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Scheuermann's kyphosis

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 Scheuermann’s kyphosis
Amy L. McIntosh and Daniel J. Sucato
Purpose of review
Scheuermann’s kyphosis is a condition characterized by
increased posterior rounding of the thoracic spine in
association with structural deformity of the vertebral
elements. Currently, there is debate over whether anterior
procedures are necessary in the surgical treatment of
Scheuermann’s kyphosis.
Recent findings
Nonoperative treatment is reserved for skeletal immature
patients (Risser 2 or less) with a progressive deformity that
is cosmetically or functionally unacceptable. Surgical
indications for Scheuermann’s kyphosis should be
assessed on a case-by-case basis, but in general patients
with pain, a rigid deformity, a curve of more than 70–758,
progressive deformity and an unacceptable cosmetic
appearance are surgical candidates. Newer technologies,
such as third generation segmental instrumentation, in
combination with compression rod techniques have nearly
eliminated the need for combined anterior–posterior
procedures. When an anterior procedure is deemed to be
necessary, prone video-assisted thoracic surgery anterior
release and fusion is an attractive alternative to formal open
anterior release to provide the anterior release, followed by
posterior correction and then placement of structural graft.
Summary
Combined anterior–posterior procedures are rarely
necessary with current spine instrumentation and
techniques. Proper fusion level selection, avoidance of
adjacent posterior ligamentous tension band resection, and
preventing overcorrection will limit junctional kyphosis.
Keywords
Scheuermann’s kyphosis, treatment
Curr Opin Orthop 18:536–543.
ß 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Mayo Clinic/Texas Scottish Rite Hospital for Children, Rochester, Minnesota, USA
Correspondence to Dr Amy Lynn McIntosh, MD, Mayo Clinic/Texas Scottish Rite
Hospital for Children, 200 First St SW, Mayo Building 14th Floor, Rochester,
MN 55905, USA
Tel: +1 507 284 2511; fax: +1 507 266 4234; e-mail: mcintosh.amy@mayo.edu
Current Opinion in Orthopaedics 2007, 18:536–543
Abbreviations
TLSO thoracolumbar-sacral orthosis
VATS video-assisted thoracic surgery
ß 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins
1041-9918
536
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Introduction
Increased kyphosis, or humpbacked deformity, refers to
posterior rounding of the spine when viewed from the side.
Normal thoracic kyphosis from T5 to T12 ranges from 20 to
458 (Cobb’s angle) [1]. Scheuermann’s kyphosis is a con-
dition characterized by increased posterior rounding of the
thoracic spine in association with structural deformity of
the vertebral elements [2]. In 1920, Scheuermann ident-
ified the radiographic characteristics of a fixed angular
kyphosis with anterior wedging of the vertebral bodies
and irregularities of the vertebral apophyses [3].
This deformity, initially described only for the thoracic
spine (more common), can also occur in the thoraco-
lumbar and lumbar spine. Thoracic and thoracolumbar
Scheuermann’s kyphosis are defined by the location of
the apex of the deformity. In the thoracic type, the apex
ranges from T7 and T9. The thoracolumbar apex ranges
from T10 and T12. Lumbar Scheuermann’s disease is
characterized by the typical radiographic changes associ-
ated with Scheuermann’s kyphosis but may only demon-
strate clinical loss of the normal lumbar lordosis.
The cause of the condition is unknown, but multiple
theories have been suggested including osteonecrosis of
the vertebral ring apophyses, intrinsic weakness of the
cartilaginous end plate, osteochondrosis, transient osteo-
porosis, malabsorption, infection, and endocrine disorders
[2]. No signs of juvenile osteoporosis or other bony
metabolic abnormalities have been documented on histo-
pathology. Altered endochondral ossification in the
vertebral endplates, however, has been consistently found
[4]. This typical disorganized endochondral ossification is
probably a result rather than a cause of the condition.
These varied and inconsistent changes have not provided
any insight into the cause of the condition [5].
The reported incidence of Scheuermann’s kyphosis has
ranged from 0.4% to as high as 10% of adolescents
between 10 and 14 years old [6]. The condition has its
onset during the prepubertal growth spurt, becoming
apparent at around 10–12 years of age. Although we
and others [2,7] have seen a greater proportion of males
with this condition, some report equal male and female
prevalences [8].
Clinical presentation of Scheuermann’s
kyphosis
Patients seek evaluation for increased rounding of the
thoracic spine, and occasional back pain. When pain is
 Scheuermann’s kyphosis McIntosh and Sucato 537

Figure 1 Abrupt posterior angulation on forward bend
Radiographic findings for Scheuermann’s
kyphosis
Patients should be evaluated with standing posteroanter-
ior and lateral 36-inch (90 cm) spine radiographs. There is
great variability in the quality of standing lateral radio-
graphs of the spine and over or underexposure can lead
to difficulty identifying clear anatomic landmarks for
measurement of curve magnitude. In a recent study by
Stotts et al. [9] there was a 108 interobserver error in the
measurement of kyphosis on lateral spine radiographs.

