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.

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.

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.

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.

Pediatric spinal deformity: what every orthopaedic surgeon needs to know

Pediatric spinal deformity is an integral part of orthopaedic surgical practice. In a general or specialized practice, the well-versed orthopaedic surgeon should be aware of the diagnostic methods and the natural history from which practice standards are derived. It is important to be aware of the spectrum of spinal deformity in children (from early-onset scoliosis to adolescent idiopathic scoliosis, kyphosis, and spondylolisthesis) and current principles of growth and maturation as applied to the spine and the thorax. This information should be helpful in attaining the appropriate diagnosis, treatment, and/or referral for a pediatric patient with a spinal deformity.

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.

[Operative treatment of severe spine deformities]

87 patients with scoliosis, 32 cases with kyphosis of a various etiology were operated. Patients with severe scoliotic deformations (the total angle 75-140 [Russian character: see text]) got 2 types of the treatment. The first group consisted of 18 patients who were operated in two-stage surgery during the same anesthesia. In the second group (69 patients) after anterior diskectomy within 10-20 days preliminary correction of deformation with halo-pelvic traction was carried out followed by main stage of operation the final dorsal correction of deformation with Cotrel-Dubousset instruments. A significant (more than 40%) correction of deformation was achieved in both groups. However in the 2nd group the value of main angle exceeded 90 [Russian character: see text]. There were operated 32 patients with severe kyphotic deformities. Out of them 15 patients had severe posttraumatic vertebral kyphotic deformations (dislocation fractures of III-IV type according to Denis classification), 11 cases had--postlaminectomy kyphoses, 6 patients suffered from Scheuermann-Mau's disease. The patients with dislocation-fractures underwent laminectomy, reposition of dislocation, and transpedicular fixation of the vertebral column. In 14 patients dislocation was reduced completely, in the one case partially, but in all cases stable spondylosyndesis was achieved. In 8 patients dislocation-fractures were complicated by paraplegia or rough paraparesis), the 3 cases showed practically entire regress after operation, in the 5 cases no evident improvement in the neurologic status occurred. Patients with postlaminectomy kyphoses were treated with wedge vertebrotomy at the top of a curve, dorsal correction and fixation of the vertebral column with CDI system. In the 4 cases there was noted significant improvement in the neurologic status. Patients with Scheuermann-Mau's kyphosis were treated with anterior multilevel diskectomy, followed by halo-pelvic traction, and later dorsal correction of deformation with CDI system. Treatment resulted in significant correction of deformation was achieved and physiological or close to physiological sagittal profile of spine was restored.

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.

Scheuermann's kyphosis following cervical spinal cord injury

BACKGROUND

Scheuermann's kyphosis is an uncommon autosomal dominant disease that manifests as a progressive thoracic skeletal deformity. It can lead to severe restrictive lung disease or predispose to spinal cord injury (SCI). Neurologic sequelae are rarely reported in the literature.

METHOD

Case Presentation

SUMMARY

A 47-year-old man sustained a cervical SCI requiring surgical anterior fusion and reoperation for fracture of the affected vertebra. One year after SCI, he presented with further kyphotic progression and cervical spine instability. Clinical presentation and family history led to a diagnosis of Scheuermann's kyphosis. To prevent further progression, he underwent extensive multilevel anterior and posterior surgical stabilization.

CONCLUSION

This case illustrates the importance of early diagnosis and treatment of progressive spinal deformities. With proper surgical correction, this patient made substantial gains in mobility, self-care, and respiratory status.

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.

Analysis of the sagittal plane after surgical management for Scheuermann's disease: a view on overcorrection and the use of an anterior release

STUDY DESIGN

A historic cohort study was conducted to investigate surgical correction and sagittal alignment in 33 patients with thoracic Scheuermann's disease.

OBJECTIVE

To evaluate kyphosis correction, correction loss, sagittal balance, and the effect of an anterior release.

