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Scheuermann’s Kyphosis:
Introduction to Problem and Recent Literature Review
Daniel M. Sciubba, MD
Professor of Neurosurgery, Oncology and Orthopaedic Surgery
Johns Hopkins University
Department of Neurological Surgery
Email: [email protected]
Disclosure
• Research
– AANS, CNS, NASS, NREF, SRS, AOSpine, DOD & JHMI research grants
• Teaching
– Honoraria (AANS, AOSpine, Depuy, Medtronic, Globus, Stryker, Orthofix)
• Editorial Board– Journal of Neurosurgery, Spine
• Study Groups
– Spine Tumor Knowledge Forum (AOSpine)
– International Spine Study Group (ISSG)
• Consulting– Medtronic, Depuy-Synthes, Stryker, Nuvasive, Stryker
Kyphosis:
What is ‘normal’
kyphosis?
• T1 - T12 male & female < 40º
– Roaf (1960) : 20º - 40º
– Rocher (1965) : 35º
– Stagnara (1982) : 30º - 50º
– Oxborrow et al (SRS 1997) :15º- 45º
Holger Werfel Scheuermann
(1877-1960)
• Danish orthopedic surgeon who first
described the entity "Scheuermann's
Disease", relating to disabling back pain
caused by a juvenile spine kyphosis.
• Scheuermann correctly attributed this
"disease" to vertebral endplate deformities
which he believed were due to ossification
failures.
November 1, 2017 4
Kyphosis:
• Congenital
• Postural
• Scheuermann’s Disease
•http://www.back.com/causes-developmental-scheuermann.html
Postural Kyphosis
• Usually < 60°
• “round shoulders”
• “slouching”
• Flexible
• No wedging, no end plate irregularities
• Non-structural: complete reduction with hyperextension
(bending backwards)
Scheuermann’s Kyphosis
• Scheuermann (1921):
– Male > Female ratio 7.3:1
– Prevalence 0.4-8% pop.
• Bradford (1973) : 1:2
• Halal (1978) and Findlay (1989):
– ? Autosomal dominant transmission
• Damborg (SRS 2004) – prevalence
– 2.8% M:F 3.6:2.1
– Monozygotic twins 2-3x greater
than Dizygotic twins
Pathological Process ?
• Thickened A.L.L (bowstring effect)
• Wedging of disc and vertebral body
• Altered endochondral ossification of end plate cartilage
• Decreased collagen & increased proteoglycan
Clinical Presentation
• Occurs when healthy, rectangular shaped vertebrae
become wedge shaped.
• Symptoms are similar to other types of kyphosis:
1. Severe back pain with sports and other activities
2. A rigid curve of the spine that gets worse when bending and only
partially corrects itself when standing
3. Difficulty standing erect
4. Chest pain or difficulty breathing caused by decreased lung
capacity
5. Tight hamstring muscles in the legs
6. Forward posture of the head and neck
November 1, 2017 11
Radiographic Findings
• Apex – usually between T7 & T9
• Negative sagittal balance
– C7 plumbline > 2cm posterior to sacral promontory
– Compensatory hyperlordosis of cervical & lumbar spine
– Lumbar spondylolithesis
• Sorenson criteria:
– > 5° anterior wedging
– At least 3 adjacent vertebral bodies
• (Drummond (2), Bradford (1))
– Schmorl’s nodes, irregular endplates, disc space narrowing
Natural History
• Benign course
• < 75° at maturity– No long-term difficulties
• > 75° at maturity– May seek medical attention due to cosmesis
and/or back pain
– Over compensation lumbar/cervical
• Physical signs & symptoms– prepubertal growth spurt
Natural History and Long-Term Follow-up
• 37-year follow-up study of untreated Scheuermann’s
disease was performed of 80 patients, compared to
a sample of the general Finnish population
(n=3,935).
– Scheuermann patients had a higher risk for back
pain and disability score.
– The degree of thoracic kyphosis was not
associated with back pain, quality of life, or
general health. (Ristolainen et al. Eur Spine J
2012).
