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Scheuermanns Disease

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Other Names

  • Osteochondrosis of the Vetebral Endplate
  • Avascular Necrosis of the Vetebral Endplate
  • Avascular Necrosis of the Inferior Vetebral Endplate
  • Avascular Necrosis of the Superior Vetebral Endplate
  • Scheuermann kyphosis
  • Juvenile kyphosis
  • Juvenile discogenic disease

Background

  • This page describes Scheuermann's Disease (SD), a condition of hyperkyphosis of the spine due to anterior wedging of the vertebral bodies and discs

Definition

  • Diagnosis is made by anterior wedging of greater than or equal to 5° in 3 or more adjacent vertebral bodies
    • Note that this is generally accepted but not universally agreed upon

History

Epidemiology

  • Prevalence is between 1% to 8% in the United States[1]
  • Male > Female with a ratio of 2:1[2]
  • Most commonly diagnosed between ages 12 and 17 (need citation), rarely diagnosed under age 10

Pathophysiology

  • General
    • Diagnosis is typically made between the ages of 12 and 17 years
    • Parents tend to notice a postural or "hunchbacked" appearance
    • Patients may also endorse back pain
  • Discordant vertebral end plate mineralization and ossification during growth
    • Leads to asymmetric vertebral body growth and wedge-shaped vertebral bodies
    • 3 adjacent vertebral wedged vertebral bodies > 5° is pathognomonic
  • The thoracic spine is most commonly affected, followed by the lumbar spine
    • Rigidity of curve distinguishes from postural kyphosis
  • The exact etiology is poorly understood, likely multifactorial and theories include[3]
    • Autosomal dominant component has been demonstrated in twin studies
    • Avascular or osteonecrosis of anterior apophyseal ring
    • Herniation of disc material leading to loss of anterior height
    • Abnormal collagen and proteoglycan ratio
    • Dural cysts
    • Biomechanical stress
    • Increased HGH secretion
    • Osteoporosis due to dysfunction of calcium metabolism
    • Inflammatory disease
    • Hypovitaminosis

Associated Conditions

Pathoanatomy


Risk Factors

  • Unknown

Differential Diagnosis


Clinical Features

  • History
    • Up to 50% of patients will endorse lower back pain, more commonly in thoracolumbar deformities than isolated thoracic
    • Most will have some sort of cosmetic or postural deformity
    • Clothes may fit differently, shoulders appear more rounded
    • Typically no inciting event
  • Physical Exam: Physical Exam Back
    • Inspection will identify a rigid, kyphotic or even hyperkyphtoic curve
    • Typically accentuated by forward bending
    • Curve does not resolve with extension, prone or supine
    • May also identify cervical or thoracic lordosis, scoliosis or tight hamstrings
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Lumbar Spine, Standard Radiographs Thoracic Spine
    • Imaging modality of choice initially
    • Consider imaging the entire spine regardless of symptom location
  • Findings on lateral view
    • Rigid hyperkyphosis > 40°
    • Anterior wedging > 5° on 3 or more adjacent vertebral bodies
    • Does not improve with hyperextension
  • Other findings
    • Irregular vertebral endplates
    • Schmorl nodes
    • Loss of disc space height
    • Scoliosis
    • Spondylolysis/spondylolisthesis
    • Disc herniation
    • Schmorl nodes: herniation of disc into vertebral endplate
  • Cobb technique
    • Used to measure angle between endplates
    • Use tilt angle of of the end vertebral bodies that are most tilted in the kyphotic deformity, both proximally and distally on AP radiographs[4]

MRI

  • Can be useful to better evaluate soft tissue injuries
  • Useful for pre-operative planning

CT

  • Avoid if possible in pediatric population

Other

  • Consider checking pulmonary function tests to assess lung function

Classification

  • Levels of involvement
    • Type I (Classic) - Thoracic spine involvement only, with the apex of curve T7-T9
      • Most common, better prognosis
    • Type II - Thoracic and lumbar involvement, with the apex of curve T10-T12
      • Less common
      • Associated with increased back pain, progression, severity
  • Degree of kyphsosis
    • Normal is 20° - 40°
    • Pathologic is > 40°
    • Around 95° can cause neurologic injury, myelopathy[5]
    • Case reports of neurologic compromise as low as 53°[6]
    • Curves > 100° can lead to restrictive lung disease[7]