SUMMARY OF BACKGROUND DATA

Currently, both posterior and anteroposterior techniques seem to produce impressive corrections for Scheuermann's disease. However, few reports have been made on sagittal malalignment after surgery.

METHODS

A cohort of 33 patients who had undergone surgery for their Scheuermann's kyphosis were reviewed: Group A: posterior technique (n = 16), Group B: anteroposterior technique (n = 17). Pre- and postoperative curve morphometry (Cobb, Ferguson, Voutsinas), balance (C7 plumb line), and Oswestry score were compared.

RESULTS

The mean follow-up period was 4.5 +/- 2 years (range, 2-8.2 years). The mean preoperative kyphosis (Cobb) was 78.7 degrees +/- 8.9 degrees, and the mean postoperative kyphosis was 51.7 degrees +/- 10.3 degrees. At follow-up evaluation, the correction loss was 1,4 degrees +/- 3.9 degrees. There was no difference in curve morphometry, correction, sagittal balance, average age, and follow-up period between Groups A and B. One junctional kyphosis, in Group B, was noted. After surgery, all the patients were satisfied, and the Oswestry score showed significant improvement. No neurologic complications were observed.

CONCLUSIONS

Good follow-up results included a 100% follow-up rate, adequate corrections, little correction loss, lower Oswestry scores, and a high satisfaction rate in both groups. The anteroposterior treatment did not influence the curve morphometry more than posterior fusion only. In reducing postoperative sagittal malalignment, the authors believe that surgical management should aim at a correction within the high normal kyphosis range of 40 degrees to 50 degrees, consequently providing good results and, particularly in flexible adolescents and young adults, minimizing the necessity for an anterior release.

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.

Surgical treatment of Scheuermann's disease with segmental compression instrumentation

Twenty-one patients with Scheuermann's kyphosis had surgery for progressive kyphotic deformity of 50 degrees or greater. There were six adolescents, with a mean age of 15.6 years (range, 13-17 years) and 15 young adults, with a mean age of 25.4 years (range, 18-40 years). All patients had posterior spine arthrodesis with segmental compression instrumentation. Seven patients with rigid kyphosis had combined anterior and posterior spine arthrodesis. One patient died of superior mesenteric artery syndrome. In the group of 13 patients with posterior arthrodesis only, followup was 4.5 years. The mean preoperative thoracic kyphotic curve of 68.5 degrees improved to 40 degrees at latest review, with an average loss of correction of 5.75 degrees. Junctional kyphosis occurred in two patients with a short arthrodesis: one at the cephalad end and one at the caudal end of the fused kyphotic curve. In the second group of seven patients with combined anterior and posterior arthrodesis, followup was 6 years. The mean preoperative thoracic kyphotic curve of 86.3 degrees improved to 46.4 degrees at latest review, with an average loss of correction of 4.4 degrees. Overall, there was no postoperative neurologic deficit and no pseudarthrosis. Thus, posterior arthrodesis and segmental compression instrumentation seems to be effective for correcting and stabilizing kyphotic deformity in Scheuermann's disease. Despite a long operating time, this technique provided significant correction, avoiding the development of any secondary deformity in most patients. Combined anterior and posterior spine arthrodesis is recommended for rigid, more severe kyphotic deformities.

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.

Stuart Weinstein: advancing the specialty of orthopaedics

Images

Painful adult thoracic Scheuermann's disease. Diagnosis by discography and treatment by combined arthrodesis

This is the case report of a 42-year-old woman with chronic thoracic pain, nonradicular and refractory to all nonoperative treatment. Radiographs showed the classic findings of Scheuermann's disease, but without abnormal kyphosis. Magnetic resonance imaging scans showed multilevel thoracic disc degeneration typical of long-term Scheuermann's disease. Thoracic discography revealed concordant pain at T6-7 and T7-8. Treatment consisted of an anterior fusion, T5-11, and posterior fusion of T3 through L1, with Cotrel-Dubousset instrumentation. At follow-up, she was pain free and able to work full time and had been able to return to golf, her favorite recreation. Discography of the thoracic spine, as of the lumbar spine, can reveal the true source of pain and thus lead to precise and effective treatment.