11/1/2017 14
Treatment Options:
Non-operative:• Reassurance
• Bracing
Operative:• Posterior correction
• Anterior correction
• Combined correction
Non-operative Treatment:
• Observation: – Asymptomatic, non-progressive
deformity, recommended first for most patients
• Postural exercises:– Extension muscle strength; Prescribed
with brace treatment
• Serial Casting:– For rigid, larger curves
– Prior to initiating bracing treatment
• Bracing– Prerequisites: Adequate curve
flexibility, sufficient growth remaining, patient compliance, Sachs – 45-75 deg
Intensive Physical Therapy
Effect of Intensive Rehabilitation on Pain in Patients with
Scheuermann’s Disease
Weiss HR, Dieckmann J,Gerner HJ Stud Health Technol Inform
2002;88:254-257
11/1/2017 17
• 351 patients, from 17-21 years old with kyphotic angle 53-64o, underwent intensive PT.
• Pain was significant between sex and location of disease: – Numeric pain scale: 2.1 for females with thoracolumbar Scheuermann’s,
1.9 for thoracic (p<0.05)
– 1.4 for males with thoracolumbar Scheuermann’s, 1.8 for males with Scheuermann’s.
• Following intensive rehabilitation, there was pain reduction between 16-32% across all patients.
Bracing
• If curve progresses/severe curve - designed to hold spine
straight with shoulders pulled back and chin upright.
• Takes pressure off vertebrae, allowing growth of bony area in
front of vertebrae to catch up with growth in back
• Usually worn for 16-24 hours a day for one year. Only used in
patients who are still growing and is not effective for adults.
• Similar to bracing for scoliosis, but needs to extend up higher
proximally than for idiopathic scoliosis to control kyphosis.
(upper thoracic/over shoulders/neck base)
• Apex – T8 or above (Milwaukee); T9 or below (molded TL
space)
• Adolescents find bracing difficult - uncomfortable, hot, rigid,
unattractive, self-conscious. (Milwaukee brace)
November 1, 2017 18
Bracing Outomes
• 50% correction should be expected with brace treatment
• Gradual loss of correction will occur when the use of the brace
is discontinued.
– 15° loss of correction at 18 months after brace therapy. Sachs, et al.,[26]
– poor success rate for brace treatment in patients in whom kyphosis was
greater than 75°.
• generally not indicated in the skeletally mature patient because
it does not alter the natural history of curvature progression.
November 1, 2017 19
Current Literature on Bracing
• 56 adolescents, mean age 14 y.o., with
thoracic Scheuermann’s kyphosis were
treated with the kyphologicTM brace.
11/1/2017 20
– The average Stagnara angle at presentation
was 55.6o and in-brace correction was 36% of
initial angle (p<0.001). Mean in-brace Stagnara
angle was 39o. (Weiss et al. Scoliosis 2009).
• A retrospective study was conducted of 120 patients, with different angles of
Scheuermann’s kyphosis, treated with Milwaukee brace and physiotherapy.
– Mean angle of kyphosis at presentation was 63o.
– Mean angle of kyphosis was 36.5o after treatment for all patietnts
– Mean improvement for patients <75o at presentation was 25.3o (p<0.001)
– Mean improvement for patients at or >75o at presentation was 26.7o
(p<0.001). (Etemadifar et al. J Craniovertebr Junction) Spine 2017).
Risk of Progression
• 197 patients with Scheuermann’s kyphosis were treated with
Milwaukee brace. (Bradford et al. JBJS 1975)
– 96% had progression pre-bracing
– 70% had progression after maturity
– In those that completed treatment for over 3 years (n=75),
40% had improvement in kyphosis and 45% had
improvement in vertebral wedging.
• Failures were for (1) patient cooperation; (2) dorsal vertebral wedging
greater than 10o in more than 1 vertebra; (3) the presence of skeletal
maturation; (4) initial dorsal kyphosis >65o.
