As its name suggests, post-traumatic kyphosis is a condition that results from serious injury, such as a fall from a height, a motor vehicle accident, a horseback riding accident, or even a bounce off a wave while boating. When the impact from such events causes fractures and/or dislocation of the vertebrae (disks of the spine), a kyphotic deformity - an abnormal curve of the spine - can develop, especially if the injury is not treated promptly.
To understand the effect of these injuries, it can be helpful to think of the healthy spine as a series of bony blocks, the vertebrae, which are connected by facet joints that permit movement in the spine. Disks sit between the vertebrae and provide cushioning and protection. The spinal cord runs through the spinal canal, a passage created by the vertebrae.
Post-traumatic kyphosis may occur from the lower lumbar spine (in the lower back) to the cervical spine (in the neck).
Figure 1: Diagram detailing the sections of the spine, with the neck (cervical) section at the top.
[Image courtesy of www.SpineUniverse.com]
When viewed from the side, a curve of the spine that measures between 40-50 degrees is considered to be a normal part of spine alignment. In patients with post-traumatic kyphosis, however, the curve may exceed the normal range, usually in a small segment of the spine. This occurs when fractures of the vertebrae cause wedging and the normally block-shaped vertebrae become angulated, resulting in a spinal deformity, pain, and a limited range of motion.
Bernard A. Rawlins, MD, an attending orthopaedic surgeon on the Spine Care Institute at Hospital for Special Surgery (HSS), describes two types of patients with post-traumatic kyphosis: those who require care in the acute phase, immediately after trauma, and those who seek treatment after the spine has healed in an abnormal alignment.
In patients who are seen immediately following trauma, pain is the primary symptom. “Because trauma patients often have multiple injuries, including those affecting the head, neck, and abdomen, it’s important that they undergo a complete evaluation - including a neurologic assessment - before we begin any intervention,” Dr. Rawlins says. Tools used to evaluate the patient include:
For those whose injury has healed in an abnormal alignment, back pain may be accompanied by an inability to stand erect, as well as associated neck pain that results from efforts to do so. “In an attempt to compensate for their kyphosis, patients may also develop abnormal lordosis, an excessive arching of the lower spine and the cervical spine in the neck, and overuse of the muscles to maintain alignment,” Dr. Rawlins explains.
Some patients may also develop early satiety, a feeling of fullness that occurs more quickly than normal when eating. This sensation occurs when the abdominal contents are squeezed against the diaphragm due to the abnormal curve of the spine.
Because post-traumatic kyphosis can progress if the injury heals without intervention, the goal for patients in the acute phase is to correct the spinal alignment as soon as it is safe to do so.
Treatment recommendations are based on a variety of factors, including the type of fracture (some kinds of fractures make the patient more susceptible to kyphosis), the site of the fracture, the extent of angulation in the affected part of the spine, and the size of the patient.
If non-surgical treatment is recommended, the orthopedist will put the patient in a brace to support the spine as it heals, and physical therapy is initiated to alleviate pain, strengthen surrounding muscles, and improve posture.
However, if the kyphosis is significant, surgery may be recommended to avoid the long-term consequences of kyphosis, including pain, hyperextension, and overuse injuries from lordosis in the neck and the lower back.
“The goal of surgery is to alleviate pain, restore the spine to proper alignment, and improve neurologic function,” explains Dr. Rawlins.
Surgical treatment for post-traumatic kyphosis is accomplished through spinal fusion and stabilization with instrumentation. In patients who are in the acute phase of their injury, the surgeon usually performs a posterior spinal fusion, approaching the area through the back. Patients who have a kyphotic deformity that has healed in this position may require an anterior-posterior approach, in which the surgeon makes one incision in the front of the body and another from the back, in one or two stages.
Figures 2 & 3: X-rays showing a female patient with a compression fracture as the result of a boating accident.
Figure 2 (left) shows the wedged, angular vertebrae in the center of the image, as noted by the white arrow.
Figure 3 (right) shows the corrected vertebrae after treatment with spinal fusion and instrumentation.
“In addition to fusion, some patients may require an osteotomy - a cut through the bone - in order to restore proper alignment,” Dr. Rawlins says. The orthopedic surgeon may also need to remove bone fragments from the spinal canal to help protect the spinal cord and relieve any associated pain. Throughout treatment and recovery, patients are monitored to ensure that any neurologic symptoms are detected and addressed promptly.
With increasingly sophisticated surgical techniques and instrumentation, surgical treatment for kyphosis is easier to recover from than ever before.
In the absence of other injuries, patients who have had the posterior procedure only may be up and out of bed the next day. For those who undergo an anterior and posterior procedure, recovery may be more gradual. To help maintain alignment during healing, the patient may wear a brace for up to three months. Physical therapy after surgery is generally recommended and the requirement varies with age.
Patients who undergo fusion can expect some reduction in the range of motion in their back, but the degree to which this occurs varies widely and is partly dependent on the number of levels of the spine that are fused.
Future improvements in the treatment of post-traumatic kyphosis are likely to lie in techniques that improve the rate at which fusions heal, according to Dr. Rawlins. Biologic proteins that increase and enhance fusions are currently the focus of numerous clinical trials.
Summary by Nancy Novick. Diagnostic imaging courtesy of the HSS Department of Radiology and Imaging.