyphosis.

METHODS

Sixteen patients with a diagnosis of Scheuermann's kyphosis were selected to undergo thoracoscopic anterior spinal release, disc excision, and fusion in conjunction with instrumented posterior correction and spine fusion. Cobb angle of the kyphosis were measured before the operation and during the follow-up period to evaluate the correction. Pre- and post-operative Oswestry disability Index (ODI) were collected to evaluate the pain relief.

RESULTS

All 16 patients underwent successfully corrections. The mean preoperative kyphosis (Cobb) was 78.8 degrees (70 degrees-92 degrees), the mean postoperative kyphosis (Cobb) was 40.5 degrees (36 degrees-47 degrees), and the last follow-up evaluation of the kyphosis was 41.7 degrees (36 degrees-50 degrees ). All patients obtained satisfied pain relief. The mean preoperative ODI was 37.3 (0-72), and the mean postoperative ODI was 6.4 (0-30).

CONCLUSION

Combined thoracoscopic anterior spinal release and posterior correction is a good method for the treatment of Scheuermann's kyphosis.

[Low back pain among children and adolescents]

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical outcome and radiographic results after operative treatment of Scheuermann's disease

The aim of this prospective study was to evaluate radiographic findings, patient satisfaction and clinical outcome, and to report complications and instrumentation failure after operative treatment of Scheuermann's disease using a combined anterior and posterior spondylodesis. The loss of sagittal plane correction after removal of the posterior instrumentation was analysed. The indication for surgery was a thoracic kyphosis greater than 60 degrees in adolescents and adults with persistent back pain, which failed to respond to conservative treatment. Thoracic kyphosis and lumbar lordosis angles were measured by the Cobb method at preselected time points and at final follow-up. Sagittal plane alignment was measured as translation. The validated Scoliosis Research Society Instrument (SRSI) questionnaire was sent to all patients at follow-up. P-values were calculated using the Wilcoxon signed rank test (P<0.05 is significant). Between October 1987 and August 1999, 23 consecutive patients underwent operative treatment. The median follow-up was 75 months (range 25-126 months). Median preoperative thoracic kyphosis was 70 degrees (range 62 degrees-78 degrees) and median preoperative lumbar lordosis was 68 degrees (range 54 degrees-84 degrees). Immediate postoperative median thoracic kyphosis was 39 degrees (range 28 degrees-54 degrees) (P<0.05) and immediate postoperative median lumbar lordosis was 49 degrees (range 35 degrees-63 degrees) (P<0.05). These significant corrections were maintained at early follow-ups conducted 1 year and 2 years postoperatively. At final follow-up, the median thoracic kyphosis had significantly increased, to 55 degrees (range 36 degrees-65 degrees) (P<0.05 relative to immediate postoperative value), and the median lumbar lordosis had increased to 57 degrees (range 44 degrees-70 degrees) (P<0.05). The late deterioration of correction in the sagittal plane was mainly caused by removal of the posterior instrumentation, and occurred despite radiographs, bone scans and thorough intra-operative explorations demonstrating solid fusions. The median SRSI score was 83 points (range 55-106). There was no significant correlation between the radiographic outcome and the SRSI score (P>0.05). Our series showed relatively fair outcome after operative treatment in Scheuermann's disease. Therefore, the indication for surgery in patients with Scheuermann's disease can be questioned.

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.

Study of vertebral morphology in Scheuermann's kyphosis before and after treatment

Variation of vertebral morphology in Scheuermann's Kyphosis before and after orthopedic treatment is usually measured by the entity of the curve, using Cobb's method, and by vertebral wedging. But the lack of correlation between these parameters and the clinical evolution of the deformity, lead to the possibility of other alterations that can explain part of the kyphosis deformities before and after the treatment. In this group of alterations the inclination of anterior and posterior walls, that express the trapezoid deformity of vertebras, seem to be more reliable indicators of curve response to ortopedic treatment.

Scheuermann kyphosis: long-term follow-up

BACKGROUND CONTEXT

There is considerable controversy as to the optimal treatment of Scheuermann kyphosis. Proposed modalities have included exercise, bracing and surgery.

PURPOSE

The purpose of this study was to document the functional capacity and radiographic findings in adults who have been previously treated for Scheuermann kyphosis.

STUDY DESIGN

A cohort study of all patients with Scheuermann kyphosis treated in a single institution using three different treatment modalities: exercise and observation, Milwaukee bracing and surgical fusion using the Harrington Compression System.

PATIENT SAMPLE

Sixty-three patients were evaluated at a mean of 14 years after treatment (10 to 28 years).

OUTCOME MEASURES

Two different functional evaluation instruments were used. Radiographic evaluation was carried out in 38 patients (60%).

METHODS

Patient interviews were conducted using a specially designed questionnaire. Patients were then asked to undergo standing radiographs. Patients were divided into groups depending on the location of their kyphosis and the manner in which they had been treated. Standard statistical analysis was then carried out.

