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Scheuermann's kyphosis
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Scheuermann’s kyphosis McIntosh and Sucato 537
Figure 1 Abrupt posterior angulation on forward bend Radiographic findings for Scheuermann’s
kyphosis
Patients should be evaluated with standing posteroanter-
ior and lateral 36-inch (90 cm) spine radiographs. There is
great variability in the quality of standing lateral radio-
graphs of the spine and over or underexposure can lead
to difficulty identifying clear anatomic landmarks for
measurement of curve magnitude. In a recent study by
Stotts et al. [9] there was a 108 interobserver error in the
measurement of kyphosis on lateral spine radiographs.
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538 Pediatric orthopaedics – prosthetics and orthotics
A lateral bolster radiograph of the spine should be Figure 3 Typical radiographic characteristics of lumbar
Scheuermann’s
obtained prior to the initiation of brace or surgical treat-
ment. This radiograph is obtained by placing the patient
supine with a bolster positioned at or below the apex of
the kyphotic deformity. The patient should be resting
comfortably with their hips and knees flexed. The weight
of the freely hanging head and upper thorax provide
the force to extend the spine. Following 5 min in this
position, a lateral spine radiograph is obtained [2].
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Scheuermann’s kyphosis McIntosh and Sucato 539
finding suggests that orthotic management is perhaps not procedure. The need for the anterior procedure, however,
indicated for a deformity of large magnitude, but that can be questioned when adequate correction and fusion
smaller deformities can be maintained or improved with are achievable by a posterior procedure alone.
orthotic treatment.
Determining fusion levels
Cast treatment Fusion levels are determined from the standing lateral
When passive correction on lateral bolster radiograph radiograph. The upper limit of fusion must include the
is less than 40%, brace treatment is not likely to be most proximal vertebra that is tilted into the kyphosis,
effective. Risser casts can be applied in a serial fashion which generally means fusion to T2. If the fusion stops
to produce more correction of the kyphosis. This treat- distal to this level, there is a risk that a postoperative
ment regimen, used more extensively in Europe, entails junctional kyphosis will develop. Similarly, the caudal
applying two or three casts (changed every 2–3 months) extent of the fusion should include the first lordotic disk
in an attempt to progressively correct the deformity. space, which commonly includes one level distal to the
Following the 6–9-month period of casting, the measured end vertebra of the kyphosis. Failure to extend
patient is then treated with a Milwaukee brace or into the lumbar lordosis similarly risks a caudal junctional
other type of retention brace to maintain the correction kyphosis [19].
during the remainder of the growth. With such a regimen,
not only is the deformity improved by as much as The concept of the ‘stable’ vertebra that is routinely used
40%, but there is less loss of correction. In a series in the determination of fusion levels for scoliosis can be
reported by Ponte and associates, only 48 of correction used for kyphosis [20]. On the standing lateral spine
was lost [17]. radiograph, draw the posterior sacral vertical line. This
line is drawn from the posterior edge of the S1 body and
The use of cast treatment in an adolescent rests largely on extended proximally until it intersects (or bisects) one of
the patient’s desire to achieve maximum correction with- the lumbar vertebrae (Fig. 4). The vertebra bisected
out resorting to surgery. Because of the prolonged and by this line is the ‘stable’ vertebra. Occasionally, the
relatively inconvenient treatment period (6–9 months in vertebra immediately above the true ‘stable’ vertebra
casts and a minimum of six additional months in a brace), can be the distal fusion level, as long as the posterior
such therapy will never succeed without the total com- sacral line intersects some part of the more proximal
pliance and desire of the adolescent. vertebra. This is particularly true when the disk above
it is lordotic or neutral. If the disk above is in any degree
Nonoperative treatment of lumbar of kyphosis, the safe fusion level will have to be extended
Scheuermann’s disease one level more distal [20].