Scheuermann's kyphosis. The Portuguese technique of surgical treatment

Between 1969 and 1989, we performed posterior segmental instrumentation on 38 patients with thoracic Scheuermann's kyphosis. We used a dynamic system without sublaminar fixation, and a kyphosis of 50 degrees was the main indication for surgery. The mean initial angle was 68 degrees (50 to 100) and the mean final kyphosis was 43 degrees at five-year follow-up, with a mean final loss after surgery of 3.7 degrees. Reconstruction of the vertebral bodies, vertebral wedging and the anterior-body height ratio were observed even in skeletally mature patients. There were no medical complications. There were three cases of loss of correction by more than 10 degrees and one of rod fracture with pseudarthrosis. The role of non-operative treatment is evaluated and early surgical treatment is advocated.

Cord compression caused by multiple disc herniations and intraspinal cyst in Scheuermann's disease

STUDY DESIGN

The design for this article is a case report.

OBJECTIVES

Reported is the case of a patient with Scheuermann's disease who experienced spastic paraparesis caused by multilevel disc herniations and intraspinal meningeal cyst occurring together.

SUMMARY OF BACKGROUND DATA

Although Scheuermann's disease is associated with disc degeneration and calcification, multilevel disc herniations causing neurologic deficit is exceedingly rare.

METHODS

A patient diagnosed with Scheuermann's disease was evaluated by laboratory tests and radiographs because of paresthesin in bilateral lower extremities.

RESULTS

Evaluation revealed a "cyst" that was separated from the proper subarachnoid space and a disc herniation.

CONCLUSIONS

Intraspinal cyst and multilevel disc herniations could coexist in Scheuermann's disease. Both could contribute to cord compression. Drainage of the cyst, anterior decompression of the disc herniations, and interbody fusion to stabilize the diseased segments produced good results after 2 years.

An analysis of sagittal curves and balance after Cotrel-Dubousset instrumentation for kyphosis secondary to Scheuermann's disease. A review of 32 patients

STUDY DESIGN

This study compared preoperative and postoperative saggittal curves and spinal balance in patients undergoing spinal fusion with Cotrel-Dubousset instrumentation for severe kyphosis secondary to Scheuermann's disease. Also determined was patient satisfaction regarding relief of pain and correction of the deformity. Thirty two patients with kyphosis > 75 degrees underwent spinal fusion with Cotrel-Dubousset instrumentation.

OBJECTIVES

To evaluate the initial and long-term correction of the primary kyphosis and changes in lumbar lordosis and sagittal balance, and to determine the incidence and etiology of junctional sagittal deformities.

SUMMARY OF BACKGROUND DATA

The average preoperative kyphosis was 85 degrees (range, 75 degrees to 105 degrees) with an average correction at final follow-up of 43 degrees (range, 26 degrees to 65 degrees). Preoperative lumbar lordosis averaged 75 degrees (range, 58 degrees to 100 degrees) and at final follow-up averaged 55 degrees (range, 23 degrees to 74 degrees). Most of the patients demonstrated negative sagittal balance and became slightly more negatively balanced postoperatively.

RESULTS

Maintenance of correction postoperatively was excellent, with only a 4 degree average loss of correction. There was spontaneous reduction in lumbar lordosis of varying degrees. Proximal junctional kyphosis was associated with over-correction (> 50%) of the kyphotic deformity or a fusion starting short of the proximal vertebra in the measured kyphosis. Distal junctional kyphosis developed in patients whose fusion ended short of the first lordotic segment.

CONCLUSIONS

This procedure appeared to yield good results when proper levels of fusion were selected and correction > 50% was not attempted.

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.