Management

Prognosis

  • One third of the patients with curves of 74° or more failed bracing and progressed to surgery[8]
  • Research shows 60-90% improvement of pain with surgery (need citation)
  • Studies suggest residual curves >75° lead to worse functional outcomes (need citation)

Nonoperative

  • Indications
    • Kyphosis less than 60°
    • Asymptomatic
  • Medications
  • Activity modification
  • Physical Therapy
    • Emphasis on stretching, core strengthening
  • Extension bracing
    • Consider in patients with at least 45° of kyphosis, more commonly 60° - 80°
    • Options include Milwaukee Brace, Kyphologic Brace, Boston Brace
    • Anticipate approximately 50% correction with brace, slowing of progression
    • Compliance can be challenging
  • Follow up
    • Annual follow up imaging should be obtained to monitor child

Operative

  • Indications
    • Kyphosis > 75° with unacceptable deformity or pain
    • Neurological deficit or myelopathy
    • Refractory pain
  • Technique
    • Smith-peterson osteotomy
    • Anterior release
    • Fusion

Rehab and Return to Play

Rehabilitation

  • Emphasis on restoring normal lordosis
  • Maintain tolerated cross training program
  • As athletes pain improves, expand to full conditioning program

Return to Play

  • Degree of symptoms will help dictate return to play
    • Symptomatic athletes may struggle to return to sports
    • Some athletes, such as gymnasts will only have disc and end plate changes without kyphosis and may be able to return to full athletics[9]
  • Many sports can be played with the brace on
    • May be able to be out of brace for sport, in brace when not participating

Complications

  • Chronic Back Pain
  • Progressive cosmetic deformity
  • Less commonly neuro defecits or myelopathy
  • Surgical complications
    • Pseudoarthrosis
    • Persistent pain
    • Neurological complications
    • Distal junctional kyphosis in up to 30% of patients
    • Proximal junctional kyphosis
    • Hardware failure
    • Superior mesenteric artery syndrome

See Also


References

  1. Makurthou AA, Oei L, El Saddy S, Breda SJ, Castaño-Betancourt MC, Hofman A, van Meurs JB, Uitterlinden AG, Rivadeneira F, Oei EH. Scheuermann disease: evaluation of radiological criteria and population prevalence. Spine. 2013 Sep 01;38(19):1690-4.
  2. Damborg F, Engell V, Andersen M, Kyvik KO, Thomsen K. Prevelence, concordance, and heritability of Scheuermann kyphosis based on a study of twins. J Bone Joint Surg Am. 2006;88:2133-2136.
  3. Lowe TG. Current concepts review: Scheuermann disease. J Bone Joint Surg Am. 1990;72:940-945.
  4. https://now.aapmr.org/scheuermanns-disease/
  5. onstein JE, Winter RB, Moe JH, et al. Neurologic deficits secondary to spinal deformity. A review of the literature and report of 43 cases. Spine (Phila Pa 1976). 1980;5:331-355.​
  6. Ryan MD, Taylor TK. Acute spinal cord compression in Scheuermann’s disease. J Bone Joint Surg Br. 1982;64:409-412.
  7. Murray PM, Weinstein SL, Spratt KF. The natural history and long-term follow-up of Scheuermann kyphosis. J Bone Joint Surg Am. 1993;75:236-248.
  8. Sachs B, Bradford D, Winter R, et al. Scheuermann kyphosis. Follow-up of Milwaukee-brace treatment. J Bone Joint Surg Am. 1987;69:50-57.​
  9. D’ Hemecourt, P. A., & Hresko, M. T. (2012). Spinal Deformity in Young Athletes. Clinics in Sports Medicine, 31(3), 441–451.
Created by:
John Kiel on 30 June 2019 20:52:41
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Last edited:
6 October 2022 00:02:29
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