The current technique used at our institution requires

the patient to stand erect with hips and knees extended,
and arms resting comfortably at shoulder height on a
crossbar positioned directly in front of them.

The posteroanterior film may demonstrate a mild sco-

liosis that rarely exceeds 258 and shows minimal vertebral
rotation. This view also allows an assessment of skeletal
present, it is commonly localized to the interscapular maturity by estimation of the Risser sign. The lateral film
area (apex of the deformity) or the lumbar area, most will demonstrate thoracic kyphosis over 408 and the
likely due to excessive lordosis with resultant facet joint radiographic criteria defined by Sörensen in 1964: more
stresses. Parental concerns usually are related to the than 58 of anterior wedging of three consecutive adjacent
cosmetic deformity, and the progressive nature of the vertebral bodies at the apex of the kyphosis; irregular
deformity. vertebral apophyseal lines, combined with flattening and
wedging; narrowing of the intervertebral disk spaces; and
On physical examination, the erect patient will demon- a variable presence of Schmorl’s nodes (Fig. 2) [10].
strate increased thoracic kyphosis with sloping shoulders.
Forward posturing of the head and neck is secondary to
Figure 2 Typical radiographic appearance of Scheuermann’s
increased cervical lordosis. Increased lumbar lordosis will kyphosis
also been seen in concert with weakened abdominal
muscles leading to a mildly protuberant abdomen. The
Adam’s forward bend test may demonstrate slight truncal
asymmetry associated with mild scoliosis. When viewed
from the side, the Adam’s test will show an abrupt
posterior angulation of thoracic spine (Fig. 1). This
deformity is not easily corrected with postural changes
or passive manipulation. The lumbar lordosis is usually
reversible, but the cervical lordosis may become fixed.
Although the nuerologic exam is normal, tight or con-
tracted hamstrings are seen in these patients.

Clinical presentation of lumbar

Scheuermann’s disease
Adolescents with lumbar Scheuermann’s disease typi-
cally present with progressive low back pain that pre-
cludes involvement in athletic activity and may interfere
with activities of daily living. They may also complain of
radiating pain into the buttocks and lower extremities,
and may have pain that awakens them from sleep.

Physical examination reveals significant loss of the nor-

mal lumbar lordosis. The flattened lumbar region is rigid
which may give the appearance of spasm. Lumbar flexi-
bility is limited and painful. No scoliosis is noted, and the
neurologic exam is normal.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 538 Pediatric orthopaedics – prosthetics and orthotics

A lateral bolster radiograph of the spine should be Figure 3 Typical radiographic characteristics of lumbar
Scheuermann’s
obtained prior to the initiation of brace or surgical treat-
ment. This radiograph is obtained by placing the patient
supine with a bolster positioned at or below the apex of
the kyphotic deformity. The patient should be resting
comfortably with their hips and knees flexed. The weight
of the freely hanging head and upper thorax provide
the force to extend the spine. Following 5 min in this
position, a lateral spine radiograph is obtained [2].

A preoperative MRI should be reviewed for patients with

atypical or rapidly progressive kyphosis, or any neurologic
signs and symptoms. Tribus reported an 18-year-old boy
who had transient paraparesis during surgical correction
of Scheuermann’s kyphosis, which was recognized after
the somatosensory evoked potentials dropped and
the patient subsequently failed a wakeup test. Severe
thoracic spinal stenosis was diagnosed postoperatively
and required decompression prior to a successful reopera-
tion with instrumented correction [11]. Other case reports
in the literature have documented thoracic compression
in association Scheuermann’s kyphosis [12,13].

