Introduction

The spine is divided into three sections: the cervical spine or neck, the thoracic spine or mid back, and the lumbar spine or low back. Each of these sections has a specific, normal curve to it. The cervical spine looks like a backward “C”, which is called a lordotic curve. The thoracic spine has a regular “C” shape with the opening of the “C” in the front of your body, which is called a kyphotic curve. The lumbar spine, like the cervical spine, also has a backward “C” shape or lordotic curve.

Kyphosis is the term used to describe a type of abnormal curve in the spine in which there is too much forward curve in the spine. Kyphosis can have varying symptoms and degrees of severity, from minor changes in the shape of your spine to severe deformity, nerve problems, and chronic pain. The larger the abnormal curve, the more serious the problem.

Kyphosis is most common in the thoracic spine, though it can also affect the cervical and lumbar spine. Kyphosis in the thoracic spine exaggerates the natural curve of the thoracic spine. Kyphosis in the cervical or lumbar spine is a condition in which the normal inward curve of the spine reverses. This causes an abnormal forward curve in the spine.

Methods of treating kyphosis have evolved over time. Today there are numerous effective treatment options for correcting a severe kyphotic deformity.

There are a number of different types and causes of kyphosis. Each of these is discussed in detail below along with specific symptoms and approaches to diagnosis and treatment.

Causes

Postural Kyphosis

Cause

Postural Kyphosis is sometimes called “round back.” It is the result of poor posture. This condition is most common in adolescents and young adults.

Symptoms

Slouching when standing or sitting causes the spine to curve forward. Postural kyphosis is often accompanied by hyperlordosis of the lumbar (lower) spine. The lumbar spine naturally has a lordosis or inward curve. Hyperlordosis means the lumbar spine compensates for too much thoracic kyphosis by curving too far in the inward direction. Postural kyphosis corrects itself when you lie down on a flat surface, or when your spine is hyper-extended.

Diagnosis

There are no noticeable vertebral abnormalities on X-rays because structural damage or deformity does not cause this kyphosis.

Treatment Options

Postural kyphosis is easily corrected with education about proper posture, including some retraining on how to sit and stand correctly. Special bracing or casting is usually not necessary. Strengthening exercises for your back muscles can be helpful in correcting posture.

Scheuermann’s Kyphosis

Scheuermann’s kyphosis is a “developmental” type of kyphosis, meaning that it happens during growth. The vertebral bodies wedge forward. Normal vertebrae are rectangular-shaped and stacked on top of one another like building blocks, with a soft cushion between each one. If the front of the vertebra wedges closer together in a triangular shape, the spine starts to curve forward more than normal. This disease develops in adolescents while their bones are still growing. It happens to about one percent of this age group, affecting an equal number of boys and girls.

Cause

The cause of Scheuermann’s kyphosis has not been discovered, but there are many possible theories about its development. Scheuermann, a Danish radiologist, proposed that the problem started because cartilage of the spinal bone’s ring died from a lack of blood supply. He suggested that this interrupted bone growth during development, leading to wedging of the affected vertebrae.

Most researchers think that some sort of damage to the growth area of the vertebrae starts the process. The abnormal growth produces wedging of the vertebrae, which eventually leads to problems of kyphosis. For instance, there may be a vertebral disorder during the rapid growth spurts of adolescence, which causes abnormal bone growth. Many spine specialists also suspect that a problem with the mechanics of the spine (the way it is put together and functions) plays a part in Scheuermann’s kyphosis. Others suggest mild osteoporosis could contribute to the deformity. Muscle abnormalities have also been considered as a possible cause. And there does seem to be a high genetic predisposition to this disease, meaning that it runs in families.

Scheuermann originally noticed this spinal deformity in agriculture workers who were frequently hunched or bent over. This of course led to the question of whether poor posture could lead to extra kyphosis. While this is a logical question, the connection between posture and this deformity has never been confirmed. However, poor posture has been shown to play a role in making the problem worse. Therefore, correcting postural problems can sometimes help improve the abnormal kyphosis.