RESULTS

At time of follow-up evaluation there were no differences in marital status, general health, education level, work status, degree of pain and functional capacity between the various curve types, treatment modality and degree of curve. Patients treated by bracing or surgery did have improved self-image, which they attributed to their treatment. Patients with kyphotic curves exceeding 70 degrees at follow-up had an inferior functional result. At time of final follow-up there were no statistical differences in degree of kyphosis and mode of treatment.

CONCLUSIONS

By carefully selecting the appropriate treatment for patients with Scheuermann kyphosis on the basis of the patient's age, spinal deformity and the severity of back pain, it is possible to achieve a similar functional result at long-term follow-up. Despite different treatment protocols, patients with Scheuermann kyphosis tend to achieve a similar functional result at long-term follow-up.

String test measurement to assess the effect of spinal deformity correction on spinal canal length

STUDY DESIGN

Long cassette coronal and lateral radiographs before and after surgical correction were analyzed and string test measurements made by three observers in 55 surgical cases (13 surgical types).

OBJECTIVES

The purpose of the study was to assess the effect of various corrective maneuvers for spinal deformity on the spinal canal length.

SUMMARY OF BACKGROUND DATA

When perioperative neurologic deficit occurs, the surgeon removes implants because they are displaced into the spinal canal or the canal has been lengthened. It is important to know the effect certain constructs have on canal length because the ability of the spinal cord to adapt to canal lengthening is variable.

METHODS

On the coronal radiographs the concave, convex, midvertebral, and adjusted midvertebral line, and on the sagittal radiographs, the anterior and posterior vertebral body lines were measured. The adjusted coronal line was the assumed path of the spinal cord starting at the midportion of the vertebral body at the top and the bottom of the deformity and then in between, hugging the pedicles as closely as possible while staying inside the pedicles. Adjustments for magnification were made.

RESULTS

Anterior compression instrumentation without cages (n = 5) consistently shortened the spinal canal (mean delta -6.67 +/- 2.30 mm, P = 0.003), whereas instrumentation with cages (n = 13) lengthened the canal (mean delta 10.54 +/- 7.58 mm, P = 0.0003). Thoracic curves treated by posterior corrective forces (n = 14) demonstrated lengthening of the canal (mean delta 10.14 +/- 5.23 mm, P = 0.0001), large (n = 5) curves (81-140 degrees, mean delta 13.47 +/- 7.05 mm), and medium (n = 7) curves (50-80 degrees, mean delta 8.43 +/- 3.24 mm).

CONCLUSIONS

Many deformity correction maneuvers, although they do not directly include application of posterior or anterior distraction forces, do indirectly lengthen the spinal canal.

Radiographic abnormalities in the thoracolumbar spine of young elite skiers

An increased frequency of radiologic abnormalities in the thoracolumbar spine has been reported among young athletes in various sports, but there are no data concerning ski sports. To evaluate the incidence of these abnormalities in young elite skiers, we compared 120 skiers younger than 17 years old (alpine skiers, ski jumpers, and Nordic cross-country skiers) with a random sample of 39 control subjects of the same age who had no history of high-performance sports participation. Standardized anteroposterior and lateral radiographs of the entire lumbar spine, the lower thoracic spine, and the upper part of the sacrum were obtained from each athlete and each control subject. Radiographs were evaluated by two independent observers for the presence and size of anterior and posterior endplate lesions and Schmorl's nodes. The elite alpine skiers and ski jumpers demonstrated a significantly higher rate of anterior endplate lesions than did the control subjects. This finding might be attributable to excessive loading and repetitive trauma of the immature spine under high velocity, especially in the forward bent posture.

Progressive pseudorheumatoid dysplasia

A rare case of progressive pseudorheumatoid dysplasia (PPD) in a 9-year-old girl is presented. Clinically, chronic painless swollen joints, accompanied by progressive motion restriction and progressive walking difficulties, were found. Radiologically, there was enlargement of the epimetaphyseal portions of the large joints, metacarpal heads, and phalanges, and generalized platyspondyly with irregular delineation of the endplates of the vertebral bodies. The radioclinical features at the peripheral joints were originally misdiagnosed as juvenile rheumatoid arthritis (JRA), and the structural spinal abnormalities were neglected and interpreted as Scheuermann's disease. However, the absence of active inflammatory parameters argues against JRA, whereas the low age of onset of the irregularities at the vertebral endplates is an argument against the diagnosis of Scheuermann's disease. The combination of the dysplastic abnormalities of the spine, with platyspondyly and Scheuermann-like lesions at an unusually low age of onset, and radiological features mimicking JRA of the peripheral joints, is the clue to the diagnosis of this rare autosomal-recessive disease. This case is the first to document the MRI features of PPD of the spine.

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.

[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.

Scheuermann's juvenile kyphosis

OBJECTIVE

Two cases are discussed to illustrate two different presentations, progressions and treatments of Scheuermann's juvenile kyphosis.

CLINICAL FEATURES

In one case, a 13-yr-old boy suffered from a 2-yr history of lower back pain. Radiographs demonstrated irregularity of the upper lumbar vertebral endplates, associated with Schmorl's nodes. The second case is one of a 14-yr-old boy who was seen in an orthopedic outpatient clinic. Radiographs revealed wedging of the anterior border of T6, T7, and T8 vertebrae with a thoracic spine kyphotic deformity measuring 72 degrees.

