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.

Issues With Big Data: Variability in Reported Demographics and Complications Associated With Posterior Spinal Fusion in Pediatric Patients

BACKGROUND

Clinical and administrative registries provide large volumes of data that can be used for clinical research. However, there are several limitations relating to the quality, consistency, and generalizability of big data. In this study, we aim to compare reported demographics and certain outcomes in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), neuromuscular scoliosis (NS), and Scheuermann kyphosis (SK) between 3 commonly utilized databases in pediatric orthopaedic research.

METHODS

We used International Classification of Diseases, Ninth Revision (ICD-9), International Classification of Diseases, 10th Revision (ICD-10), and Current Procedural Terminology (CPT) codes to identify patients in the National Surgical Quality Improvement Program (NSQIP), Healthcare Cost and Utilization Project (HCUP), and Pediatric Health Information System (PHIS) between the ages of 10 to 18 that underwent PSF for AIS, SK, and NS from 2012 to 2015. We compared various demographic factors, such as sex, race/ethnicity, age, and rates of postsurgical infection and 30-day readmissions. Data was analyzed with descriptive and univariate statistics.

RESULTS

We identified 9891 patients that underwent PSF in NSQIP, 10,771 patients in PHIS, and 4335 patients in HCUP over the study period. There were significant differences in patient demographics, readmission rates, and infection rates between all patients that underwent PSF across the databases (P<0.01), as well as specifically in patients with AIS (P<0.01). HCUP had the highest proportion of Hispanic patients that underwent PSF (13.5%), as well as patients who had AIS (13.3%) or NS (17.9%). The PHIS database had the highest proportion of patients undergoing PSF for SK. Among patients with NS, there were significant differences in race across the databases (P<0.01), but no significant differences in sex, ethnicity, or readmission (P>0.05). In addition, there were significant differences in race (P=0.04) and readmission (P=0.01) across databases for patients with SK, but no differences in sex or ethnicity (P>0.05). NSQIP reported the highest rate of 30-day readmissions for patients undergoing PSF (17.9%) compared with other databases (HCUP 4.1%, PHIS 12.1%).

CONCLUSIONS

There are significant differences in patient demographics, sample sizes, and rates of complications for pediatric patients undergoing PSF across 3 commonly utilized US administrative databases. Given the variability in reported outcomes and demographics, generalizability is difficult to extrapolate from these large data sources. In addition, certain databases should be selected to appropriately power studies focusing on particular patient populations or outcomes.

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.

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.

Long term prognosis of Scheuermann's disease: The association with fragility fracture - The MINOS cohort

The aim was to assess the association of Scheuermann's disease (SCD) with fracture risk (vertebral, peripheral) and bone mineral density (BMD) in older men. SCD was assessed on the baseline lateral spine radiographs using the Berlin criteria in 766 men aged 50-85. We evaluated the association of SCD and its diagnostic criteria with incident fracture (vertebral over 7.5 years, peripheral over 10 years) and BMD (baseline). SCD prevalence was 25.2%. SCD and its criteria showed inconsistent associations with BMD at different skeletal sites. Eighty-four men had incident fractures. After adjustment for age, weight, spine BMD, prevalent vertebral fractures, prior falls and score of disc space narrowing due to osteoarthritis (DSN-OA), SCD was not associated with vertebral fracture risk. Vertebral endplate irregularities (EI), one of its diagnostic criteria, were associated with higher vertebral fracture risk (OR = 3.26, 95% CI: 1.34-7.94, p < 0.01). Vertebral fracture risk was higher in men with EI and low spine BMD vs. men without these characteristics (OR = 12.84, 95% CI: 3.12-52.83, p < 0.005). EI was associated with higher vertebral fracture risk in men without severe DSN-OA and without prevalent vertebral fractures. Peripheral fracture risk was lower in men with SCD (HR = 0.39, 95% CI: 0.18-0.83, p < 0.02) and EI. Peripheral fracture risk was higher in men without SCD who had low femoral neck BMD vs. men with SCD and normal BMD (HR = 4.68, 95% CI: 1.09-20.03, p < 0.05). In conclusion, EI were associated with high vertebral fracture risk. SCD and EI were associated with lower peripheral fracture risk. The associations of SCD and its criteria with BMD were inconsistent.

