Continuing Medical Education (CME)

KYPHOSIS
By

Dr. Mirza Mohammad Nijrabi

Consultant Orthopaedic Surgeon - FMIC

KYPHOSIS
Kyphosis is an abnormal
posterior angulation of the
spine (can be seen in the
cervical spine, dorsal spine
and thoracolumber spine).

KYPHOSIS
Postural development
Postural is the relationship of the
parts of the body to the vertical line
passing through the center of
gravity.

KYPHOSIS
When a child begins standing upright, the
antigravity muscles produce postural spinal
curve and the normal sagittal contours of the
spine begin to appear.
The normal range of thoracic Kyphosis is 20-45
degree.

Classification of kyphosis
1. Postural kyphosis.
(Or round back deformity)
Postural round back of
adolescence is a benign
deformity that is
correctable by means of
passive and active forces

Classification
2. Scheuermann
Scheuermanns disease.
Scheuermann's disease is
a structural kyphosis of
the thoracic or
thoracolumbar spine that
occurs in 0.4% to 8.3% of
the general population. It
occurs slightly more often
males.

Classification
The cause of Scheuermanns disease is
probably multifactorial.
Scheuermann proposed that the
kyphosis resulted from avascular
necrosis of the ring apophysis of the
vertebral body.

Classification
2. Congenital kyphosis
Failure of formation
Failure of segmentation
Mixed form

Classification
3. Post traumatic
Structural bone or
ligament failure

Classification
4. Neuromuscular disorders
Myelomeningocele
Developmental (secondary to paralysis)

Classification
5. Post laminectomy
6. Post radiation therapy
7. Metabolic disease

Osteoporosis

Osteomalacia

Osteogenesis imperfecta

Classification
8.

9.

Skeletal dysplasia
Achondroplasia
Mucopolysacharidosis
Neurofibromatosis
Collagen disease
Marfans disease

Classification
8. Neoplastic
Benign, Malignant, Primary, Metastatic
9. Post infectious
Bacterial, Fungal, Tuberclosis

CONGENITAL KYPHOSIS
Congenital Kyphosis is a
posterior angulation of the
spine due to a localized
congenital malformation of
one or more vertebrae

CONGENITAL KYPHOSIS
Etiology
The cause of congenital Kyphosis
remains unknown. During embryologic
development, these abnormalities
develop in the spine between the fifth
and eight weeks of gestation.

Etiology
Resent research has found that carbon
monoxide exposure with its resultant
hypoxia has led to reproducible
congenital spinal deformities in mice
offspring.
Clinical data that indicated a potential
increases in exposure to fumes and
carbon monoxide in mothers of children
with congenital spine deformity

CLASSIFICATION
1 Failure of Formation (Type 1)
2 Failure of Segmentation (Type 2)
3 Mixed Anomalies (Type 3)

Failure of Formation

Failure of Formation
In Kyphosis due to defects in
vertebral body formation,
part or all of the vertebral
body is deficient, several
contiguous levels may be
affected, which produce
greater deformity and
disabilities.

Failure of Formation,
Congenital Kyphosis due to either
failure of formation (type 1) or mixed
anomalies (type 3) tend to be
relentlessly progressive
Deformity due to two adjacent type 1
vertebral anomalies will progress more
rapidly and with more severity than
deformity due to a similar single
anomaly.

Failure of Formation
The posterior elements
(spinous process, pedicles,
transverse process ) remain
present and accompany the
deficient vertebral body.

Failure of Formation
Growth continues normally
in the posterior portion of
the spine but not anteriorly
The relentless progression of
deformity usually occur.

Failure of Formation
In case of defect in
formation the risk of
developing paraplegia
is much greater then
defect of segmentation.
Greater risk of
paraplegia in Kyphosis
between T4-T9.

Failure of Formation
The common age of paraplegia
during adolescents growth spurt.
Onset paraplegia following
minimal trauma in young
children can be seen.

Failure of Formation
The apical area of the Kyphosis
can occur at any level, most
frequently between the tenth
thoracic and the first lumber
spine.

Failure of segmentation

Failure of segmentation
In Kyphosis due to defect in
segmentation the anterior
portion of two or more
adjacent vertebral bodies
are fused together.