INTERVENTION AND OUTCOME

The first case was treated conservatively. The patient maintained his improvement at 6 month follow-up. The second case was initially treated with a brace that the patient did not wear regularly as directed. The kyphotic deformity progressed from 72 degrees to 92 degrees. An operation was performed to reduce the kyphotic curve and prevent further progression. On review 6 yr later, the patient was well without back pain or other complications. The kyphotic curve measured 65 degrees.

CONCLUSION

Scheuermann's juvenile kyphosis is a common spinal deformity in the adolescent. A radiographic appearance of wedging of the anterior portion of the vertebral bodies with marked kyphotic deformity suggests the diagnosis of classical Scheuermann's disease. However, the lumbar type of Scheuermann's disease should be considered in young patient with radiographic evidence of irregular vertebral endplates, Schmorl's nodes and a decreased disc space without wedging. Nevertheless, significant progression of the curve in both the typical and atypical types of Scheuermann's disease is rare, but can occur. An algorithm is presented to facilitate decision making in the management of Scheuermann's juvenile kyphosis.

Are radiologic changes in the thoracic and lumbar spine of adolescents risk factors for low back pain in adults? A 25-year prospective cohort study of 640 school children

STUDY DESIGN

This report was based on a 25-year prospective cohort study and designed as a self-administered questionnaire with low back pain as the main topic.

OBJECTIVE

To identify whether radiologic changes in the thoracic and lumbar spine and a history of low back pain in the adolescent period represent risk factors for low back pain in adults.

SUMMARY OF BACKGROUND DATA

Six-hundred-forty 14-year-old school children were examined with x-rays of the thoracic and lumbar spine and registered by the school doctor regarding a history of low back pain.

METHODS

All of the x-rays and the short journals from the school doctor's registration were reviewed. This primary information was the basis of the investigation 25 years later.

RESULTS

Eleven percent of the cohort had a history of low back pain in adolescence, and the results showed an 84% lifetime prevalence of low back pain in these subjects as adults and an increased frequency of low back pain the last month and week before they answered the questionnaire, compared with the rest of the cohort. These problems were associated with increased morbidity and decreased working capacity. Thirteen percent had radiologic abnormalities, mainly Scheuermann changes, in the thoracic and lumbar spine as adolescents, with no positive correlation to low back pain in this period. Unlike other reports, our results did not confirm a positive correlation between x-ray changes in the lower spine in adolescents and a higher prevalence of low back pain in adults. Stepwise logistic regression analyses showed that low back pain in the growth period and familial occurrence of back disease are important risk factors for low back pain later in life, with an observed probability of 88% if both factors are present.

CONCLUSION

This study suggests that low back pain in the growth period is "a real problem," with a trend toward aggravation as time passes. Thus, implementing preventive measures in schools may be very important.

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.

Increased Tc-99m MDP in multiple lumbar intervertebral disk spaces in Scheuermann disease without concomitant radiographic calcification or diskitis

A radionuclide bone scan serendipitously revealed deposition of Tc-99m MDP in multiple lumbar intervertebral disk spaces in a 29-year-old man with extensive trauma to the left femur as a result of a motor vehicle accident. In the authors' experience, alcoholic liver disease or altered weight bearing secondary to prior trauma are not associated with intervertebral radiotracer uptake. Although it is possible that radiographically undetectable microcalcifications in the intervertebral disk spaces associated with degenerative changes, common in Scheuermann disease, account for this unusual finding, a literature search found that increased disk uptake had been reported only in two patients with Scheuermann disease who had concomitant active or healing diskitis. No other causes of increased disk uptake of Tc-99m MDP were found.

Similar radiologic lesions of localized Scheuermann's disease of the lumbar spine in twin sisters

SUMMARY OF BACKGROUND DATA

Hereditary and mechanical factors are considered to be the principal etiologic factors of Scheuermann's disease.

OBJECTIVES

The authors report identical twins presenting similar lesions of localized lumbar osteochondrosis, which were worse in the one twin that practiced strenuous sports activities.

CONCLUSIONS

These observations suggest, at least in some of these patients, a basic role for genetic factors in the occurrence of the disease and an influence of mechanical strain on its severity.

Bone scintigraphy in patients with atypical lumbar Scheuermann disease

Fourteen patients presenting during an 8-year period with radiographic changes suggestive of atypical lumbar Scheuermann disease (ALSD) involving one or more vertebral levels and low-back pain symptoms were referred for bone scintigraphy. Eleven of these studies included single-photon emission computed tomography (SPECT). The bone scans were reviewed with the intent of defining the scintigraphic characteristic of ALSD. Eleven of the 14 patients had subtle increases in activity on planar bone scintigraphy and/or SPECT at the radiographic sites of involvement. These scintigraphic findings should be distinguished from the more intense radiotracer uptake patterns of infection (osteomyelitis and discitis) and trauma (fracture).

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.