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Scheuermanns Disease
From WikiSM
Contents
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
- Vertebral Body
- Wedged anteriorly, typically in adjacent fashion
- Anterior Longitudinal Ligament may be thickened
- Intervertebral Disc may be narrowed
Risk Factors
- Unknown
Differential Diagnosis
- Fractures
- Neurological
- Musculoskeletal
- Autoimmune
- Infectious
- Pediatric
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
- Type I (Classic) - Thoracic spine involvement only, with the apex of curve T7-T9
- Degree of kyphsosis
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
- For short term relief
- NSAIDS, Acetaminophen
- 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
- Internal
- External
- Sports Medicine Review Back Pain: https://www.sportsmedreview.com/by-joint/back/
References
- ↑ 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.
- ↑ 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.
- ↑ Lowe TG. Current concepts review: Scheuermann disease. J Bone Joint Surg Am. 1990;72:940-945.
- ↑ https://now.aapmr.org/scheuermanns-disease/
- ↑ 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.
- ↑ Ryan MD, Taylor TK. Acute spinal cord compression in Scheuermann’s disease. J Bone Joint Surg Br. 1982;64:409-412.
- ↑ 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.
- ↑ 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.
- ↑ 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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