Orthotic treatment is the mainstay of treatment for
lumbar Scheuermann’s disease. It allows for the relief Anterior release and fusion technique
of pain and may halt the progressive deformity of the In rigid kyphoses of large magnitude (especially in ske-
spine. A TLSO is molded to encourage a more normal letally mature individuals), an anterior release and fusion
lumbar lordotic contour. With brace treatment the low of the apical portion of the deformity may be advisable to
back pain quickly resolves and over time the lucent increase the correctability by posterior instrumentation.
defects in the anterosuperior vertebral bodies may This allows the surgeon to balance the spine more
improve [2]. harmoniously and probably improve the rate of fusion
[14]. It could be argued that larger deformities not
Operative treatment adequately corrected by posterior instrumentation alone
Surgical treatment of Scheuermann’s kyphosis is went on to pseudarthrosis because the fusion mass was
reserved for patients with pain, a rigid deformity, a curve under tension rather than compression.
of more than 70–758 or progressive deformity, and an
unacceptable cosmetic appearance. According to Lowe, a If an anterior release and fusion procedure is elected, it is
kyphosis should never be reduced more than 50% of the usually performed as the first stage of a two-stage
preoperative deformity, both to prevent neurologic com- approach, with both stages usually performed on the
plications and to avoid junctional kyphoses at the ends of same day. The release should include the rigid apical
the fusion [18]. Historically, the biomechanical principles segments (as determined on a hyperextension lateral
of kyphosis correction have included elongating the radiograph) and can encompass essentially the entire
anterior column of the spine, providing some form of thoracic spine if necessary. The release is performed
anterior column support, and shortening the posterior through a right-sided thoracotomy or thoracoscopically.
column of the spine. Because of the first two principles, The right side is generally more approachable because
the use of an anterior release and fusion has been the cardiac structures and great vessels fall to the left of
accepted as part of a standard two-stage corrective the spine.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
540 Pediatric orthopaedics – prosthetics and orthotics
Figure 4 Posterior sacral vertical line utilized to determine ligated and divided only after they have been temporarily
distal fusion level
occluded for 20 min, and intraoperative monitoring shows
no signal degradation from ischemia. Ligation of these
vessels can result in paraplegia due to cord ischemia,
known as anterior spinal artery syndrome. The contents
of the disk space should be evacuated and the vertebral
apophysis should be removed from the endplates. The
rib that has been resected for the thoracotomy approach
is morcellized and used as the interbody bone graft.
The pleura is then closed with running suture to achieve
hemostasis and to maintain the rib graft in the interbody
spaces.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Scheuermann’s kyphosis McIntosh and Sucato 541
remaining, and if the kyphosis corrects to less than 508 The typical posterior construct includes a minimum of
on a lateral bloster radiograph, then an instrumented eight anchors above and below the apex of the kyphosis
posterior fusion alone may be sufficient. [29]: three to five pairs of pedicle hook–transverse
process claws cephalad to the apex of the kyphosis,
The patient is placed on a standard four-poster spinal and similar number of paired pedicle screws caudad to
frame, with the abdomen free and the hips flexed to the apex of the kyphosis [29]. Implants should not be
decrease lumbar lordosis. Because exposure of the upper placed in the canal via a laminotomy near the apex of the
thoracic segments will be necessary, the patient’s head is kyphosis because of the risk that these implants may
slightly flexed to facilitate access to T1 if necessary. With protrude anteriorly during the corrective maneuver. In
posterior fixation, multisegment hook–screw systems fact, the rod pushes against the lamina to correct
have been used to correct kyphosis. These systems allow the kyphosis.
for segmental fixation with hooks or screws which
increase the stability of the construct. The original instrumentation used for kyphosis correc-
tion – the Harrington compression rod system [14,30–32]
Pedicle screw fixation has theoretical advantages over – has regained popularity in a modified form for correct-
hook fixation: the three-column support of multisegment ing kyphosis. The original Harrington compression
pedicle screw constructs provides extremely secure pur- instrumentation was effective in obtaining correction
chase and construct stability; and the lack of iatrogenic but there was an unacceptable loss of correction [30].