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.

[Complaints of back pain in childhood: find curable causes]

Three children, a 13-year-old boy and a 3-year-old and 6-year-old girl, were presented to the hospital with back pain, caused by Scheuermann's disease, spondylodiscitis and sickle cell disease, respectively. The boy with Scheuermann's disease received exercise therapy, the spondylodiscitis was treated with antibiotic therapy and the girl with sickle cell disease was given hyperhydration and folic acid. Although back pain is a common problem in children and teenagers, it is infrequently reported in the clinic. In contrast to back pain in adults, the same complaint in childhood is more often caused by a serious disorder which should be treated. Various causes of back pain in children can be distinguished: mechanical problems, infections of the lumbar spine, neoplasia, inflammation, and other causes, such as sickle cell disease. A child or adolescent presenting to the clinic with complaints of back pain deserves a careful detailed evaluation of the history, appropriate physical examination and additional investigation. Alarm symptoms are an increase in back pain, age below 4 years, pain during the night, restriction in function, systemic complaints or neurological deficits.

Rapidly progressive paraplegia due to an extradural lumbar meningocele mimicking a cyst

✓Unlike arachnoid meningoceles, arachnoid cysts frequently cause local pressure effects probably because there is no free communication between the cyst and the subarachnoid space. Following the first detailed description of cystic lesions of spinal nerve roots by Tarlov in 1938, a simplified classification of spinal meningeal cysts was developed in 1988, containing three major categories. The authors report on a lumbar intraspinal extradural meningocele that caused incomplete paraplegia in an otherwise healthy 31-year-old man in whom magnetic resonance imaging revealed stigmata of Scheuermann disease. Intraoperatively, the lesion was classified as a transitional-type lesion, in accordance with Type IA of the Nabors classification, because a communication with the subarachnoid space was observed. After complete removal of the meningocele, the patient's recovery was prompt and complete.

Thoracic cord compression caused by disk herniation in Scheuermann's disease: a case report and review of the literature

We present the case of a 14-year-old male with Scheuermann's disease and significant neurological deficit due to thoracic disk herniation at the apex of kyphosis. He was treated with an anterior decompression, anterior and posterior fusion in the same setting using plate, cage and a segmental instrumentation system. The patient had an excellent outcome with complete neurological recovery.

Experience with combined video-assisted thoracoscopic surgery (VATS) anterior spinal release and posterior spinal fusion in Scheuermann's kyphosis

STUDY DESIGN

Retrospective.

OBJECTIVES

To determine whether anterior endoscopic release and posterior spinal fusion could achieve stable correction in Scheuermann's kyphosis.

SUMMARY OF BACKGROUND DATA

The initial treatment of choice of Scheuermann's kyphosis is thoracic hyperextension and postural exercises and/or Milwaukee brace. Milwaukee bracing is most efficacious in the early stages when the curvature is flexible and in the skeletally immature. However, it is known that larger curves, vertebral wedging greater than 10 degrees, and skeletally mature patients will not usually respond to this treatment. Surgery is indicated in the skeletally immature with severe deformity where brace treatment has failed to prevent progression. Posterior spinal instrumentation can achieve adequate correction in the less rigid curves. However, the more rigid curves have been shown to be resistant to posterior spinal fusion alone, therefore needing anterior spinal release.

METHODS

Between 1995 and 2001, 19 patients underwent video-assisted thoracoscopic surgery and posterior spinal fusion for the treatment of Scheuermann's kyphosis. The average age was 17.4 years with closed triradiate cartilage in all. Average follow-up was 2.7 years. An average of 8.3 discs were released anteriorly; an average of 13 levels were fused posteriorly.

