Relationship between Scheuermann disease and symptomatic thoracic spinal stenosis: A retrospective study

OBJECTIVE

This study aimed to investigate the possible relationship between Scheuermann disease (SD) and the pathophysiological factors of thoracic spinal stenosis (TSS), including ossification of the ligamentum flavum (OLF), ossification of the posterior longitudinal ligament (OPLL), and thoracic disc herniation (TDH) in patients with symptomatic TSS.

METHODS

Demographic and radiological data from 66 consecutive patients diagnosed with symptomatic TSS from 2013 to 2018 were retrospectively collected and divided into 3 groups depending on the underlying pathomechanism of TSS: TDH group (18 patients; 6 women; mean age ± standard deviation [Sd] = 59.89 ± 11.34), OPLL group (12 patients; 8 women; mean age ± Sd = 56.08 ± 14.74), and OLF group (36 patients; 20 women; mean age ± Sd = 58.69 ± 9.77). A total of 41 age-matched healthy individuals (19 women; mean age ± Sd = 54.88 ± 13.63) were designated as the control group. In each group, both typical and atypical SD criteria were radiologically examined. The demographic data and presence of SD between the control group and 3 subgroups of TSS pathomechanisms were evaluated.

RESULTS

SD characteristics were identified in 83.33% (15/18) of patients in the TDH group, 44.44% (16/36) in the OLF group, 25% (3/12) in the OPLL group, and 17.07% (7/41) of the control individuals. When analyzed by the chi-squared test and logistic regression analysis, the presence of SD was significantly associated with TDH (P < 0.01) and OLF (P < 0.05) but not OPLL (P > 0.05). Patients with TDH and OLF showed peak involvement of T10/11, and patients with OPLL did not. Furthermore, we determined that age, sex, body-mass index, and smoking status were not the risk factors for TDH, OPLL, and OLF (P > 0.05). SD was found to be a risk factor for TDH (P < 0.01) and OLF (P < 0.05) but not for OPLL (P > 0.05).

CONCLUSION

Evidence from this study indicated that SD might be a risk factor for OLF and TDH but not for OPLL.

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.

Craniosynostosis, Scheuermann's disease, and intellectual disability resembling Shprintzen-Goldberg syndrome: a report on a family over 4 generations: Case report

RATIONALE

Craniosynostosis is a disorder characterized by premature fusion of cranial sutures with subsequent development of abnormal craniofacial contour associated with variable skeletal and extra-skeletal abnormalities. In this family syndromic type of craniosynostosis was recognized and the etiology behind diverse forms of deformities have been diagnosed.

PATIENT CONCERNS

The negative impact of the disorder on the child and his family is enormous. Particularly when the diagnosis is late and little can be done. Though counselling the family through discussing the whole picture of the disorder might lessens their concern.

DIAGNOSES

Diagnosis is the corner stone of management. In this paper we aimed to sensitize pediatricians, physicians, and orthopedic surgeons concerning the necessity to recognize syndromic associations early on.

INTERVENTIONS

Patients with syndromic craniosynostosis are usually associated with a complexity of malformation complex. Craniofacial surgery can be of remarkable help if the diagnosis is made early. It requires a series of corrections to avoid intellectual disability and other neurological deficits.The timing of interventions is strongly correlated on the timing of diagnosis.

OUTCOMES

The earliest the diagnoses, the much better the outcomes are. And consequently avert the psychological and the financial cost on the patient and his family.

LESSONS

The golden principle of medicine should prevail in all medical disciplines, which states: The more you see, the more you know and conversely the more you know is the more you see.

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.

Hypothesis about an existent biomechanical cause-effect relationship between Schëuermann's kyphosis and scoliosis

Schëuermanńs kyphosis is usually observed with a mild idiopathic scoliosis, and there is parity between these two diseases. The aim of this work is to establish a hypothesis about the existence of a biomechanical causal relationship between Schëuermann's kyphosis and scoliosis. To achieve this, a literature review was conducted. A simple mechanical model of the passive thoracolumbar subsystem was created to support part of the discussion. This mechanical model describes the passive thoracolumbar subsystem under ideal conditions of equilibrium. After giving consideration to the system under these conditions, some of the geometrical changes that may be found in Schëuermanńs kyphosis are considered. Next, this work discusses the evolution of the spine, taking into account its relationship with stable equilibrium, which the passive subsystem tends toward. We hypothesized about the postural response of the body to compensate for possible situations of imbalance. In conclusion, it can be found that a change in the alignment of the spine may occur due to the postural adaptation of the body to an inadequate mechanical situation that may lead to scoliotic deformity of the spine.

[Current concepts on Scheuermann kyphosis: clinical presentation, diagnosis and controversies around treatment]

Scheuermann kyphosis is a structural deformity of the thoracic or thoracolumbar spine that develops prior to puberty and deteriorates during adolescence. There is limited information on its natural history but many patients are expected to have a benign course. Severe kyphosis can progress into adult life and cause significant deformity and debilitating back pain. Conservative treatment includes bracing and physical therapy, but although widely prescribed they have not been scientifically validated. Surgical treatment may be considered in the presence of a progressive kyphosis producing severe pain resistant to conservative measures, neurological compromise, or unacceptable deformity. This is associated with significant risks of major complications that should be discussed with the patients and their families. Modern techniques allow better correction of the deformity through posterior-only surgery with lower complication rates. Simultaneous shortening of the posterior vertebral column across the apical levels, along with spinal cord monitoring, reduces the risk of neurological deficits.