Symptoms

Symptoms of Scheuermann’s kyphosis generally develop around puberty, between the ages of 10 and 15. It’s hard to determine when the problem begins because X-rays don’t show the changes until the child turns 10 or 11. The disease is often discovered when parents notice the onset of poor posture, or slouching, in their child. The adolescent might experience pain and fatigue in the mid back. The pain is rarely disabling or severe at this point, unless the deformity is severe.

The extra kyphosis is generally slow to develop. When it progresses to the point the rounded curve becomes noticeable, a concerned parent or teacher will suggest a doctor visit. This is what leads most children to get medical help-not the presence of pain. By comparison, adults who developed Scheuermann’s early in life tend to seek help because pain from the deformity becomes unbearable.

A rigid curve in the spine is common with Scheuermann’s kyphosis. The curve gets worse with bending over and only partially corrects when standing up straight. Pain typically increases with time and severity of the deformity. Some patients with Scheuermann’s kyphosis also have scoliosis-about one third. Scoliosis is another type of spinal deformity that usually occurs in teenagers. Looking at an X-ray from the front, scoliosis curves side to side, like an “S” rather than a straight line. Learn more about adolescent idiopathic scoliosis.

People who have Scheuermann’s kyphosis usually don’t have nerve problems from the spinal deformity. However, a severely rounded spine can squeeze the contents of the chest and abdomen. The disorder may eventually put pressure on the heart, lungs, and abdomen. This can mean chest pain, shortness of breath, and a loss of appetite.

Diagnosis

To diagnose Scheuermann’s Kyphosis, an X-ray of your spine will probably be taken. The extra kyphosis will show up on the X-ray and can be measured in degrees. If your problem is simply due to postural problems, nothing else abnormal will show up on your X-ray. But if your kyphosis is due to Scheuermann’s disease, your X-ray will show three or more adjacent vertebra that are wedged together at least five degrees each. In addition, the X-ray will show if there are Schmorl’s nodes (the small herniations of disc through the endplates of the vertebrae). Arthritis may show up on X-rays in adults with extra thoracic kyphosis. These changes generally coincide with an increase in pain.

Treatment Options

Conservative Treatment

Treatment of Scheuermann’s kyphosis is somewhat controversial. It depends on many things such as your age, the severity of the curve, and the flexibility of the curve. If possible, the deformity will be treated without surgery.

One option for treating Scheuermann’s Kyphosis is bracing. The goal of bracing is to try to “guide” the growth of the vertebrae in order to straighten your spine. The brace will only successfully straighten the spine in patients who are still growing. The brace is designed to hold the spine in a straighter, upright posture. This is thought to work by taking pressure off the front half of your vertebra, allowing the growth of the bone in the front to catch up with the growth in the back. In order patients, a brace may be used to support your spine and relieve pain, but it will not improve the curve.

Many braces are available that keep your shoulders pulled back and your chin upright. Braces are usually effective in adolescents with curves of less than 75 degrees. If young patients are consistent in wearing the brace, worsening of the curve can be limited and there may be correction of the deformity within two years. The brace allows remodeling and corrected growth of the developing spine. The brace is usually worn from 16 to 24 hours each day for one year, then just at night for two years.

Your doctor may also prescribe physical therapy. A well-rounded rehabilitation program assists in calming pain and inflammation, improving mobility and strength, and making daily activities easier. People who are prescribed a brace tend to benefit even more when physical therapy is included. Patients may require rechecks with the physical therapist once or twice each year during periods of growth.

Surgery

Surgery is usually only recommended for Scheuermann’s Kyphosis if X-rays show a kyphosis over 75 degrees. A curve less than 75 degrees is usually treated with observation or a brace. Surgery is occasionally performed for cosmetic reasons. Because the surgery is serious and involves the spine, it generally is not recommended just to improve appearance.