11/1/2017 21
Indications for Surgery
• Pain in kyphotic area (TL & L > Thoracic)
• Pain in compensatory cervical / lumbar lordosis
• Curves > 75º or rapidly progressing curves > 60º
• Altered respiratory function (>110º curves)• Stagnara 1982
Operative Treatment
Goals:• Reduction of thoracic hyperkyphosis
• Sagittal balance maintenance/ correction
• Pain relief
Options:• Anterior Alone
• Combined - Open
• Combined – Thoracoscopic
• Posterior Alone – Current Trend: Posterior alone
– Reserve ant. Release/ fusion for larger stiffer curves
Anterior Surgery Alone
Interbody structural
support• Femoral ring allograft
• Titanium surgical mesh and autograft
• Synthetic ramps/cages
• Instrumentation
Anterior - Scheuermann’s
• 28 patients
• Age 14 – 36
• Indications pain / cosmetic
deformity
• Minimum follow up 2 years
(range 2 – 6)
• Pre-op 88º (range 74º - 98º)
• Post-op 47º (range 46º - 50º)
• Final follow-up 48º - 55º
Gaines RW, Marks DS, Thompson AG, Ohlin A, Moller H, Min K, Finch G. SRS Annual meeting, Buenos Aires 2004
Follow-up
(2 yrs)
Posterior Surgery
• Bradford (1975), Kostuick (1990) loss of correction /pseudarthrosis
• Cotrel (1978), Hall (1990) use of more powerful compression systems reduced loss of correction
• Ponte (1985) routine re-exploration at 3 months reduced pseudarthrosis
• Ponte (1996) multi level closing wedge osteotomy
• Harms (1998) multi segmental pedicle screws
• Lenke (2005) multi level pedicle screw with posterior osteotomy
Lenke
Posterior Alone
• Kyphosis corrects to < 50° on hyperextension in skeletally immature
patients
• Elderly patient when the goal is pain relief and not deformity correction
• Potential posterior complications:
– loss of correction, pseudarthrosis, failure of instrumentation, neuro
deficit, excessive blood loss, infection, sagittal imbalance
Fusion Levels:Upper vertebral level of the kyphosis (T1 or T2)
First lordotic segment distally
Basic Construct
– Double-Rod Multisegment Hook Systems
• Two double level claws (pediculo-transverse) above
• Pedicle hook and two-laminar claw below
• All pedicle screws
– Correction achieved by:
• Cantilever mechanism
• Segmental compression following segmental posterior column shortening by multiple osteotomies
Posterior Alone
Lim et al (2004):– Review of 23 consecutive
patients:• 20 pts underwent combined AP
fusion with ant release & posterior multisegmental instrumentation
• 3 pts underwent PSF with multisegmental instrumentation
– Kyphosis: 83°→ 46 °→ 51° at follow up
– Complications: 43% minor; 17% major; 0% life threatening
– Multisegmental instrumentation- safe & effective treatment
Combined: Open Technique
11/1/2017 34
Surgical Treatment of Scheuermann’s Kyphosis Using a Combined Antero-posterior Strategy and Pedicle Constructs: Efficacy,
Radiographic and Clinical Outcomes in 111 Cases
Koller at al Eur Spine J 2014
• Consecutive series of Scheuermann Kyphosis patients treated with anterior release and posterior fusion.
• 111 Patients, mean age 23 years old, were included for an average follow-up of 24 months.
• Average Cobb angle at fusion was 68o; 37o post-operatively. – Preoperative bending films were highly correlated with
postoperative and follow up Cobb angles (r=0.7, p<0.05)
– Increased junctional kyphosis angle (JKA + 1) was associated with a higher risk of revision surgery (p=0.049).
– Increased fused segments was negatively correlated with SRS-24 self-image scores (r=-0.5, p<0.05).