Short segmental kyphosis following fusion for Scheuermann's disease

Six of 14 patients surgically treated for Scheuermann's disease developed a short segmental kyphosis adjacent to the fusion. In four patients, the original fusion had incorporated the end vertebrae of the curves. However, there was mild wedging of the end vertebra, which led to a loss of correction occurring at the junction between fused and unfused segments. These losses averaged 13 degrees (range, 6-29 degrees) at follow-up, ranging from 1 to 5.5 years (average, 2.8 years). The resultant short segmental kyphosis ranged in magnitude from 15 degrees to 34 degrees (average, 23 degrees). The kyphosis occurred distally in five patients and proximally in one patient. The risk of developing a short segmental kyphosis may be minimized if the fusion and instrumentation extend beyond all wedged vertebrae to the first "square" vertebra. This will necessitate fusing into the upper lumbar spine for many patients.

[Treatment of Scheuermann's disease with the active-passive Gschwend erection corset]

In a retrospective study of 31 patients we give a report about the experience with the Geschwend-brace in the therapy of acute M. Scheuermann. The indication for therapy with this brace was given if there was no possibility to stop the progression of the kyphosis by intensive physiotherapy. During the whole time of therapy the brace could not be removed by the patients. Within a follow-up of 24 month in average after the end of brace treatment, we saw a permanent correction of kyphosis of 18 degrees in 22 patients (71%). In 2 patients there was no change of kyphosis and in 7 patients (22%) we saw a progression of 7 degrees. An erection of the wedge-shaped vertebrae we couldn't see in our patients. Permanent correction of kyphosis by Gschwend-brace could be achieved by starting the therapy early, long enough time of treatment about 1,5-2 years and a good compliance.

Thoracic disk herniation and Scheuermann's disease

The authors report 6 cases of thoracic disk herniations in patients with Scheuermann's disease. They underline the relationship between the neurological symptomatology and Scheuermann's disease by the herniation and evolution in their treatment by a new surgical approach.

Techniques of internal fixation for degenerative conditions of the lumbar spine

The indications and techniques for internal fixation of the lumbar spine in degenerative conditions have changed drastically since internal fixation was first applied to the spine almost 100 years ago. Anterior instrumentation and fusion may be used for repair of pseudarthrosis after posterolateral fusion; symptomatic lumbar scoliosis associated with degenerative disc disease; late pain secondary to posttraumatic kyphosis; postlaminectomy instability; and lumbar pain secondary to thoracolumbar kyphosis. Posterior instrumentation and fusion has been performed with Luque instrumentation over 3-4 levels in cases of multilevel instability. Combined anterior and posterior instrumentation and fusion are required for lumbosacral fusion in lumbar scoliosis with degenerative disease, and surgical correction of postsurgical lumbar kyphosis (flat-back syndrome). The techniques are demanding but with attention to detail can be performed with acceptably low-complication rates.

[Results of operative treatment of Scheuermann disease]

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

Combined anterior and posterior fusion for Scheuermann's kyphosis

Combine anterior and posterior fusion provides and maintains good correction in patients with Scheuermann's kyphosis. A fusion which includes the entire deformity, especially at lower end, is a requisite for a satisfactory result. Intervening halofemoral traction may not improve results. Pulmonary functions may decrease somewhat postoperatively but, in the large majority of cases, still remain within normal limits. We think that anterior and posterior fusion remains the procedure of choice in severe or rigid Scheuermann's kyphosis.

The surgical management of patients with Scheuermann's disease: a review of twenty-four cases managed by combined anterior and posterior spine fusion

Twenty-four patients with Scheuermann's kyphosis underwent correction of the deformity through a combined anterior and posterior spine fusion. All patients had a solid arthrodesis and most were relieved of their preoperative pain. Deformity was improved in all patients. Significant loss of correction did not occur in the fusion area but it did occur below the posterior arthrodesis in five patients.

Surgical treatment of Scheuermann's adult kyphosis: case report

A 39-year-old woman with severe Scheuermann's kyphosis complaining of back pain was treated surgically. The following operations were performed in stages to correct a fixed kyphosis: (1) total diskectomy through an anterior approach; (2) application of the halo pelvic distraction apparatus; (3) anterior spine fusion following correction by spinal distraction. She was relieved of her complaints and deformity at a 3 year follow-up examination.

