Scheuermann kyphosis, also known as Scheuermann disease, juvenile kyphosis, or juvenile discogenic disease, is self-limiting skeletal neuromuscular with the orthopedic abnormal condition of hyperkyphosis or bending forward that involves the vertebral bodies and discs of the spine identified by anterior wedging of greater than or equal to 5 degrees in 3 or more adjacent vertebral bodies. The thoracic spine is most commonly involved, although involvement may also include the thoracolumbar/lumbar region as well [rx]. Scheuermann’s disease vertebrae grow unevenly with respect to the sagittal plane; that is, the posterior angle is often greater than the anterior vertebral angle. This uneven growth results in the signature “wedging” shape of the vertebrae, causing kyphosis of the spine. It is named after Danish surgeon Holger Scheuermann.[rx][rx][rx]
Causes of Scheuermann Kyphosis
The exact cause is not currently known, and the condition appears to be a multifactorial and genetic condition.[rx] Several candidate genes (such as FBN1, which has been associated with Marfan) have been proposed and excluded using the disease.[rx]
The front of the spine stops growing, while the back of the spine continues to grow, forming a wedge-shaped vertebra. This condition may be considered to be congenital or may be developed because of osteoporosis at a younger age, due to heavy lifting, cerebral palsy, and posture problems.
Symptoms of Scheuermann Kyphosis
Scheuermann’s disease is notorious for causing lower and mid-level back and neck pain frequently found, which can be severe and disabling. The sufferer may feel pain at the apex of the curvature of the spine, which is aggravated or increased by physical activity and by periods of standing or sitting; this can have a significantly detrimental effect on their lives as their level of activity is curbed by their disability. The sufferer may feel isolated or uneasy amongst their if they are children, depending on the level of deformity.
- The distinction between poor posture and Scheuermann’s Kyphosis is that Scheuermann’s curve is much more rigid and the Hyperkyphosis doesn’t reverse with hyperextension may be painful.
- Rounded back frequently causes back pain.
- Back pain is located over the apex of kyphosis.
- Back pain and pelvic pain involve the lower lumbar spine when excessive lordosis is present.
- Non-radiating pain.
- Physical disability.
- Decreased range of motion/strength in the back.
- Repeated lung disease with curvature greater than 90°.
- Hamstring tightness is most common
- Scoliosis.
- Lumbosacral spondylolisthesis.
- Disc degeneration.
- Decreased participation in athletic activity.
- Increased BMI is correlated with kyphosis magnitude.
In addition to the pain associated with Scheuermann’s disease, many sufferers of the disorder have a loss of vertebral height and depending on where the apex of the curve is, may have a visual ‘hunchback’ or ’round back shape are found. It has been reported that curves in the lower thoracic region cause more pain than upper parts, whereas curves in the upper region present a more visual deformity. Nevertheless, it is typically pain or cosmetic surgical reasons that prompt sufferers to seek help for their condition. In some studies, kyphosis is better characterized for the thoracic spine than for the lumbar spine.[rx][rx]
Diagnosis of Scheuermann Kyphosis
History and physical along with x-ray AP/lateral radiographs comprise the essential components for evaluating Scheuermann kyphosis. Lateral radiographs are required for diagnosis and diagnostic criteria including the following [rx]:
- Rigid hyperkyphosis, greater than 40 degrees
- Anterior wedging are found greater than or equal to 5 degrees in three or more adjacent vertebral bodies
Technique for Determining Degree of Kyphosis on Lateral Imaging
- The line is drawn along the superior endplate of the vertebrae most tilted vertebrae on the cephalad portion of the kyphotic curve
- The line is drawn along the inferior endplate of the most tilted vertebrae on the caudal portion of the kyphotic curve
- The angle formed by the intersection of lines perpendicular measurement to the above-described lines is the measured Cobb angle
Technique for Determining Degree of Anterior Wedging on Lateral Imaging
- The line is drawn from posterior to anterior along the superior endplate are visible
- The line is drawn from posterior to anterior along the inferior endplate
- The angle formed by the intersection of these lines anteriorly is the measured Wedge angle
Other Associated Findings Noted on AP/Lateral Radiographs
- Irregular vertebral endplates
- Schmorl nodes
- Loss of disc space height
- Scoliosis
- Spondylolysis/spondylolisthesis
- Disc herniation
Although typically not a necessity, MRI can be helpful to further evaluate anatomic changes or for pre-operative planning. CT imaging is usually not needed. There are also no specific laboratory tests or histologic findings necessary for the diagnosis of Scheuermann kyphosis.[rx][rx]
A physical exam for diagnosing disc pain may include one or more of the following tests
- Palpation – Palpating (feeling by hand) certain structures can help identify the pain source. For example, worsened pain when pressure is applied to the spine may indicate sensitivity caused by a damaged disc, Scheuermann kyphosis, diffuse idiopathic skeletal hyperostosis, and disc desiccation.
- Movement tests – Tests that assess the spine’s range of motion may include bending the neck or torso forward, backward, or to the side. Additionally, if raising one leg in front of the body worsens leg pain, it can indicate a Scheuermann kyphosis.