Herrera-Soto et al (2005):– Review of 19 skeletally mature
patients (17.4 yrs) having undergone video-assisted thoracoscopic anterior release combined with PSF
– 8.3 disc released anteriorly; 13 levels fused posteriorly
– Kyphosis: 84.8°→ 43.7 °→ 45.3° at follow up
– Complications: pleural effusions (2); pneumothorax (2); inferior hook out (1)
– Viable treatment option for more severe & rigid curves
Combined technique:
Thoracoscopic
Johnston et al (2005):• Retrospective review
• 27 patients with 24-56 months FU
– Group 1 (20 pts) → PSF only
– Group 2 (7 pts) → Ant. release & fusion of 5-7 apical segments
• No difference in sagittal plane measures nor correction (Group 1=53%, Group 2=46% correction)
• No difference in correction from immediate post op & fu
Posterior vs AP Combined
Lee et al (2005):
• Results of 18 posterior only pts to 21 AP combined pts (AP)
– Similar average age, pre-op kyphosis, PSF levels, SRS scores
• Kyphosis correction at FU
– 51.8% (PO) vs 38.5% (AP), p<0.001
• Complications → 0/18 pts (PO) vs 8/21 pts (AP)
• Posterior only achieved & maintained better correction & had less
complications
11/1/2017 37
Operative Management of Scheuermann’s Kyphosis in 78 Patients
Lonner et al. Spine 2007
• 78 patients with Scheuermann’s Kyphosis were included in this study.
• Mean age 16.7 years old.
– Overall mean preoperative Cobb kyphosis 78.8o; mean postoperative Cobb 51.4o.
• 42 underwent combined anteroposterior
– Mean preoperative Cobb 82.6o for this group; mean postoperative Cobb 55.8o
• 36 had posterior alone
– Mean preoperative Cobb 74.4o; mean postoperative Cobb 46.2o.
• Proximal and distal junction kyphosis >/=10o occurred in 25 (32.1%) and 4 (5.1%), respectively.
– Among PJK, the magnitude of junctional kyphosis correlated directly with pelvic incidence and indirectly with percent correction.
Posterior w/ SPO vs. AP
11/1/2017 38
Scheuermann’s Kyphosis: Comparison Between the Posterior
Approach Associated with Smith-Peterson Osteotomy and Combined
Anterior-Posterior Fusion
Temponi et al. Rev Bras Ortop 2011
• 28 patients split into two groups:
• Group 1: AP– Mean age 19 years, preoperative kyphosis 77.6o, postoperative kyphosis
35.8o, and average correction of 53.2%.
– Mean postop pain VAS=0.6
• Group 2: Posterior + SPO – Mean age 27.3 years, preoperative kyphosis 72.9o, postoperative
kyphosis 44.3o, and average correction 39.3%.
– Mean postop pain VAS=0.5
• Both techniques were adequate in treating SK.
• Deformity correction and pain was greater in AP
Surgical Controversy
• Comparison of Scheuermanns kyphosis correction posterior only pedicle screws versus anterior release and posterior hybrid
• Lee SS Lenke LG Bridwell KH et al SRS 2005
• ‘Better radiological correction with pedicle screws only, 38% implant complication rate with AP Hybrid BUT no clinical difference between the groups at 2 years’
• Operative management of Scheuermanns kyphosis in 78 patients• Newton PO, Sponseller P, Lenke LG, Crawford AH et al SRS 2005
• ‘Loss of correction was less with anterior / posterior BUT the degree of correction with posterior only screws was better’
• Surgical correction of sagittal plane deformity in Scheuermanns kyphosis
• Grevitt MP Mehdian SH Webb JK et al SRS 2001
• ‘Combined anterior and posterior surgery gave better overall correction and maintenance of correction than posterior pedicle screw alone’ (Stiffer curves – bend to >45º - AP / flexible curves – bending to <45º posterior only)
11/1/2017 40
Complications of Spinal Fusion for Scheuermann Kyphosis: A Report of the Scoliosis Research Society Morbidity and
Mortality Committee
Coe et al. Spine 2010
• Retrospective multicentre database study. 683 procedures involving spinal fusion for Scheuermann Kyphosis were included
• Mean patient age was 21 years. 73% were </= 19 years old.