[Results of corrective surgery in juvenile cyphosis (scheuermann's disease) using Harrington's compressive rods (author's transl)]

The authors present the results of 20 corrective procedures for juvenile cyphosis using Harrington compressive rods and Hibbs spondylodesis. 16 procedures date back more than one year (average 3 years, 4 months). 10 cases of pure dorsal cyphosis. The pre-operative Cobb-angles for cyphosis averaged 52 degrees, postoperatively an average of 24 degrees was measured. This reflects a 57 p.c. average immediate correction (41 p.c. for pure dorsal cyphosis, 71 p.c. for dorso-lumbar cyphosis) following surgery nearly all cases showed a significant loss of correction (average 43 p.c., dorsal 37 p.c., dorso-lumbar 49 p.c.). Three main reasons for this loss of correction are discussed and documented in detail. 1. Mal-centered and too short a length of spondylodesis; 2. insufficient corrective growth of wedge shaped vertebral bodies post surgery and 3. frequent lumbar decompensation into total round back deformity of the pure thoracic spondylodesis. The following changes in procedure to solve the problem of loss of correction are proposed. 1. Combined posterior and anterior fusions and 2. upper lumbar dorsal fusion together with extended thoracic spondylodesis. The changing indication is discussed. The main but not fatal complication was postoperative wound infection (15 p.c.).

Juvenile kyphosis

Scheuermann's disease is a common cause of kyphosis developing in the juvenile period. Untreated, the deformity may progress, producing significant pain and, rarely, neurologic signs and symptoms. Successful treatment is possible with the Milwaukee brace, provided that the child has not reached skeletal maturity. Bracing will produce a superior result in terms of correcting the deformity and reversing vertebral wedging. Surgery may occasionally be necessary for severe kyphosis, especially in the adult who presents with pain and/or neurologic problems. Combined anterior and posterior approach is the preferred surgical procedure.

[Surgical interventions on the vertebral bodies of the thoracic spine (author's transl)]

27 operations on the vertebral bodies of the thoracic spine are reported. Indications for operation included markedly progressive infantile and juvenile scoliosis, correction of severe kyphoses in congenital malformation, fractures, Scheuermann's disease and post-laminectomy as well as tuberculous spondylitis and tumors. The two uppermost thoracic vertebrae can be reached by the method of Southwick and Robinson, the two lowest vertebrae from an extraperitoreal-subdiaphragm approach. Thoracotomy was chosen for the remaining thoracic vertebrae. If the staff and material are available, operations on the thoracic vertebrae can be regarded as relatively safe and, in many cases, are the only possibility for obtaining a satisfactory or good result. In spite of this, strict indications must be observed. Severe complications (death, paraplegia etc.) did not occur in any of the patients.

Scheuermann's juvenile kyphosis. A histologic study

The case histories and gross and microscopic findings of two adolescent patients with Scheuermann's kyphosis demonstrate that the anterior longitudinal ligament is bowstrung across the apex of the hyphosis. The microscopic findings include markedly irregular end plates and end plate disruption with protrusion of disk material into the vertebral body. The ring apophysis does not show avascular necrosis. The intervertebral disk is interpreted as normal both by routine histology and electron microscopy. It is postulated that Scheuermann's kyphosis may be secondary to vertebral osteoporosis occurring during the juvenile period rather than to an intrinsic abnormality in the intervertebral disk or ring apophysis.

Scheuermann's kyphosis. Results of surgical treatment by posterior spine arthrodesis in twenty-two patients

Twenty-two patients with Scheuermann's kyphosis were treated with correction, Harrington instrumentation (in twenty-one), and posterior spine fusion. This procedure relieved pain and corrected deformity in all patients but loss of correction of 5 degrees or more occurred in sixteen of the twenty-two patients, including all those whose initial kyphosis was greater than 70 degrees. The incidence of complications was so high that this procedure should ordinarily be performed only for disabling pain or spinal cord compression.