- Muscle strength – A neurological exam may be conducted to assess muscle strength and determine if a nerve root is compressed by Scheuermann kyphosis. A muscle strength test may include holding the arms or legs out to the side or front of the body to check for tremors, muscle atrophy, or other abnormal movements, etc.
- Reflex test – Nerve root irritation can dampen reflexes in the arms or legs. A reflex test involves tapping specific areas with a reflex hammer. If there is little or no reaction, it may indicate a compressed nerve root in the spine, Scheuermann kyphosis.
- Physical examination – should include assessment of sensation with pinprick and touch in the upper extremity, thorax, and abdomen in the dermatomal regions mentioned above to check for radiculopathy and also in the lower extremity to check for myelopathy. Also, for the lower extremity, proprioception and reflexes and toned should be evaluated.
Lab Test
- Laboratory testing – may include white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).
- Elevated ESR – could indicate infection, malignancy, chronic disease, inflammation, trauma, or tissue ischemia.
- Elevated CRP – levels are associated with infection.
Imaging
- X-rays – view the bony vertebrae in your spine and can tell your doctor if any of them are too close together or whether you have arthritic changes, bone spurs, osteophyte formation, diffuse idiopathic skeletal hyperostosis, thoracic discogenic pain syndrome, Scheuermann kyphosis, or fractures narrowing of the spinal canal. It’s not possible to diagnose diffuse idiopathic skeletal hyperostosis, thoracic discogenic pain syndrome, disc desiccation with paracentral disc herniation in this test alone.
- Magnetic Resonance Imaging (MRI) scan – It is a noninvasive test that uses a magnetic field and radiofrequency waves to give a detailed view of the soft tissues of your spine with thoracic discogenic pain syndrome, diffuse idiopathic skeletal hyperostosis, Scheuermann kyphosis, and paracentral disc herniation. Unlike an X-ray, nerves and discs are clearly visible. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. An MRI can detect which disc is damaged and if there is any nerve compression disc desiccation, diffuse idiopathic skeletal hyperostosis. It can also detect bony overgrowth, spinal cord tumors, abscesses, or narrowing of the spinal canal.
- A myelogram – It is a specialized X-ray where dye is injected into the spinal canal through a spinal tap. An X-ray fluoroscope then records the images formed by the dye color. The dye used in a myelogram shows up white on the X-ray, allowing the doctor to view the spinal cord and canal, thoracic discogenic pain syndrome, a bulging disc paracentral disc herniation, disc desiccation in detail, or Scheuermann kyphosis. Myelograms can show a nerve being pinched and a bulging disc by a herniated disc, bony overgrowth, narrowing of the spinal cord tumors, disc desiccation, thoracic discogenic pain syndrome, Scheuermann kyphosis, and abscesses.
- Computed Tomography (CT) scan – It is a noninvasive test that uses an X-ray beam and a computer to make 2-dimensional images of your spine. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. This test is especially useful for confirming which bulging disc and narrowing of the spinal canals are damaged, Scheuermann kyphosis, thoracic discogenic pain syndrome.
- Electromyography (EMG) & Nerve Conduction Studies (NCS) – EMG tests measure the electrical activity of your muscles. Small needles are placed in your muscles, and the results are recorded on a special machine. NCS is similar, but it measures how well your nerves pass an electrical signal from one end of the nerve to another. These tests can detect nerve damage and muscle weakness and a bulging disc, disc desiccation, thoracic discogenic pain syndrome, Scheuermann kyphosis, paracentral disc herniation.
- Discogram – A discogram may be recommended to confirm which bulging disc is painful if surgical treatment is considered. In this test, the radiographic dye is injected into the disc to recreate disc pain from the dye’s added pressure. Electrodiagnostic evidence of fibrillation potentials and the absence of a tibial H-wave may aid in further confirming the diagnosis of lumbar canal stenosis, thoracic discogenic pain syndrome, and disc desiccation.[rx]
Treatment of Scheuermann Kyphosis
Non-Pharmacological
- Exercise and physical therapy – These are essential for getting back pain under control and improving stiffness and range of motion. Swimming is especially beneficial because it provides a full-body workout without the risk of injury. Physical therapy can reduce the stiffness associated with thoracic discogenic pain syndrome, Scheuermann kyphosis. Exercises might also increase the range of motion in your joints. Ask your doctor about specific exercises you can do. He or she might refer you to a physical therapist for further guidance.
- Heat – This can help relieve early-morning pain and stiffness.
- Stretching – Therapy regimens aim to strengthen back and core musculature while stretching the hamstring muscles. No study has clearly shown that this is an efficacious treatment, but, in theory, it can work to decrease lumbar lordosis. It is less clear if stretching and therapy have any effect on a rigid kyphosis.