Fusion surgery is mainly used to correct Scheuermann’s kyphosis. The operation has two parts. One operation is done on the front of the spine (anterior), and another one is done on the back (posterior). These two surgeries used to be done about one week apart. Now many doctors are doing both operations on the same day.

The anterior operation is usually done to “release” tight ligaments along the front of the spine. Cutting these ligaments and removing the discs between the vertebrae increases flexibility in the spine. This allows the spine to be straightened easier when rods are put in from the back of the spine. Next, the surgeon begins the posterior procedure by working from the back of the spine. This is where the actual correction of the spinal curve happens. Rods are attached along the spine to align the spine and hold the spine in its corrected position.

Because most surgeries to correct kyphosis involve a rigid spine, both anterior and posterior surgical procedures are generally needed. There are some cases of kyphosis, however, that can be corrected by the posterior procedure alone. In fact, some doctors are performing posterior-only surgery for Scheuermann’s kyphosis regardless of the size of the curve.

For the posterior-only approach, pedicle screws are used at each spinal level to be fused. Rods are connected to the screws, allowing a large amount of correction to occur. When this approach is chosen, the anterior procedure is not used. For some patients, the posterior procedure alone can realign the spine.

Your doctor will advise you of which type of surgery is best for you. The surgical approach used will depend upon t your age, the flexibility of your spine, the location and degree of the curve, and whether there is pressure on any of your nerve roots.

Congenital Kyphosis

Cause

Congenital kyphosis means a person is born with some sort of defect, such as incomplete formation of the spine. This can lead to a severe abnormal kyphosis.

Symptoms

Extreme kyphosis is the most common cause of paralysis in the lower part of the body, other than trauma or infection. With congenital kyphosis, there is a strong (20-30 percent) chance of congenital abnormalities with the body’s urinary collecting system.

Diagnosis

If this type of kyphosis is suspected, your doctor may suggest that you have a special X-ray that looks at your kidneys (called an IVP), an ultrasound of the kidneys, a myelogram, or an MRI. The myelogram and the MRI can show whether or not the parts of the spine have developed normally. A 3-D CT scan gives a three dimensional view of the misshapen vertebrae.

Treatment Options

Severe congenital kyphosis deformities are usually treated surgically. Conservative treatment plans are less successful at correcting this type of kyphosis. Early surgical intervention generally produces the best results and can prevent progression of the curve. The type of surgical procedure will depend on the nature of the abnormality.

If nonsurgical treatment is chosen, there is a critical need for observation and close medical follow-up to prevent possible problems later.

Paralytic Disorders

Conditions that cause paralysis can lead to kyphosis. Paralysis can be caused by disorders such as Polio, muscular dystrophy, and Cerebral Palsy (paralysis caused by trauma at birth or developmental defects in the brain). The development of kyphosis in these cases is gradual rather than sudden.

Post-traumatic Kyphosis

Injury to the spine can lead to progressive kyphosis and nerve problems in the spine. A vertebral fracture in your thoracic or lumbar spine will almost always cause some degree of kyphosis. Post-traumatic kyphosis is sometimes treated with either bracing or surgery. The choice will depend on the severity of your condition.

Post-surgical Kyphosis

Kyphosis can develop after spine surgery has been done to correct other problems. This usually occurs when the procedure does not heal as intended. For example, a spinal fusion may not heal, and the unstable fusion may cause your spine to collapse into kyphosis. The ligaments of your spine may not heal strongly enough to support the vertebrae, and a kyphosis develops. A second operation might be needed.

Degenerative Kyphosis

There are cases of kyphosis that are caused by degeneration (wear and tear of the spine). Over time, the degenerative process can result in collapse of an intervertebral disc, changes in the shape of your vertebrae, and weakening of the ligaments that support your spine. This can result in the gradual development of a kyphosis over many years. Once the kyphosis begins to form, it gets worse because the imbalance of the forces continually increases the wear and tear on your spine.