Radiographic findings for lumbar

Scheuermann’s disease
Standing posteroanterior and lateral spine radiographs
should be obtained. The posteroanterior film will not
show scoliosis, but the involved vertebrae are larger in
the anteroposterior dimension than the noninvolved verte-
brae. The lateral film will show decreased lumbar lordosis
and possible kyphotic deformity at the thoracolumbar
junction. The lumbar vertebrae will be scalloped with
lucent defects at the anterosuperior corners. Schmorl’s
nodes and end plate irregularities may be seen (Fig. 3) [6].
Nonoperative treatment of Scheuermann’s
kyphosis
Indications for nonoperative treatment include relative
skeletal immaturity (Risser 2 or less) and a progressive
deformity that is cosmetically or functionally unaccep-
table (usually greater than 608). Some authors believe
that virtually any Scheuermann’s deformity can be man-
aged nonoperatively in the skeletally immature patient
[14]. The goal of nonoperative management is twofold: to
control the deformity, and to attempt to reconstitute the
anterior vertebral height by applying hyperextension
forces.
usually supplemented with anterior sternal or infraclavi-
cular outriggers to provide an extension moment cepha-
lad to the apex [15]. An advantageous feature of the
Milwaukee brace that is not available with the TLSO
is the ability to progressively bend more correction into
the posterior kyphosis pads over time.
Initially, bracing should be prescribed on a full-time
basis, with the patient allowed to remove the brace for
1–2 h per day in order to perform exercises. Radiographs
should be obtained every 3–4 months, with progressive
correction bent into the posterior kyphosis pads as tol-
erated. Brace treatment should continue until skeletal
maturity is achieved. For males this may require orthosis
wear until Risser 5. Although a weaning period from brace
wear is usually recommended, there is no statistical
evidence that a particular weaning schedule is more
efficacious than another.

Brace therapy The results of orthotic management of Scheuermann’s

For a thoracic apex (T8 or above), the Milwaukee brace is
recommended [7], as it is the only orthosis that can
effectively apply three-point corrective forces to a mid-
thoracic apical vertebra. The brace should also decrease
the lumbar lordosis and help correct the negative sagittal
balance. For a thoracolumbar deformity (at or below T9) a
thoracolumbar-sacral orthosis (TLSO) can be tried,
disease show that the deformity can be effectively
improved during brace wear; when brace wear is termi-
nated, however, a loss of correction occurs. In a series
reported by Sachs and associates [16], larger deformi-
ties (more than 748) at the start of treatment showed
the most significant loss of correction after brace discon-
tinuance, resulting in little overall correction. This