RESULTS

Average preoperative kyphosis was 84.8 degrees. Average postoperative kyphosis was 43.7 degrees. Average kyphosis at follow-up was 45.3 degrees. Only 1.6 degrees of correction loss was noted. No junctional kyphosis was present. Two patients developed pleural effusion; one required thoracocentesis. Two patients developed pneumothorax. One patient underwent revision surgery for inferior hook pullout. One required mechanical ventilation.

CONCLUSIONS

Combined video-assisted thoracoscopic surgery release and posterior spinal fusion for the treatment of Scheuermann's kyphosis is a viable option for the treatment of the more severe and rigid curves.

Neurologic compression by thoracic disc in a case of scheuermann kyphosis - an infrequent combination

Scheuermann disease is a rigid kyphosis due to vertebral wedging in the thoracic or lumbar spine. It is very rarely associated with neurologic compromise. Thoracic disc herniation leading to dural sac compression is also an infrequent pathology. We describe here a young man with Scheuermann disease who presented with symptoms and signs of neural compression. The cause of compression was a thoracolumbar disc, rendering him non-ambulant without support. He required transthoracic surgical decompression. The neurological status of the patient improved rapidly after surgery. At his latest follow-up he was independently ambulant with full restoration to activities of daily living.

[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.

Results of surgical treatment for kyphotic deformity of the spine secondary to trauma or Scheuermann's disease

The authors have performed a retrospective study of 20 patients who underwent surgical treatment for kyphosis secondary to trauma (10 patients) or Scheuermann's disease (10 patients) between 1992 and 2000. The mean follow-up was 60 months (range, 32-90) and 59.5 months (range, 24-109) respectively. Radiological evaluation of Scheuermann kyphosis included assessment of thoracic kyphosis angle (TKA), lumbar lordosis angle (LLA), scoliosis angle (SA) and sagittal vertical axis (SVA); radiological evaluation of post-traumatic kyphosis included the determination of local kyphosis angle (LKA) and SA, if present. A posterior approach was performed in 6 cases and a combined anterior and posterior approach was performed in 4 cases of SD whereas patients with post-trauma kyphosis were treated using an anterior approach in one case, a posterior approach in another and a combined anterior and posterior approach in 8 cases. The mean TKA in Scheuermann cases was 71 degrees (65 degrees-80 degrees) preoperatively and 41 degrees (31 degrees-52 degrees) postoperatively. There was a mean loss of correction of 5 degrees. No positive sagittal balance was present during follow-up. The mean TKA in post-trauma cases was 38 degrees (25 degrees-62 degrees) pre-operatively and 14 degrees (range -15 degrees-28 degrees) postoperatively. At the last visit, the mean loss of correction was 2 degrees. Proximal junctional kyphosis developed in two cases with Scheuermann kyphosis (17 degrees and 13 degrees) and in one case with post-traumatic kyphosis (17 degrees). These findings show that good results can be achieved in the treatment of kyphosis secondary to trauma or Scheurmann's disease, with appropriate selection of the surgical approach.

Nonsurgical treatment of kyphosis

An increase in thoracic kyphosis in children and adolescents is usually the result of postural kyphosis or Scheuermann's kyphosis. Although no structural deformity of the spine is observed in postural kyphosis, wedging of vertebral bodies and disk space narrowing are noted radiographically in patients with Scheuermann's kyphosis. Effective interventions for adolescents with postural kyphosis include exercises to relieve lower extremity contractures and strengthen abdominal musculature coupled with practiced normal posture in stance and in sitting. Skeletally immature patients with Scheuermann's kyphosis benefit from a similar exercise program but also require the use of a spinal orthosis. Bracing of the spine in patients with Scheuermann's kyphosis results in permanent correction of vertebral deformity, unlike bracing in patients with idiopathic scoliosis. The evaluation of children and adolescents with increased thoracic kyphosis is an important aspect of the decision process used to determine appropriate interventions.