• 338 (49%) were posterior spinal fusions (PSF)
• 73 (11%) were anterior spinal fusions (ASF)
• 272 (40%) same-day ASF+PSF
• 99 complications were reported (14%)
– Wound infection (3.8%)
– Acute neurologic complication rate (1.9%) including 4 spinal cord injuries (0.6%)
– Mortality rate was 0.6%
• Complications were more common among adults (22%) compared with pediatric patients (12%) (p=0.002)
• Overall incidence of complications did not differ significantly between the PSF (14.8%) and same-day ASF/PSF (16.9%) (p=0.5)
Junctional Kyphosis
• Complications of surgical management of Scheuermanns kyphosis
• Crawford AH, Morley TR et al SRS 1998
• ‘Post operative distal junctional kyphosis was reduced by including the first lordotic disc in the fusion’
• Operative management of Scheuermanns kyphosis in 78 patients
• Newton PO, Sponseller P, Lenke LG, Crawford AH et al SRS 2005
• ‘Proximal junctional kyphosis related to pelvic incidence’
• Proximal junctional kyphosis in patients following treatment for Scheuermanns kyphosis – what are the risks?
• Sun EC et al
• 27% PJK at 5 years was not related to magnitude of curve correction but to flavum or ligament disruption and UIV level
11/1/2017 42
Anterior Release for Scheuermann’s Disease: A Systematic Literature Review and Meta-analysis
Yun C, Shen CL. Eur Spine J 2017
• Systematic review for outcomes of anterior release and posterior fusion (AP), or posterior-only surgery (PO).
• 23 studies met inclusion criteria, with a total of 711 patients. Mean follow-up was 42.4 months.
• Pooled correction loss
– AP: 4.1 (3.4, 4.8)
– PO: 3.8 (3.3, 4.4)
• Median blood loss
– AP: 2156 ml (910-3150)
– PO: 823 ml (620-1086)
• Median operative time
– AP: 325 min (307-662)
– PO: 243 (141-378)
• PJK
– AP: 17.7% (0-31.3%)
– PO: 6.3% (0-16.7%)
• DJK
– AP: 21% (0-33.3%)
– PO: 6.4% (0-37.5%)
• Self-image improvement
– AP: 63.5% (31.3-100%)
– PO: 63.5% (31.3-100%)
• Pain relief
– AP: 70.7% (31.3-100%)
– PO: 51.7% (33.3-100%)
• Need for reoperation
– AP: 16.4% (6.7-40.9%)
– PO: 10.3% (0-22.7%)
• PO and AP had comparable correction loss. Meta-analysis regression demonstrated correction loss decreased over each decade—possibly due to improvements in instrumentation and surgical technique.
• PO group had advantages in blood loss, surgical time, PJK and DJK
Outcomes
The Natural History and long term follow-up of Scheuermanns kyphosis
Murray PM, Weinstein SL et al JBJS 75A 1993:236-248
• 67 patients with 32 years follow-up
• No difference in pain / ADL / Fatigue / Self esteem /
• employment / sick leave for back pain or sciatica /
• psychiatric disorders compared to controls
• The site and intensity of pain were different, they had jobs with less physical requirement compared to controls and had less extension
• Kyphosis of <100 had normal pulmonary function
Outcomes
• Long term follow-up of patients treated for Scheuermanns Kyphosis
• Soo C L, Esses S I SRS Ottowa 1996
• 63 pts.14 year FU. No difference between Observation
• Bracing / Surgery in any of the assessed domains
• Average increase in kyphosis of 22º in the surgical group at final FU (note Harrington posterior instrumentation only)
• 94% all patients, regardless of treatment regime, worked without restriction
• Patients treated by bracing or surgery reported that their self image was better however there was no radiological support for this
• Pts with >70° kyphosis had inferior functional results
Sagittal Stable Vertebrae (SSV) Method
Distal Fusion Level Selection in Scheuermann’s Kyphosis: A
Comparison of Lordotic Disc Segment Versus the Sagittal Stable
Vertebrae
Kim HJ et al Global Spine J 2017
11/1/2017 45
• 44 patients divided into 2 groups:
– Group 1 (n=26) had distal lowest instrumented vertebra (LIV) distal to or at the level of the
sagittal stable vertebrae (SSV)
– Group 2 (n=18) LIV was proximal to the SSV
• Mean follow-up 3.1 years, no difference in demographics between groups
• Group 1 had greater average lordotic disc angle below LIV compared to
Group 2 (p=0.02).
• Subgroup analysis demonstrated extending fusions to the SSV rather than
first lordotic disc resulted in fewer distal LIV complications requiring revision
vs. fusing proximal to SSV