[Spinal deformities and their mechanopathology in oarsmen (author's transl)]

Motional analysis of the spinal segments with an x-ray amplifyer and studies of mechanical stress in the spine at oarsmen show, that during the phase of driving through with the oars immersed, the direction of the resulting load in the spine is approximately vertical to the next vertebral body. While referring to the vertebral bodies the direction of the resulting load does not change essentially, the size of the load differs conspicuously during active motion. In rowing the quantity of stress in the spine is limited by the torque of the counterforce, the erector trunci. Using an exact and correct rowing technique the quality of stress is compatible with the physiologically axial stresspattern of the vertebral body and the intervertebral disque. The frequency of peakstress in active rowing may possible lead to early and augmented degenerative changes in the vertebral bodies. In 45 Austrian top oarsmen the spine was examined clinically and radiologically, 68% showed signs of a previous Scheuermann's disease, while degenerative changes of vertebral bodies were found in 48%. Comparing spinal damages in different sports used in the training of the examined oarsmen, only in bicycling a similar pathomechanical effect on the spine could be observed.

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.

Assessment of bone density in children with Scheuermann's disease

Twenty four children with Scheuermann's disease (11 girls and 13 boys) aged 9-18 years measured for bone mineral density. The total skeleton (TB BMD) and lumbar spine (L2-L4 BMD) mineral density were investigated by dual energy X-ray absorptiometry (DEXA). In nine patients with Scheuermann's disease and backache we found lower levels of TB BMD and L2-L4 BMD in comparison with reference population of Lunar database. Osteopenia in these children may be caused by decreased physical activity due to vertebral pain.

What is a vertebral fracture?

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

[The development of spinal movements and sagittal curves in postural defects, idiopathic scoliosis and Scheuermann disease (results of longitudinal studies on 5, 10 and 14 year old subjects)]

A given population was followed by authors for 10 years. Children suffering from postural defects, structural scoliosis, spinal osteochondrosis were separated from a normal group. Spinal mobility and posture were compared with the mobility of normal, healthy boys and girls aged 5-14 years. In postural defects physiologically curves could be seen. The range of motion hasn't been physiologic in structural scoliosis. The rotation and flexion of the spine were increased while the lumbar flexion was decreased. Physiologic trend was found in Scheuermann disease, however high values of spinal rotation wasn't found. Extremely increased thoracic kyphosis was found only in children aged 14 years. Perhaps the change of motion is an etiologic factor in structural scoliosis.

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

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

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

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

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

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

Plantar weight-bearing pattern in idiopathic scoliosis

Eighty-four patients were objectively evaluated with a weight-bearing pattern analyzer to determine whether spine deformity has an effect on the amount of weight borne on the right versus left foot and on the fore versus the hind foot. Patients with idiopathic scoliosis treated with bracing and surgery and patients with Scheuermann's kyphosis treated with bracing were compared with control subjects. Patients with right thoracic and thoracolumbar curves did not bear more weight on the right foot, as was previously thought. Patients with relatively unaffected lumbar spines exhibited normal sagittal plane weight-bearing patterns, whereas patients with double major and lumbar curves did show abnormalities in the weight-bearing pattern. Bracing of curves less than 40 degrees did not alter the plantar weight-bearing pattern, but it did significantly alter the pattern in curves greater than 40 degrees. Surgically treated patients were found to have increased hindfoot weight-bearing irrespective of the curve type or surgery.

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

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

[New aspects in the treatment of Scheuermann's disease with hippotherapy (author's transl)]

It had already been shown by clinical and x-ray examinations that various types of riding therapy exercise a favourable influence on the shape of the vertebral column. This has now been confirmed by means of analytical movement studies. Whereas the active exercises in riding therapy strengthen the musculature, especially in the region of the trunk, hippotherapy deserves special attention, since it has a considerable influence on the removal or at least reduction of segment fixation of the various parts of the spinal column. This form of therapy, as part of physiotherapy, is absolutely indispensable since it achieves a multitude of therapeutic aims. It is pointed out that hippotherapy does not involve any risk of damaging the intervertebral disks as a result of pressure.

Scheuermann's kyphoscoliosis associated with Charcot-Marie-Tooth syndrome

Much confusion and disagreement exists regarding the classification and characteristics of inherited disorders manifesting neurogenic muscular atrophy. Many authors consider Charcot-Marie-Tooth syndrome (CMTS) and Roussy Levy syndrome (RLS) forme fruste or variants of Friedreich's ataxia (FA). Familial kyphoscoliosis has often been described in FA and RLS but not with CMTS. The purpose of this paper is to present detailed clinical and laboratory findings in a family with three cases of Scheuermann's kyphoscoliosis and CMTS in three generations. In all cases Scheuermann's kyphoscoliosis was associated with pes cavus, markedly diminished vibratory and position sensation in the lower extremities, absent deep tendon reflexes and muscular atrophy, predominantly of the distal muscles. Fine rhythmic tremor of outstretched hands and positive Romberg sign were present in one case only. Serum creating phosphokinase was elevated in two cases. Motor nerve conduction studies revealed impaired function in the median, ulnar, tibial and peroneal nerves. Sensory nerve conduction wal also impaired in median and ulnar nerves. There was evidence of left ventricular hypertrophy in one case only. The nosology and relationship between CMTS, RLS and FA are discussed.