Scheuermann Disease

The adolescent will present with (1) cosmetic/postural deformity and/or (2) subacute thoracic pain. The deformity is typically appreciated in the early-mid teenage years by child, parents, or on a school screening exam. With respect to subacute thoracic pain, there is usually no identifiable inciting event. The pain is worse with activity and improved with rest.

Physical exam shows rigid hyperkyphotic curve, accentuated with forward bending. The hyperkyphosis does not resolve with an extension or lying prone/supine, further supporting the “rigid” nature of this deformity. Other associated findings on an exam might include cervical or lumbar hyperlordosis, scoliosis, and tight hamstrings. Although neurologic deficits are uncommon, a thorough neurologic exam must be completed [2][4].

At each visit, the patient’s spinal range of motion should be evaluated in all planes of motion: flexion/extension, right/left lateral bending, and right/left rotation. The degree of hyperkyphosis should also be followed over time via serial imaging to assess the degree of progression. Tracking the patient’s functional range of motion as well as the degree of deformity will help guide the appropriate intervention and prognosis.

History and physical along with AP/lateral radiographs comprise the essential components for evaluating Scheuermann kyphosis.
Lateral radiographs are required for diagnosis, and diagnostic criteria including the following [4]:

• Rigid hyperkyphosis, greater than 40 degrees

• Anterior wedging, greater than or equal to 5 degrees in three or more adjacent vertebral bodies

Technique for Determining Degree of Kyphosis on Lateral Imaging [3][4][3]

• Line is drawn along the superior endplate of the most tilted vertebrae on the cephalad portion of the kyphotic curve

• Line is drawn along the inferior endplate of the most tilted vertebrae on the caudal portion of the kyphotic curve

• The angle formed by the intersection of lines perpendicular to the above-described lines is the measured Cobb angle

• Hyperkyphosis is described as, measured Cobb angle greater than 40 degrees

Technique for Determining Degree of Anterior Wedging on Lateral Imaging [3][4][3]

• Line is drawn from posterior to anterior along the superior endplate

• Line is drawn from posterior to anterior along the inferior endplate

• The angle formed by the intersection of these lines anteriorly is the measured Wedge angle

• Anterior wedging of greater than or equal to 5 degrees in three or more adjacent vertebral bodies, with an associated rigid hyperkyphosis greater than 40 degrees, is diagnostic for Scheuermann disease

Other Associated Findings Noted on AP/Lateral Radiographs [3][4]

• Irregular vertebral endplates

• Schmorl nodes

• Loss of disc space height

• Scoliosis

• Spondylolysis/spondylolisthesis

• Disc herniation

Although typically not a necessity, MRI can be helpful to further evaluate anatomic changes or for pre-operative planning. CT imaging is usually not needed. There are also no specific laboratory tests or histologic findings necessary for the diagnosis of Scheuermann kyphosis.

Nonoperative Management [1][7]

1. Stretching, lifestyle modification, NSAIDs, plus/minus physical therapy

1. Indication

• Kyphosis less than 60 degrees and asymptomatic

2. Course

• Majority of patients fall into this category

• Patients typically do well without significant longterm sequelae

2. Extension bracing plus “A”

1. Indication

• Kyphosis 60 to 80 degrees plus/minus symptomatic

2. Course

• Bracing typically required for 12 to 24 months

• Most effective in skeletally immature patients

• Typically, does not improve curve but rather impedes progression

3. Braces [8]

• Milwaukee brace

• Kyphologic brace

• Thoracolumbosacral orthosis-style Boston brace

Operative Management [1][2]

1. Spinal fusion, typically combination of anterior release + fusion as well as posterior instrumentation + fusion

1. Indications

• Kyphosis greater than 75 degrees causing unacceptable deformity

• Kyphosis greater than 75 degrees with associated pain

• Neurologic deficit/spinal cord compression

• Severe refractory pain

2. Course

• Majority of patients experience symptomatic improvement as well as improved curve deformity towards normal

• Operative/postoperative complications must be considered

• Postural kyphosis (flexible postural deformity)
• Hyperkyphosis attributable to another known disease state
• Postsurgical kyphosis
• Ankylosing spondylitis
• Scoliosis

The majority of patients are successfully treated with conservative measures as previously discussed [2]. Pain in the affected region typically improves after skeletal maturity is reached, although patients with Scheuermann kyphosis are at increased risk of chronic back pain as compared to the general population.

Patients with a kyphotic curve less than 60 degrees at skeletal maturity typically have no long-term sequelae.

Potential complications

• Progressive cosmetic deformity
• Chronic back pain
• Neurologic deficits/spinal cord compression

Postoperative complications

• Pseudoarthrosis (most common complication)
• Persistent pain

For surgical patients, inpatient rehabilitation might be necessary for mobility and strength training as well as aggressive postoperative pain management.

Although not always a necessity, it is good practice for any patient with some degree of suspected spinal deformity to establish care with either an orthopedic spine surgeon or neurosurgeon.

Neurosurgery or orthopedic spine surgery consultation should be obtained for any patient with the following:

• Hyperkyphosis unresponsive to conservative management
• Any neurologic deficit
• Patients with compromised pulmonary function testing, attributable to their kyphosis

Important patient education includes [9]:

• Extension-based stretching/strengthening program
• Hamstring stretching exercise program
• Proper postural and body mechanic techniques for ADLs
• Appropriate use and handling of braces

Although the overall prognosis of this disease is relatively good, given young patients are most commonly affected it is important and medically prudent to notify the patient and family members early in their course of care the potential for long-term sequela and the unpredictable nature of things such as chronic back pain associated with the condition.