Kyphosis is a curvature in the sagittal plane (front to back plane) of the body with the apex of the curve directed posteriorly. It exists as part of the normal spine alignment and may measure up to forty-five degrees. Studies looking at chest radiographs in normal individuals have shown that this number can increase with age.
Curvatures in the coronal plane (side to side plane) are not part of the normal spine alignment and when they exist, with a minimum of 10 degrees, it is called scoliosis. A variety of causes and conditions may result in excessive kyphosis, however, the types that are seen most frequently include postural kyphosis and Scheuermann’s kyphosis.
Postural kyphosis usually becomes noticeable during adolescence and occurs more commonly in girls than in boys. Parents may perceive an abnormal prominence in the young person’s posture, or it may be detected during a routine visit to the pediatrician.
Illustration of a normal spine with forward bending.
Illustration of increased prominence from Kyphosis with forward bending.
As with other forms of kyphosis, diagnosis is made on the basis of physical examination - the patient stands perpendicular to the orthopaedist who can then assess the curve - and with radiographs (x-rays). Postural kyphosis is distinguished by the lack of rigidity in the spine and the lack of structural abnormalities of the vertebral bodies on radiographs.
Most patients with postural kyphosis can achieve good results—correction of the curve to within the normal range—with education in proper posture and participation in an exercise program. In the small percentage of patients who do not respond to this treatment, the orthopedist may prescribe the use of a brace until the curve is corrected or the child reaches skeletal maturity. Results of this treatment vary with the patient’s willingness to wear the brace as advised and commitment to a physical therapy regimen.
Kyphosis patient wearing a brace.
Radiograph of a patient with Kyphosis
Radiograph of a patient wearing brace demonstrating correction
Scheuermann’s kyphosis is a condition characterized by excessive kyphosis and structural change of the vertebrae. Patients with this deformity have a curve that is more rigid than that seen in postural kyphosis. Radiographs reveal irregularities in the spinal discs in at least three adjacent levels. As with postural kyphosis, the condition is usually diagnosed in adolescence.
When left untreated, Scheuermann’s kyphosis can progress. Accompanying pain and cosmetic deformity can also be anticipated. For the young patient with Scheuermann’s kyphosis and a small curve, one that is less than 50 degrees, treatment by bracing can be effective. Physical therapy alone is not usually effective in these individuals. Surgery may be indicated in those patients with large curves (>70 degrees) and or pain.
The orthopedic surgeon restores physiologic alignment to the spine by performing one or more of the following: excising abnormal discs, fusing the affected vertebrae together, and placing instrumentation in the spine as needed to maintain correct posture while the spine heals. Surgery through the back of the spine is frequently the procedure of choice, however, patients with a large rigid curve, in addition to the posterior procedure, may also require an anterior approach through the chest.
The radiographs of a 14 year old girl with Scherermann's Kyphosis measuring 85 degrees who underwent spinal fusion with instrumentation correcting her spine to 36 degrees.
With increasingly sophisticated surgical techniques and instrumentation, surgical treatment for kyphosis is easier to recover from than ever before. Patients who require only one posterior procedure (incision in the back) are up and out of bed the next day. For those who undergo a second anterior procedure, the incision is made through the chest or thoracoscopically and recovery may be more gradual. Patients may not need to wear a brace following surgery and generally experience minimal loss of motion. General anesthesia is used during these surgeries and hospitalization lasts between 5-7 days depending on the extent of surgery and age. Physical therapy after surgery is generally recommended and the requirement varies with age.
In patients with good bone quality, excellent results can be achieved. Success is defined as a solid fusion that eliminates pain and in which the correction of the curve is achieved and maintained, providing a balanced spine.
As noted, postural kyphosis and Scheuermann’s kyphosis are just two types of kyphosis that require treatment. Other types include:
Post-menopausal women may develop excessive kyphosis with vertebral wedging as the result of the reduction in bone density that accompanies osteoporosis. In patients with this condition, kyphosis is difficult to correct. However, measures can be taken to prevent early development by good perimenopausal counseling and medication, which may be obtained through the Osteoporosis Prevention Center at HSS. In some cases, early minimally invasive techniques are an option if the fracture is found early.
Original summary prepared by Nancy Novick