ligament injury required for the proper placement of Other complications of or drawbacks to the compression
hooks, which disrupts the posterior tension band predis- rod system included rod fracture, caudal hook pullout,
posing to junctional kyphosis [20]. and the need for postoperative immobilization due to the
Figure 5 Skeletally mature Scheuermann’s patient treated with posterior spinal fusion: sagittal improvement from 90- to 35-
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
542 Pediatric orthopaedics – prosthetics and orthotics
lack of stiffness and fatigue susceptibility of the small- When an anterior procedure is deemed to be necessary,
diameter, 18-inch (3.125 mm) rod. Tightening com- prone VATS anterior release and fusion is an attractive
pression nuts along a threaded rod also has a high ‘fiddle alternative to formal open anterior release. Proper level
factor’. The fact remains, however, that moving a nut selection, avoidance of posterior ligamentous tension
along a threaded rod is mechanically superior to any band resection, and preventing overcorrection will limit
extrinsically applied compression or distraction force, postoperative complications associated with junctional
as a maximal mechanical advantage can be generated kyphosis.
in a slow, measured application.
creating space between adjacent laminae, which can then 5 Robin C. The etiology of Scheuermann’s disease. Philadelphia: Lippincott-
Raven; 1997.
be closed during a cantilever or compression maneuver. 6 Blumenthal SL, Roach J, Herring JA. Lumbar Scheuermann’s. A clinical series
We resect the inferior portion of the lamina along with and classification. Spine 1987; 12:929–932.
complete facet resection, producing a closing-wedge 7 Ascani E, LaRosa G. Scheuermann’s kyphosis. New York: Raven Press;
1994.
‘osteotomy’ at each segment. The closure of each seg-
8 Boehm H. Simultaneous front and back surgery: a new technique with a
ment is best done by the compression rod technique. thoracoscopic or retroperitoneal approach in the prone position [abstract]. In:
Placement of apical implants (such as supralaminar Fourth International Meeting of Advanced Spine Techniques; July 1997;
Bermuda. Wheaton: IMAST; 1997.
hooks) in the spinal canal should be avoided because
9 Stotts AK, Smith JT, Santora SD, et al. Measurement of spinal kyphosis
of potential neurologic complications and because the implications for the management of Scheuermann’s kyphosis. Spine 2002;
implant will block complete closure of the resection 27:2143–2146.
laminotomy, preventing full correction. 10 Sorensen H. Scheuermann’s juvenile kyphosis. Copenhagen: Munksgaard;
1964.
11 Tribus CB. Transient paraparesis: a complication of the surgical management
To date, compression rod techniques in treating kyphosis if Scheuermann’s kyphosis secondary to thoracic stenosis. Spine 2001;
have achieved and maintained correction satisfactorily 26:1086–1089.
[33]. The typical loss of correction of 58 or less confirms 12 Riaz SARHL. Neurologic compression by thoracic disc in a case of Scheuer-
mann kyphosis: an infrequent combination. J Coll Physicians Surg Pak 2005;
that if the kyphosis can be corrected to a normal range 15:573–575.
(40–458 of residual kyphosis), anterior surgery appears 13 Yablon JS, Kasdon DL, Levine H. Thoracic cord compression in Scheuer-
unnecessary to maintain correction. By exchanging the mann’s disease. Spine 1988; 13:896–898.
threaded rods (following correction) to solid larger 14 Speck GR, Chopin DC. The surgical treatment of Scheuermann’s kyphosis.
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diameter rod constructs, we have been able to maintain
15 Butler MS, Robertson WW Jr, Rate W, et al. Skeletal sequelae of radiation
correction without the need for interbody fusion, and therapy for malignant childhood tumors. Clin Orthop Relat Res 1990;
so we currently prefer posterior-only instrumentation 251:235–240.
over combined anterior–posterior procedures [33] 16 Sachs B, Bradford D, Winter R, et al. Scheuermann kyphosis. Follow-up of
Milwaukee-brace treatment. J Bone Joint Surg Am 1987; 69A:50–57.
(Fig. 5).
