Research Review by Dr. Shawn Thistle©

Date:

Sept. 2007

Study Title:

Evidence Based Medicine – Analysis of Scheuermann Kyphosis

Authors:

Lowe TG & Line BG

Publication Information:

Spine 2007; 32(19S): S115-S119.

Summary:

Manual therapists and spinal surgeons have long been aware of Scheuermann’s kyphosis (also variably known as Scheuermann’s disease, vertebral epiphysitis, osteochondrosis juvenilis dorsi, juvenile kyphosis, spinal osteochondrosis), a structural disorder of the thoracic or thoracoloumbar spine. This disorder has been, and continues to be, the source of much confusion and controversy.

It is generally thought that Scheuermann’s kyphosis results from the cumulative effects of altered mechanical stresses on vulnerable developing spinal structures in adolescents. Many additional theories have also been proposed. This paper aimed to provide a current evidence update regarding the etiology and management of this condition. This review will combine an executive summary of this paper with additional information gleaned from additional resources referenced below.

History & Epidemiology of Scheuermann’s Kyphosis
  • originally described in 1920 as a rigid kyphosis occurring in adolescent patients, most commonly in the thoracic or thoracoloumbar spine
  • it is the most common cause of adolescent hyperkyphosis
  • incidence is reported between 1-8% of the population, and prevalence is approximately equal between males and females
  • the true incidence of this condition is likely higher as the diagnosis is often missed completely, or misdiagnosed as “poor posture”
  • thought to be somewhat more common in heavier children who are athletically active
Etiology & Pathology of Scheuermann’s Kyphosis
  • onset is normally just prior to puberty, after ossification of the ring apophyses
  • characterized by anterior vertebral body wedging, endplate irregularities, decreased anterior vertebral body growth, and premature disc degeneration
  • two main curve patterns exist: 1) thoracic – most common, and 2) thoracolumbar – thought to be associated with a higher risk of progression and poorer prognosis (based only on expert opinion)
  • both curve patterns are often associated with non-structural hyperlordosis of the lumbar and/or cervical spine
  • many patients will have coexisting scoliosis
  • the exact etiology is unknown, and thought to be multifactorial
  • it is thought to be at least partially hereditary (based on data from a large, Finnish study on twins published in 2006 – reference below)
  • other etiological theories are awaiting verification, as no conclusive evidence exists for any of the following: autosomal dominant inheritance, endocrine abnormalities, aseptic necrosis, vitamin deficiency, fluoride toxicity, malnutrition, juvenile osteoporosis, tuberculosis, mechanical/biomechanical factors
  • one etiological theory that does have some supporting evidence is the presence of disorganized enchondral ossification combined with a reduction in collagen and an increase in mucopolysaccharides in the endplate – all of which have been demonstrated in patients with Scheuermann’s kyphosis
Clinical & Radiographic Features of Scheuermann’s Kyphosis
  • patients may present with local pain or discomfort, hypertonic spinal musculature, vertebral and costovertebral joint fixations, decreased physical capacity, cosmetic deformity, respiratory or other visceral problems (with severe deformity), rare neurological compromise, associated scoliosis
  • Radiographic Criteria - anterior wedging of 3 or more contiguous segments by at least 5° (expert opinion), +/- endplate irregularities, +/- Schmorl’s nodes
Natural History of Scheuermann's Kyphosis
  • overall, natural history depends on the individual, and is inconsistent across studies
  • it is important to remember that structural deformity does not always result in pain
  • neurological complications secondary to this condition (ex. thoracic disc herniation, dural cysts) are thought to be rare, but have been reported in case series and case reports (only level V evidence)
  • one level III study (Murray et al.) followed 67 patients with Scheuermann’s kyphosis for an average of 32 years: subjects tended to work lighter jobs, had more severe back pain, and more concerns about their appearance; 38% had significant interference with activities of daily living because of pain; unfortunately, this study did not evaluate progression of the condition
Management of Scheuermann's Kyphosis

The literature search in this paper yielded only 4 studies: 1 assessing long term exercise and 3 assessing orthopedic bracing:
  • the one exercise study (Weiss et al. below, level IV evidence) included long-term treatment of 351 patients including osteopathic treatment, physical therapy, manual therapy, an exercise program, and psychological treatment: results included significant pain reduction between 16-32% (this study was non-descript in terms of exact interventions used)
  • all three papers assessing brace treatment were retrospective, and had no control groups (level IV evidence) – despite these design shortcomings – bracing is generally thought to be effective in skeletally immature patients
  • the most commonly used braces are: the Milwaukee brace (3 point pressure system) and the Boston brace
  • existing literature does not allow clinicians to predict whether brace treatment will improve deformity or impact clinical symptoms
  • literature pertaining to chiropractic or manual therapy management of this condition is sparse
  • in 1978, Jahn et al. outlined a suggested treatment plan for Scheuermann kyphosis including: manipulation, rest, nutritional supplementation, exercise, physical therapy, and traction – all of these approaches are logical, but as yet not supported by high level evidence
  • no firm guidelines exist, and indications for surgery remain unclear, but referral for surgical consultation may be prudent for: progressive pain that is not responding to conservative therapy, progressive curvature, neurological compromise, visceral complications, cosmetic deformity

Conclusions & Practical Application:

Scheuermann’s kyphosis is common – all manual therapists likely have patients in their practice with this condition. Keeping in mind that not all people with this condition experience back pain, it is within reason to attempt a course of conservative management for those who become symptomatic.

Unfortunately, the literature does not provide clear direction for treatment options. This is where clinical experience and patient preference take the lead. Logical treatment options include (but are not limited to): spinal mobilization/manipulation, general exercise, specific exercise (extension, foam roller, exercise ball, core stability), stretching, soft tissue therapy, or electro-modalities.

Studies assessing the following aspects of this condition are required to better guide treatment decisions:
  • natural history and progression of curves, particularly those between 70-90°
  • determination of precise guidelines to assist clinicians in referring for surgical consultation
  • effectiveness of spinal mobilization/manipulation and other manual interventions for treating associated pain, or for affecting progression of curvature
  • specific exercise protocols that are effective for pain relief or curve progression

Additional References:

  1. Damborg F et al. Prevalence, concordance, and heritability of Scheuermann kyphosis based on a study of twins. J Bone Joint Surg (Am) 2006; 88: 2133-2136.
  2. Jahn W, Griffiths JH & Hacker RA. Conservative management of Scheuermann’s juvenile kyphosis. JMPT 1978; 1(4): 228-245.
  3. Lowe TG. Scheuermann’s disease. Orthop Clin North Am 1999; 30: 475-485.
  4. Murray PM, Weinstein SL, Spratt KF. The natural history and long-term follow-up of Scheuermann’s kyphosis. J Bone Joint Surg (Am) 1993; 75: 236-248.