- Bracing – Bracing is the mainstay of non-operative management. Patients with mild-to-moderate kyphosis (<75 degrees) may consider a trial of a conservative treatment to control symptoms and minimize deformity. A kyphosis brace applies three-point bending forces that decrease thoracic kyphosis. In skeletally immature patients with thoracic kyphosis greater than 45 degrees and less than 75 degrees, bracing can be considered. Studies on the efficacy of bracing in this population do not provide convincing supportive evidence and the discomfort of the brace limits patient compliance.
- Weight and blood sugar control – Because Scheuermann kyphosis is often associated with obesity and diabetes, keeping your weight and blood sugar in a healthy range is key. Treating these conditions is the closest thing to a cure for Scheuermann kyphosis.
- Orthotics (special shoe inserts) – These may make walking easier if you have bone spurs on your Scheuermann kyphosis
- Stay hydrated – Not drinking enough water each day can cause the body to function less well or not retain enough water, including the discs, thoracic discogenic pain syndrome, Scheuermann kyphosis, and diffuse idiopathic skeletal hyperostosis.
- Don’t smoke – Cigarette use can directly affect the discs in the back and increase the rate of disc degeneration, thoracic discogenic pain syndrome, Scheuermann kyphosis.
- Maintain a healthy weight – Being overweight or obese puts extra pressure on the back and spine, which can cause desiccation, Scheuermann kyphosis, and decay of the intervertebral discs.
- Take regular exercise – Participating in regular cardio and weight-training exercises can strengthen the bones and muscles and promote a good range of motion in the back. People can ask their doctor or a physical therapist for specific exercises that support the back muscles.
- Spine-Specialized physical therapy – typically includes a combination of stretching, strengthening, and aerobic exercise to provide better stability and support for the spine.
- Massage therapy – can help reduce muscle tension and muscle spasms, which may add to back or neck pain. Muscle tension is especially common around an unstable spinal segment where a disc is unable to provide the necessary support
- Ice & Moist Heat Application – Ice application where the ice is wrapped in a towel or an ice pack for about 20 minutes to the affected region, thrice a day, helps in relieving the symptoms of a disc bulge. Heat application in the later stages of treatment also provides the same benefit.
- Use of lumbosacral back support – Generally, back braces are categorized as flexible, semi-rigid, and rigid. Rigid braces tend to be used for moderate to severe cases of pain and/or instability, such as to assist healing of spinal fractures or after back surgery. Semi-rigid and flexible braces are used for more mild or moderate pain.
- Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal back pain of all types of lumbar disc disease, thoracic discogenic pain syndrome. Therefore focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly healing PLID, Scheuermann kyphosis, and narrowing of the spinal canal. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
- In bulging disc needs ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
- Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, and salmon.
- Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
- Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items, and foods made with lots of refined sugars and preservatives.
Medications
- Analgesics – Such as paracetamol and prescription-strength drugs that relieve pain but not inflammation.
- Muscle Relaxants – These medications provide relief from spinal muscle spasms. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control muscle spasms.
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
- Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include mainly or first choice etodolac, then aceclofenac, etoricoxib, ibuprofen, and naproxen.
- Calcium & vitamin D3 – To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
- Dietary supplement – to remove general weakness & improved health.
- Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, etc.
- Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
- Oral Corticosteroid – to healing the nerve inflammation and clotted blood in the joints. Steroids may be prescribed to reduce the swelling and inflammation of the nerves. They are taken orally (as a Medrol dose pack) in a tapering dosage over a five-day period. It has the advantage of providing almost immediate pain relief within a 24-hour period.
- Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation throughout the skin.
- Steroid injections The procedure is performed under x-ray fluoroscopy and involves an injection of corticosteroids and a numbing agent into the epidural space of the spine. The medicine is delivered next to the painful area to reduce the swelling and inflammation of the nerves. About 50% of patients will notice relief after an epidural injection, although the results tend to be temporary. Repeat injections may be given to achieve the full effect. Duration of pain relief varies, lasting for weeks or years. Injections are done in conjunction with physical therapy and/or a home exercise program.
- epidural steroid injection. A steroid solution is injected into the epidural space (outer layer of the spinal canal) to reduce inflammation. This injection is by far the most common one used for herniated discs.
- Selective nerve root injection. A steroid solution and anesthetic are injected near the spinal nerve as it exits through the intervertebral foramen. This injection is also used to help diagnose which nerve root might be causing pain.
Surgery
The medical procedure is great for patients on the off chance that the nonsurgical therapy doesn’t bring back the right stance of the spine. The medical procedure is performed to fix the spine and furthermore ease torment. It is done in two methodologies; back combination and consolidated combination. In the back combination, at least two bones are melded to frame one bone. The joined combination is the combination of two medical procedures; the front and back of the spine. In the initial segment, the tendons of the spine are cut, the hazardous plate is taken out, and loaded up with bone unions which help in the bone development. In the subsequent part, spine muscles are cut and spread separated, the metal bars with snares are embedded at the edge of spine, and bone unions are embedded. The bars hold the spine with the end goal that the bone unions help in mending.
After the medical procedure, a recovery program is proposed, which incorporates fortifying and extending practices that assist to deliver the pressure of the spine muscles and further develop blood flow. These activities should be performed consistently to acquire better results.
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