17 Ponte A, Gebbia F, Eliseo F. Nonoperative treatment of adolescent hyperky-
phosis: a 30 years experience in over 3000 treated patients. Orthop Trans
Conclusion 1990; 14:766.
Surgical indications for Scheuermann’s kyphosis should 18 Lowe T. Scheuermann’s disease. Philadelphia: Lippincott-Raven; 1997.
19 Durrani AA, Choudhury SN. Complications of surgical management of
be assessed on a case-by-case basis, but in general Scheuermann’s kyphosis. [abstract]. In: Scoliosis Research Society Annual
patients with pain, a rigid deformity, a curve of more Meeting; 16–20 September 1998; New York. Milwaukee: Scoliosis
Research Society; 1998.
than 70–758, and an unacceptable cosmetic appearance
20 Lenke LG. Kyphosis of the thoracic and thoracolumbar spine in the pediatric
are surgical candidates. Newer technologies such as third patient: Prevention and Treatment of Surgical Complications. Instructional
generation segmental instrumentation in combination Course Lectures Pediatrics 2007; 197–206.
This is an excellent review on the prevention of surgical complications associated
with compression rod techniques have nearly eliminated with kyphosis surgery. Specific emphasis is placed on surgical planning and
the need for combined anterior–posterior procedures. techniques to avoid junctional kyphosis.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Scheuermann’s kyphosis McIntosh and Sucato 543
21 Mack MJ, Regan JJ, Bobechko WP, Acuff TE. Application of thoracoscopy 27 Sucato DJ, Elerson E. A comparison between the prone and lateral position
for diseases of the spine. Ann Thorac Surg 1993; 56:736–738. for performing a thoracoscopic anterior release and fusion for pediatric spinal
deformity. Spine 2003; 28:2176–2180.
22 McAfee PC, Regan JR, Zdeblick T, et al. The incidence of complications in
endoscopic anterior thoracolumbar spinal reconstructive surgery: a prospec- 28 Ferreira-Alves A, Resina J, Palma-Rodriques R. Scheuermann’s kyphosis: The
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23 Newton PO, Wenger DR, Mubarak SJ, et al. Anterior release and fusion in 29 Lowe TG. Kyphosis of the thoracic and thoracolumbar spine in the pediatric
pediatric spinal deformity: a comparison of early outcome and cost of patient: surgical treatment. Instructional Course Lectures Pediatrics 2007;
thoracoscopic and open thoracotomy approaches. Spine 1997; 22:1398– 189–196.
1406. This is a good review of the surgical treatment of kyphosis with emphasis on both
large and short radius kyphosis.
24 Herrera-Soto JA, Parikh SN, Al-Sayyad MJ, Crawford AH. Experience
with combined video-assisted thoracoscopic surgery (VATS) anterior spinal 30 Bradford DS, Moe JH, Montalvo FJ, Winter RB. Scheuermann’s kyphosis.
release and posterior spinal fusion in Scheuermann’s kyphosis. Spine 2005; J Bone Joint Surg Am 1975; 57A:439–448.
30:2176–2181. 31 Herndon WA, Emans JB, Micheli LJ, Hall JE. Combined anterior and posterior
25 Huntington CF, Murrell WD, Betz RR, et al. Comparison of thoracoscopic and fusion for Scheuermann’s kyphosis. Spine 1981; 6:125–130.
open thoracic discectomy in a live ovine model for anterior spinal fusion. Spine 32 Taylor TC, Wenger DR, Stephen J, et al. Surgical management of thoracic
1998; 23:1699–1702. kyphosis in adolescents. J Bone Joint Surg Am 1979; 61A:496–503.
26 Newton PO, Cardelia JM, Farnsworth CL, et al. A biomechanical comparison 33 Johnston CE, Elerson E, Dagher G. Correction of adolescent hyperkyphosis
of open and thoracoscopic anterior spinal release in a goat model. Spine with posterior-only threaded rod compression instrumentation: is anterior
1998; 23:530–535. spinal fusion still necessary? Spine 2005; 30:1528–1534.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.