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

finding suggests that orthotic management is perhaps not
indicated for a deformity of large magnitude, but that
smaller deformities can be maintained or improved with
orthotic treatment.
Cast treatment
When passive correction on lateral bolster radiograph
is less than 40%, brace treatment is not likely to be
effective. Risser casts can be applied in a serial fashion
to produce more correction of the kyphosis. This treat-
ment regimen, used more extensively in Europe, entails
applying two or three casts (changed every 2–3 months)
in an attempt to progressively correct the deformity.
Following the 6–9-month period of casting, the
patient is then treated with a Milwaukee brace or
other type of retention brace to maintain the correction
during the remainder of the growth. With such a regimen,
not only is the deformity improved by as much as
40%, but there is less loss of correction. In a series
reported by Ponte and associates, only 48 of correction
was lost [17].
The use of cast treatment in an adolescent rests largely on
the patient’s desire to achieve maximum correction with-
out resorting to surgery. Because of the prolonged and
relatively inconvenient treatment period (6–9 months in
casts and a minimum of six additional months in a brace),
such therapy will never succeed without the total com-
pliance and desire of the adolescent.
Nonoperative treatment of lumbar
Scheuermann’s disease
Orthotic treatment is the mainstay of treatment for
lumbar Scheuermann’s disease. It allows for the relief
of pain and may halt the progressive deformity of the
spine. A TLSO is molded to encourage a more normal
lumbar lordotic contour. With brace treatment the low
back pain quickly resolves and over time the lucent
defects in the anterosuperior vertebral bodies may
improve [2].
Operative treatment
Surgical treatment of Scheuermann’s kyphosis is
reserved for patients with pain, a rigid deformity, a curve
of more than 70–758 or progressive deformity, and an
unacceptable cosmetic appearance. According to Lowe, a
kyphosis should never be reduced more than 50% of the
preoperative deformity, both to prevent neurologic com-
plications and to avoid junctional kyphoses at the ends of
the fusion [18]. Historically, the biomechanical principles
of kyphosis correction have included elongating the
anterior column of the spine, providing some form of
anterior column support, and shortening the posterior
column of the spine. Because of the first two principles,
the use of an anterior release and fusion has been
accepted as part of a standard two-stage corrective
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Scheuermann’s kyphosis McIntosh and Sucato 539
procedure. The need for the anterior procedure, however,
can be questioned when adequate correction and fusion
are achievable by a posterior procedure alone.
Determining fusion levels
Fusion levels are determined from the standing lateral
radiograph. The upper limit of fusion must include the
most proximal vertebra that is tilted into the kyphosis,
which generally means fusion to T2. If the fusion stops
distal to this level, there is a risk that a postoperative
junctional kyphosis will develop. Similarly, the caudal
extent of the fusion should include the first lordotic disk
space, which commonly includes one level distal to the
measured end vertebra of the kyphosis. Failure to extend
into the lumbar lordosis similarly risks a caudal junctional
kyphosis [19].
The concept of the ‘stable’ vertebra that is routinely used
in the determination of fusion levels for scoliosis can be
used for kyphosis [20]. On the standing lateral spine
radiograph, draw the posterior sacral vertical line. This
line is drawn from the posterior edge of the S1 body and
extended proximally until it intersects (or bisects) one of
the lumbar vertebrae (Fig. 4). The vertebra bisected
by this line is the ‘stable’ vertebra. Occasionally, the
vertebra immediately above the true ‘stable’ vertebra
can be the distal fusion level, as long as the posterior
sacral line intersects some part of the more proximal
vertebra. This is particularly true when the disk above
it is lordotic or neutral. If the disk above is in any degree
of kyphosis, the safe fusion level will have to be extended
one level more distal [20].
Anterior release and fusion technique
In rigid kyphoses of large magnitude (especially in ske-
letally mature individuals), an anterior release and fusion
of the apical portion of the deformity may be advisable to
increase the correctability by posterior instrumentation.
This allows the surgeon to balance the spine more
harmoniously and probably improve the rate of fusion
[14]. It could be argued that larger deformities not
adequately corrected by posterior instrumentation alone
went on to pseudarthrosis because the fusion mass was
under tension rather than compression.
If an anterior release and fusion procedure is elected, it is
usually performed as the first stage of a two-stage
approach, with both stages usually performed on the
same day. The release should include the rigid apical
segments (as determined on a hyperextension lateral
radiograph) and can encompass essentially the entire
thoracic spine if necessary. The release is performed
through a right-sided thoracotomy or thoracoscopically.
The right side is generally more approachable because
the cardiac structures and great vessels fall to the left of
the spine.
 540 Pediatric orthopaedics – prosthetics and orthotics
Figure 4 Posterior sacral vertical line utilized to determine
distal fusion level
Thoracotomy approach
The transthoracic approach should parallel the rib lead-
ing to the most cephalad segment to be released and
fused. For example, a fifth rib thoracotomy would be used
to reach the T5–6 disk space. Once the chest has been
entered, the parietal pleura is opened longitudinally and a
flap is created by posterior dissection to expose the
costovertebral joints. Segmental vessels should be pre-
served to avoid neurologic complications. If preserving
the vessels does not allow adequate exposure of the upper
and lower disks, it is recommended that vessels in the so-
called watershed area of the midthoracic space (T4–9) be
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ligated and divided only after they have been temporarily
occluded for 20 min, and intraoperative monitoring shows
no signal degradation from ischemia. Ligation of these
vessels can result in paraplegia due to cord ischemia,
known as anterior spinal artery syndrome. The contents
of the disk space should be evacuated and the vertebral
apophysis should be removed from the endplates. The
rib that has been resected for the thoracotomy approach
is morcellized and used as the interbody bone graft.
The pleura is then closed with running suture to achieve
hemostasis and to maintain the rib graft in the interbody
spaces.
Thorascopic anterior release and fusion
Following the success of video-assisted thoracic surgery
(VATS) for intrathoracic procedures, Mack et al. [21]
reported the application of this technique to spinal
surgery. This technique can now be considered a feasible
alternative to open thoracotomy procedures.
Anterior thoracoscopic diskectomy and fusion has been
reported as part of the two-stage treatment of Scheuer-
mann’s kyphosis [22,23] using three to four portals,
the operator removes the apical five to six disks, with
or without segmental vessel ligation. Morcellized rib or
other bone graft is inserted after curetting the vertebral
endplates. Clinical series [23,24] and animal studies
[25,26] have demonstrated that the anterior release tech-
nique results in a correction similar to that achieved
by thoracotomy.
A further development and advantage of the thoraco-
scopic technique is the ability to perform an anterior
release and fusion with the patient in the prone position
[27]. The logical advantages of this approach include
the decreased operative time because repositioning for
the posterior procedure is avoided and simultaneous
anterior and posterior surgery can be performed. Another
important advantage is the improved pulmonary status of
the patient and avoidance of postoperative complications
because single lung ventilation is avoided [27]. Addition-
ally, for kyphosis, the ability to perform a three-stage
procedure (all in the prone position) has advantages for
the kyphotic patient. Prone VATS allows for anterior
release, posterior instrumentation and correction, fol-
lowed by placement of anterior structural grafting in
the recently opened discs from the posterior correction.
Posterior instrumentation and fusion
Ferreira-Alves and associates [28] studied patients
treated with posterior fusion for Scheuermann’s
kyphosis. They found a gradual postoperative improve-
ment in kyphosis in patients under 16 years of age that
they attributed to remodeling of the anterior vertebral
wedging. If the patient is skeletally immature (less
than Risser 3) and has some anterior growth potential
 Scheuermann’s kyphosis McIntosh and Sucato 541

