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Synonyms: Scheuermann's disease, juvenile kyphosis, Scheuermann's kyphosis
Scheuermann's disease is one of the osteochondroses. It is essentially osteochondrosis of the vertebrae. It affects the thoracic or thoracolumbar spine in adolescents, causing increased kyphosis, poor posture and possible backache. It is the most common cause of structural kyphosis in adolescents.
It is confusing that Scheuermann also described changes that can occur in the lumbar disc spaces - now called juvenile disc disorder. This is a quite separate condition.
There is a separate article giving an overview of the Osteochondroses.
- Osteochondroses all involve a defect in ossification. In Scheuermann's disease there is a defect in the secondary ossification centres of the vertebral bodies. A few vertebral bodies may be involved or the whole thoracolumbar spine.
- Hereditary factors are thought to play a part in the pathophysiology but no definite mode of inheritance or genetic marker has been established so far.
- Other factors including a correlation between Scheuermann's disease and taller height, as well as an association with increased levels of growth hormone, have also been suggested as possible causes. However, one study has disputed the increased weight and height in those with Scheuermann's disease as being part of the pathogenetic mechanism, suggesting that they were secondary results.
- Mechanical factors and trauma have also been cited as possible causes.
- Usually presents in children aged 13-16 years old.
- Occurs more commonly in boys.
- Poor posture with increased kyphosis (usually noticed by parents).
- Pain is a more common presentation if the disease affects the lumbar spine. Pain is usually worse on activity.
- Neurological symptoms may rarely be the presenting feature.
- Cardiorespiratory symptoms can also rarely occur.
- It is normal to have a degree of kyphosis. Any degree of kyphosis of more than 40° is considered abnormal.
- Kyphotic deformity may be progressive.
- Upper thoracic kyphosis is best seen in the forward flexed position; lower thoracic kyphosis may be seen at the thoracolumbar junction.
- There is reduced flexibility of the spine.
- There may be tenderness above and below the apex of the kyphosis.
- Scoliosis may also be present and is associated with Scheuermann's disease.
- You should carry out a neurological examination but neurological signs are rare.
- Postural kyphosis (known as postural round back deformity; kyphosis is flexible).
- Ankylosing spondylitis.
- Glucocorticoid-induced osteoporosis in Cushing's syndrome,which can lead to thoracic kyphosis.
- Skeletal dysplasia.
- Congenital kyphosis (failure of segmentation).
- Spinal tuberculosis (consider if there is atypical presentation).
- X-ray of the spine in a standing position is the mainstay for diagnosis. Anteroposterior (AP) and lateral views are taken. The whole thoracolumbar spine should be imaged. Changes can include:
- Wedge-shaped vertebral bodies with anterior wedging of at least 5° or more in at least 3 adjacent vertebral bodies (pathognomonic for Scheuermann's disease).
- Hyperkyphosis (greater than 40°).
- Narrow intervertebral disc spaces.
- Irregular upper and lower vertebral endplates.
- Schmorl's nodes - multiple herniations of the nucleus pulposus of the vertebral plates.
- MRI and CT scanning may also be used.
- The management is controversial. Some think that no treatment is required, as the disease usually follows a benign course with few adverse sequelae. Others believe that treatment in those who are skeletally immature will prevent future excessive deformity and pain.
- If treatment is carried out, for mild disease, avoidance of strenuous activity and weight-bearing may be all that is needed. A referral to a physiotherapist may be helpful. Observation and X-ray follow-up are carried out.
- Non-steroidal anti-inflammatory drugs may be used for pain relief provided there are no contra-indications.
- Casting, spinal braces (a Milwaukee-style brace) and bedrest may be used in more severe disease. Braces may be advised for several years.
- Surgery is usually only used if there is neurological deficit, uncontrolled pain, unacceptable cosmetic appearance or documented progression.
- Cord decompression is carried out for neurological deficit and spinal fusion techniques are used for kyphosis correction and pain control.
- Chronic back pain.
- Progressive and permanent deformity.
- Neurological deficit.
- Cardiorespiratory problems.
- The degree of clinical symptoms and signs generally depends on the degree of deformity. Those with mild deformity tend to have mild symptoms and signs.
- Mild-to-moderate Scheuermann's disease rarely requires bracing or surgery.
- A gradual loss of correction can occur after a brace is removed.
- Neurological and cardiorespiratory complication risks are very low.
- Adolescents with severe deformity and symptoms have had significant deformity correction after surgery. However, literature reviews in 2007 and 2009 concluded that there are too few studies on clinical outcomes and a poor level of evidence for available treatments.
Further reading & references
- Nowak JE; Scheuermann Disease, Medscape, Jan 2012
- Cassas KJ, Cassettari-Wayhs A; Childhood and adolescent sports-related overuse injuries. Am Fam Physician. 2006 Mar 15;73(6):1014-22.
- Lowe TG; Scheuermann's kyphosis. Neurosurg Clin N Am. 2007 Apr;18(2):305-15.
- Lowe TG, Line BG; Evidence based medicine: analysis of Scheuermann kyphosis. Spine. 2007 Sep 1;32(19 Suppl):S115-9.
- Tribus C; Scheuermann Kyphosis, eMedicine, Sep 2010
- Damborg F, Engell V, Andersen M, et al; Prevalence, concordance, and heritability of Scheuermann kyphosis based on a study of twins. J Bone Joint Surg Am. 2006 Oct;88(10):2133-6.
- Fotiadis E, Kenanidis E, Samoladas E, et al; Scheuermann's disease: focus on weight and height role. Eur Spine J. 2008 May;17(5):673-8. Epub 2008 Feb 27.
- Herrera-Soto JA, Parikh SN, Al-Sayyad MJ, et al; Experience with combined video-assisted thoracoscopic surgery (VATS) anterior spinal release and posterior spinal fusion in Scheuermann's kyphosis. Spine. 2005 Oct 1;30(19):2176-81.
- Riaz S, Lakdawalla RH; Neurologic compression by thoracic disc in a case of scheuermann kyphosis - an infrequent combination. J Coll Physicians Surg Pak. 2005 Sep;15(9):573-5.
- Tsirikos AI; Scheuermann's Kyphosis: an update. J Surg Orthop Adv. 2009 Fall;18(3):122-8.
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Dr Michelle Wright
Dr Richard Draper