Failure of segmentation
This deformity tends to be less
progressive, produce less deformity, and
is associated with a much lower risk of
paraplegia than Kyphosis due to defect
in formation.
The lower thoracic and thoracolumber
spine is the most common affected area.

Failure of segmentation
No relationship between the severity of
the Kyphosis and its location in the
spine.
Progression of these deformity is most
rapid during the adolescent growth
spurt.

Failure of segmentation
Kyphosis due to failure of segmentation
(type 2) is much less progressive,
produces less sever deformity, and has a
very low likelihood of resulting in
paraplegia.

Clinical Features
Although congenital Kyphosis has been
diagnosed prenatally, it may not be clinically
evident in the newborn or infant
Suspicion may first be raised following
examination of chest radiography obtained for
evaluation of an unrelated event such as
respiratory infection.
As the child begin to standing and walking a
localized prominence may become noticeable
or palpable

Clinical Features
On occasion, the child with congenial Kyphosis
may develop a myelopathy or paraplegia
secondary to spinal cord compression.
When congenital Kyphosis due to a defect in
vertebral formation is diagnosed a meticulous
neurologic examination should be performed to
identify any subtle abnormalities, Plan for
surgical intervention should begin immediately.

Radiographic evaluation
Congenital Kyphosis is best visualized
on a lateral radiography of the spine. It
may not be evident on the frontal plane
view.
MRI provides the clearest picture of the
spinal cord and vertebral body in very
young children. It should be ordered
immediately for Kyphosis due to defect
in vertebral formation.

Radiographic evaluation
Three dimensional CT imaging of the
spine with reconstructed image is very
useful for evaluation of the vertebral
anomalies.
MRI and CT scan should be performed
before any operative intervention is
undertaken.

Treatment
Defects of formation are more common
than defect of segmentation, can lead to
more sever deformity, and have greater
potential for producing paraplegia.

Treatment
Non operative treatment has no
beneficial effect on congenital kyphosis.
The use of an orthosis is inappropriate.
Once congenital Kyphosis due to type 1
or type 3 abnormalities is recognized
plan for surgical intervention should be
made even in the infant.

Treatment
If the kyphosis is diagnosed in a child
less then 5y old and is less than 45
degree simple posterior fusion without
instrumentation may be considered.
A hyperextension cast is used
postoperatively for 4-6 months.

Treatment
Success full outcome
with posterior fusion
have been reported,
this approach allow
some growth to occur
anteriorly in the
abnormal region of
the spine.

Treatment
An alternative approach for young child
is to combine anterior fusion using a rib
strut with posterior fusion during the
same operative intervention, this
approach produce solid fusion.
In the older child or adult, the
combination of anterior and posterior
arthrodesis is mandatory.

Treatment
As with any congenital vertebral
anomaly, associated dysraphic spinal
lesion should be ruled out prior to
surgical intervention, preoperative MRI
accomplishes this.
If a neurologic deficit present at the time
the congenital kyphosis is recognized,
treatment should be undertaken
immediately.

Treatment
If neurological deficit is minimal
(increased reflexes, positive Babinskis
sing, but no loss of motor, bowel, or
bladder function) a formal anterior
decompression of the spinal cord is not
necessary. Following a solid anterior
and posterior arthrodesis the subtle
neurologic deficit have the potential to
solve.

Treatment
If the kyphotic apex is flexible and the
patient has paraplegia a Halo vest, on
occasion minimal Halo traction should
be used, if recovery occur anterior and
posterior spinal fusion can be performed
without anterior decompression.
In rigid non flexible kyphosis traction is
contraindicated.

Treatment
If the neurological deficit is not resolved
anterior and posterior arthrodesis must be
combine with anterior decompression
The decompression must be performed
anterior to the compressed cord by
removing the posterior aspect of the
vertebral body. Posterior laminectomy will
not relieve the spinal cord compression.

Treatment
For adolescents with mild type of
congenital Kyphosis due to failure of
segmentation close monitoring for
progression is reasonable.
If the deformity is recognized at a
younger age, operative intervention
should be considered.

Freshta 14y
Congenital Kyphosis
Failure of formation

Freshta 14y
Congenital Kyphosis
Failure of formation

Post traumatic kyphosis

Hanifa 16y old girl

Hanifa 16y

Moh Husain 5y

Moh Husain 5y

Questions and discussions