Other Causes

Different types of systemic (whole body) diseases can cause a kyphosis to develop over time. These conditions include infection in your spine, cancer or tumors that involve your spine, and different types of systemic arthritis. These conditions affect the bones and soft tissues of your mid back and may produce kyphosis. Children with cancer sometimes need radiation treatment. Radiation of the spine in childhood can alter the strength of the spinal vertebrae, leading to kyphosis later in life.

Symptoms

The symptoms and severity of kyphosis vary depending on the type of kyphosis. Symptoms range from minor changes in the shape of your spine, to severe deformity, neurologic deficits, and chronic pain. Movement may become limited, making it difficult for you to turn and bend. The abnormal forward curvature can eventually appear unattractive. Pain may be present, especially if the kyphosis is caused by degenerative changes. The pain occurs primarily in the area of the kyphosis. A severe curve can also begin to put pressure on the spinal cord and spinal nerve roots, which may cause weakness in the lower extremities. Eventually there can be pressure on the lungs and abdomen, affecting breathing and appetite.

With a kyphotic deformity, the spinal cord may be stretched where the spine bends forward. The spinal cord is your body’s connection to your brain. When it is damaged or compressed, your body loses some of its ability to function properly. If pressure builds up on your spinal cord, it can cause myelopathy. Myelopathy may impair normal walking, hand and finger use, and bowel and bladder function. Doctors take these symptoms very seriously because severe myelopathy that is not treated may lead to permanent nerve damage. Pressure on your spinal cord can eventually lead to quadriplegia, which is paralysis of all four limbs.

Diagnosis

In order to make a proper diagnosis and rule out other possible conditions, the first step is to take a history. If kyphosis is suspected, your doctor will want to know about the following specific things:

• Family History – Some types of kyphosis tend to run in families, so it may have a genetic cause. Your doctor will want to know whether anyone else in your family has the same problem.
• Date of Onset – When did you first notice the appearance of your spinal condition?
• Measured Curve Progression – If X-rays have been taken of your spine in the past, the doctor will want to see whether the curve is getting worse. This can be measured comparing new X-rays with old ones, measuring the size of the curve, or measuring changes in your height.
• Presence or Absence of Pain – Not all cases of kyphosis produce pain. If there is pain, your doctor needs to know where it is, what brings it on or intensifies it, and whether there is any radicular pain (pain that radiates away from your spine). This usually comes from irritation of the nerves as they leave your spine.
• Bowel or Bladder Dysfunction – Are you having problems knowing when you have to urinate or have a bowel movement? This is extremely important because it could signal the presence of pressure on your spinal cord or the nerves that go to your pelvis.
• Motor Function – Has there been a change in how your muscles work? This may be the result of pressure on your nerves or spinal cord.
• Previous Surgery – If you have had any surgery on your spine, it may have caused the kyphosis due to weakened muscles or other problems. In order to evaluate your condition properly, it is important that your doctor knows about any spinal surgery you have had in the past.

You will then be given a physical exam. Your doctor will want to get an understanding of the curve in your back and how it is affecting you. This means first trying to get a “mental picture” of how your spine is curved from examining your back and watching you move. The doctor will look at the flexibility you have by asking you to bend in certain directions. Your doctor will generally be looking for abnormalities in the following areas:

Usually after your exam, X-rays will be ordered that allow your doctor to see the structure of your spine and measure the curve. You will be asked to hold very still in certain positions while standing or lying on a table.

Depending on the outcome of your history, physical exam, and initial X-rays, other tests may be ordered to look at specific aspects of the spine. The most common tests that are ordered are an MRI to look at your nerves and spinal cord, a CT scan to get a better picture of your vertebral bones, and a myelogram to determine whether any nerves are being irritated or pinched.