Kyphosis of the thoracic and thoracolumbar spine in the pediatric patient: normal sagittal parameters and scope of the problem

As measured by the Cobb angle, normal sagittal kyphosis is 20 degrees to 40 degrees, which encompasses most of the angulated consecutive vertebrae in the thoracic region of the spine. With pathologic kyphosis, however, the segmental analysis of different regions of the thoracic spine plays an important role. Methods of determining sagittal measurements as well as the causes of kyphosis of the thoracic and thoracolumbar spine, including Scheuermann's disease, spinal cord injury, laminectomy, neurofibromatosis, genetic origins, Marfan syndrome, and tuberculosis, are also important in determining treatment.

[Vascular spinal disturbances as one of Scheuermann's disease complications]

Spinal column pathology plays an important role in the etiology and pathogenesis of acute and chronic spinal blood supply disturbances. The aim of the study was to determine a role of degenerative-dystrophic changes, arising as a consequence of Scheuermann's disease in a mechanism of this pathology development. In patients aged 17-65 years, subjected to study of the causes of acute (8 cases) and chronic (7 cases) ischemic spinal disturbances development a significance of spinal column structures changes in juvenile kyphosis for evolution of spinal cord vascular pathology was established.

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.

The duPont kyphosis brace for the treatment of adolescent Scheuermann kyphosis

The purpose of this study was to evaluate the effectiveness of a newly designed brace in the treatment of adolescent Scheuermann thoracic kyphosis. Twenty-two children who met the roentgenographic criteria of Scheuermann kyphosis and were compliant with treatment were followed until skeletal maturity. Sixteen patients (73%) showed nonprogression of their kyphosis (nine patients demonstrated an improvement, seven patients remained unchanged), and had a mean improvement of 9 degrees (64 degrees to 55 degrees). Six patients (27%) demonstrated progression of the kyphosis and had a mean increase in their kyphosis of 9 degrees (59 degrees to 68 degrees). One patient underwent posterior spinal fusion for progressive thoracic kyphosis despite bracing. It was recommended that this brace be worn until skeletal maturity; in this study this time period was determined to be at least 16 months to induce improvement or halt progression of this disease. Flexible curves are a positive predictor of a successful outcome of bracing with the kyphosis brace. These results are comparable to previous reports in the literature describing the effectiveness of the modified Milwaukee brace in the treatment of Scheuermann thoracic kyphosis prior to skeletal maturity, and the kyphosis brace has the advantage of concealability under normal attire.

Effect of intensive rehabilitation on pain in patients with Scheuermann's disease

In our rehabilitation centre, the treatment of Scheuermann's disease consists of a daily postural education, lasting several hours. As for pain therapy, we mainly apply physiotherapeutic methods with osteopathy, manual therapy, Mc Kenzie and Brügger. In addition, we offer psychological help for pain relief. In case of severe chronic pain, we additionally treat it with acupuncture. Pain therapy with medication is only performed in rare cases. The aim of the present study was to find out if such an intensive rehabilitation programme had any effect on pain level in patients with Scheuermann's disease. An Intervention study (pre-/post-design) was undertaken including the following material: 351 patients suffering from Scheuermann's disease reported their pain level before and after an inpatient treatment. For this aim, we used a visual analog scale (VAS), a numerical scale (NS), a standardised adjective scale (VRS) and a pain frequency scale. In our group, there were 61 female patients with a thoracolumbar Scheuermann's disease, 121 female patients with a thoracic Scheuermann's disease, 92 male patients with a thoracolumbar Scheuermann's disease and 77 male patients with a thoracic Scheuermann's disease. The average age was 17 to 21 years old with an average kyphotic angle varying in the individual groups between 53 and 64 degrees. In the case of the numerical pain severity scale, pain severity was for example 2,9 in female patients with thoracolumbar Scheuermann's disease. In female patients with thoracic Scheuermann's disease, pain severity was also at 2.9. In male patients with thoracolumbar Scheuermann's disease, it was at 2.0 and in male patients with thoracic Scheuermann's disease, it was at 1.9. This numerical pain scale showed highly significant changes in pain severity: 2.1 in female patients with thoracolumbar Scheuermann's disease, 1.9 in female patients with thoracic Scheuermann's disease, 1.4 in male patients with thoracolumbar Scheuermann's disease and 1.8 in male patients with thoracic Scheuermann's disease. There was also a significant decrease in pain frequency. Seen as a whole, each scale showed a pain reduction between 16 and 32%, which is significant in all the cases and even highly significant in some cases. The in patient rehabilitation seems to have a positive effect on pain level in patients with Scheuermann's disease. In case of Scheuermann's disease in adult age, treatment is only indicated when patients suffer from pain. For those reasons, an in-patient intensive program of rehabilitation in a clinic with adequate quality structure should be considered.

Segregation analysis of Scheuermann disease in ninety families from Siberia

Scheuermann disease [OMIM number 181440] is the most common cause of structural kyphosis in adolescence. Segregation analysis using a model with gender effects was applied to 90 pedigrees from Barnaul (West Siberia, Russia) ascertained through a proband with Scheuermann disease. The transmission probability model was used to detect major gene effect. A significant contribution of a major gene to the control of the pathology was established. Inheritance of the disease can be described within the framework of a dominant major gene diallele model. According to this model, Scheuermann disease should never occur in the absence of the mutant allele. All male carriers of the mutant allele develop the disease, while only a half of female carriers manifest it. We found a high frequency of idiopathic scoliosis in the families with Scheuermann disease (0.08 vs. 0.01-0.02 in general population). We also observed a succession of idiopathic scoliosis and Scheuermann disease in consecutive generations. The familial aggregation of these two spinal pathologies in the present sample may indicate a genetic unity of Scheuermann disease and idiopathic scoliosis.

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.

["Round back" in children and adolescents]

The hyper-kyphosis or "the postural round back" is one of the most common complaints in orthopedic practice. In the majority of cases, the thoracic kyphosis are painless and flexible. The vertebral bodies are normal on radiograms. This is "the kyphotic attitude" or postural round-back. A medical treatment is not the necessary rule. Life hygiene, sports and simple supervision are needed. Nevertheless, there are still pathological fixed kyphosis, induced in the majority of cases by Scheuermann's disease. The other possible etiologies (congenital, paralytic, post-traumatic, Pott's disease, postradiation, or metabolic origin) are a lot rare ones and will be excluded by clinical examination and imaging studies. The structural hyper-kyphosis require treatment. We will approach successively steps of the diagnosis and treatment of the hyper-kyphosis of the adolescent.

[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.

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.

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.

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.

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.

[Back lumbar herniated discs and cauda equina syndrome as complications of Scheuermann's disease. A case report]

The author reports the case of a patient with spinal cord compression by a thoracic herniated disc without paraplegia as well as a cauda equina syndrome due to spondylotic and discal lesions, with small protrusions of the L4-L5 and L5-S1 discs associated with Scheuermann disease. There was complete recovery in six months with clinical treatment. The radiological evaluation using standard radiography, myelography, computed tomography, magnetic resonance imaging of the vertebral column, and electromyographic evaluation indicate a precise correlation between clinical picture and the distribution and course of lumbar spinal cord degenerations. Furthermore, a strong correlation was also found with hernias, roots and the bony sequalae of spinal cord dystrophy found in Scheuermann disease.

[Spastic paraparesis in Scheuermann disease: a case report]

A case of paraparesis due to Scheuermann's disease in a 17.5 years old boy suffering from a moderate dorsal kyphosis (Cobb angle 64 degrees) is reported. Etiologically, spastic paraparesis can be caused either by myelon compression due to extradural cysts, herniated dorsal discs, or direct myelon compression from the vertebral bodies. Radiologically, in addition an intraspinal lipom was suspected. Because of the neurological deficits surgical treatment was performed. Ventral release followed by an anterior spondylodesis was combined with a dorsal spondylodesis using the Harrington compression system. An intraspinal lipom could be excluded intraoperatively after laminectomy of the suspicious region. Three months postoperatively, no signs of any neurological deficits were observable. X-ray control demonstrated a solid spondylodesis with an Cobb angle of 38 degrees. Direct myelon compression or indirect myelon damage due to a reduced blood supply at the apex of kyphosis are supposed to be the pathophysiological pathway.