Treatment Options

Conservative Treatment

Kyphosis has a variety of treatment options. Body casts were originally used to treat kyphosis. Treatment later turned to surgery. Today, conservative treatments are chosen first whenever possible.

Conservative treatments commonly include medications, exercise, and certain types of braces to support your spine. Spinal surgery will generally be the last treatment choice due to the risks involved.

If osteoporosis is present, treatment of the condition may also slow the progression of the degenerative kyphosis. This can be accomplished in several ways. The current recommendations include increasing calcium and vitamin D intake, hormone replacement therapy, and weight-bearing exercises. Learn more about preventative measures for osteoporosis.

The use of a spinal brace may provide some pain relief. However, in adults, it will not cause the spine to straighten. Once you have reached skeletal maturity, bracing is used for pain relief rather than prevention.

Your doctor may have you work with a physical therapist. A well-rounded rehabilitation program assists in calming pain and inflammation, improving your mobility and strength, and helping you do your daily activities with greater ease and ability.

Exercise has not proven helpful for changing the kyphotic curve in the mid back or neck. However, it can be helpful when combined with bracing. Treatments address flexibility of your muscles, back strength and posture, and ways to exercise at home.

Surgical Treatment

Surgery for kyphosis has some significant risks. For this reason, surgery is only recommended when the expected benefits far outweigh the risks. Surgery will not be recommended for most cases of kyphosis but may be recommended in the following situations:

Pain

The most common reason for kyphosis surgery is pain relief for chronic discomfort that keeps getting worse. Most cases of a kyphosis surgeries are done to relieve severe pain. However, if the pain is manageable through conservative treatments, surgery will probably not be recommended.

Progression of Curve

Progression of the kyphosis deformity is another reason for considering surgery. If the curvature continues to worsen, surgery may be suggested. Surgery is recommended in this situation to prevent the problems that come from severe kyphosis.

Cosmetics

In most cases of kyphosis, surgery will not be recommended merely for the sake of appearance. However, in some cases, the kyphosis causes physical deformity that is unbearable to the patient. In these cases, surgery becomes the only option for correcting the condition. Most cases of cosmetic kyphosis surgery are in young adults that have very noticeable curves.

Procedure

When kyphosis requires surgery, doctors have many different procedures from which to choose. Each case of kyphosis is somewhat different and may require a very specialized approach for optimal results. Surgery is suggested to solve the problems brought on by the kyphosis, not just to straighten the spine. The goals of most surgical procedures for kyphosis are to:

To achieve these goals, your doctor may suggest an operation on the back of your spine, the front of your spine, or both. The goal is to first straighten your spine and then to fuse the vertebrae together into one solid bone.

Nearly all doctors will use some type of metal screws, plates, or rods, in order to help straighten your spine and hold the vertebrae in place while the fusion heals and becomes solid. The screws are placed into your vertebrae. The rods or plates then attach to the screws to connect everything together. Tightened together, they form an internal brace to hold your vertebrae in alignment while the fusion heals.

• Spine Movement – Is there pain when you twist, bend, or move? If so, where? Have you lost flexibility?
• Strength – The strength of your muscles will be tested. You might be asked to try to push or lift your arm, hand, or leg against resistance.
• Pain – Your doctor may try to determine whether you have tenderness in certain areas.
• Sensation – Can you feel certain sensations in specific areas of your feet or hands?
• Reflexes – Your tendon reflexes might be tested, such as below your kneecap and in your Achilles tendon behind your ankle.
• Motor Skills – You might be asked to walk on your heels or toes.
• Special Signs – Your doctor will also check for any indicators of something other than spinal/vertebrae problems. Some signs of other problems include tenderness in certain areas, a fever, an abnormal pulse, chronic steroid use (which leads to loss of bone mass), or rapid weight loss.
  • Reduce the deformity (straighten the spine as much as possible)
  • Stop the progression of the deformity
  • Remove any pressure from your nerves and spinal cord
  • Protect your nerves and spinal cord from further damage