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.

Progressive cord compression secondary to thoracic disc lesions in Scheuermann's kyphosis managed by posterolateral decompression, interbody fusion and pedicular fixation. A new approach to management of a rare clinical entity

During a brief period of 21 months (November 1988 to August 1990) the neurospinal unit of our institution registered three cases of Scheuermann's kyphosis with herniation of the thoracic discs. Local and intercostal pain, progressive spasticity with gait disturbance and urinary hesitancy were the most common presenting symptoms. All of the patients were surgically managed by posterolateral decompression, interbody fusion (posterolateral approach) and pedicular screw plate fixation. The average length of follow-up was 25 months. Results were excellent in two patients and good in one. All patients had improvement in neurological status, were pain-free and demonstrated sound fusion within 5 months. A new approach to management of this rare clinical entity is documented.

Juvenile discogenic disease

This study was undertaken to document an association of degenerative lumbar disc disease in patients with thoracolumbar Scheuermann's disease. During a 3-month period, 9% of 1419 of the persons referred to our center for magnetic resonance imaging of the lumbar spine demonstrated changes of both thoracolumbar Scheuermann's disease and degenerative disc disease in the lower lumbar spine. The disease was less commonly detected on computed tomography (2% of 1522 patients). The patients were relatively young: 81% were younger than 40 years and 9% were younger than 21 years. We theorize that the thoracolumbar Scheuermann's disease and the associated degenerative disc disease of the lower lumbar spine are manifestations of an intrinsic defect of the discs and/or cartilaginous end plates, which results in inadequate nutrition and structural weakness or a combination of both, and early degeneration.

[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.

Back pain in children and teenagers

Controversial opinions have been published concerning the frequency of LBP among children and adolescents. Studies from orthopaedics or neurosurgical departments have reported low figures for prevalence of specific LBP due to serious disorders. Field surveys, on the contrary, have shown that cumulative life prevalence of non-specific LBP in children and teenagers can be comparable to the prevalence data for adult populations. Some specific diagnoses are more common or characteristic of children complaining of LBP. Age, gender, sports activities and family history of LBP have been found to be significantly associated with an increased prevalence in non-specific LBP among children. Low back pain among children and teenagers is common and should be recognized. This chapter provides guidelines for a clinical approach and differential diagnoses. Most back pain in these age groups is benign and should be treated as such.

Spinal stenosis subsequent to juvenile lumbar osteochondrosis

This paper describes eight patients with spinal stenosis associated with marked osteochondrous changes in the vertebral bodies due to juvenile lumbar osteochondrosis (Scheuermann's disease). In no case was the midsagittal or interpedicular diameter of the spinal canal indicative of bony stenosis. On the other hand, in the myelograms the sagittal diameter of the dural sac was in all cases significantly narrowed, a diagnostic sign of central spinal stenosis. Therefore, myelography should always be contemplated when osteochondrous changes are present and spinal stenosis is suspected clinically regardless of whether the spinal canal diameters are normal in plain films.

Surface stereophotogrammetry of thoracic kyphosis

The thoracic kyphosis angles of 16 normal individuals, 10 patients with Scheuermann's disease and 11 with adolescent idiopathic scoliosis were measured both radiographically and from Integrated Shape Imaging System (ISIS) scans obtained by surface stereophotogrammetry. There was a high correlation between the two measures. The method of kyphosis measurement from ISIS scans was then used for 30 patients with adolescent idiopathic scoliosis who underwent corrective surgery. A significant reduction in thoracic kyphosis was observed postoperatively. In another group of 28 patients managed conservatively by bracing, some hypokyphosis developed after treatment. However, we found no association between hypokyphosis and curve progression.