remaining, and if the kyphosis corrects to less than 508
on a lateral bloster radiograph, then an instrumented
posterior fusion alone may be sufficient.
The patient is placed on a standard four-poster spinal
frame, with the abdomen free and the hips flexed to
decrease lumbar lordosis. Because exposure of the upper
thoracic segments will be necessary, the patient’s head is
slightly flexed to facilitate access to T1 if necessary. With
posterior fixation, multisegment hook–screw systems
have been used to correct kyphosis. These systems allow
for segmental fixation with hooks or screws which
increase the stability of the construct.
Pedicle screw fixation has theoretical advantages over
hook fixation: the three-column support of multisegment
pedicle screw constructs provides extremely secure pur-
chase and construct stability; and the lack of iatrogenic
ligament injury required for the proper placement of
hooks, which disrupts the posterior tension band predis-
posing to junctional kyphosis [20].
The typical posterior construct includes a minimum of
eight anchors above and below the apex of the kyphosis
[29]: three to five pairs of pedicle hook–transverse
process claws cephalad to the apex of the kyphosis,
and similar number of paired pedicle screws caudad to
the apex of the kyphosis [29]. Implants should not be
placed in the canal via a laminotomy near the apex of the
kyphosis because of the risk that these implants may
protrude anteriorly during the corrective maneuver. In
fact, the rod pushes against the lamina to correct
the kyphosis.
The original instrumentation used for kyphosis correc-
tion – the Harrington compression rod system [14,30–32]
– has regained popularity in a modified form for correct-
ing kyphosis. The original Harrington compression
instrumentation was effective in obtaining correction
but there was an unacceptable loss of correction [30].
Other complications of or drawbacks to the compression
rod system included rod fracture, caudal hook pullout,
and the need for postoperative immobilization due to the

Figure 5 Skeletally mature Scheuermann’s patient treated with posterior spinal fusion: sagittal improvement from 90- to 35-

(a) Preoperative lateral. (b) Postoperative posteroanterior. (c) Postoperative lateral.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 542 Pediatric orthopaedics – prosthetics and orthotics
lack of stiffness and fatigue susceptibility of the small-
diameter, 18-inch (3.125 mm) rod. Tightening com-
pression nuts along a threaded rod also has a high ‘fiddle
factor’. The fact remains, however, that moving a nut
along a threaded rod is mechanically superior to any
extrinsically applied compression or distraction force,
as a maximal mechanical advantage can be generated
in a slow, measured application.
3 -inch (4.8 mm) rod system
We now utilize a threaded 16
using open hooks and screws [33]. Because the threads
have been modified to make the pitch wider, the nuts can
be moved more efficiently along the rod to achieve cor-
3 -inch (4.8 mm) rod is
rective compression more rapidly. A 16
flexible enough that it can be implanted even in a severe
kyphosis without contouring with a rod bender. Once
3 -inch (4.8 mm)
correction has been achieved with the 16
rod, it is necessary to exchange the rods for larger (5.5 mm
or 6.35 mm) solid rods to provide the necessary stiffness to
the construct to avoid pseudarthrosis.
The posterior procedure for correcting kyphosis involves
creating space between adjacent laminae, which can then
be closed during a cantilever or compression maneuver.
We resect the inferior portion of the lamina along with
complete facet resection, producing a closing-wedge
‘osteotomy’ at each segment. The closure of each seg-
ment is best done by the compression rod technique.
Placement of apical implants (such as supralaminar
hooks) in the spinal canal should be avoided because
of potential neurologic complications and because the
implant will block complete closure of the resection
laminotomy, preventing full correction.
To date, compression rod techniques in treating kyphosis
have achieved and maintained correction satisfactorily
[33]. The typical loss of correction of 58 or less confirms
that if the kyphosis can be corrected to a normal range
(40–458 of residual kyphosis), anterior surgery appears
unnecessary to maintain correction. By exchanging the
threaded rods (following correction) to solid larger
diameter rod constructs, we have been able to maintain
correction without the need for interbody fusion, and
so we currently prefer posterior-only instrumentation
over combined anterior–posterior procedures [33]
(Fig. 5).
Conclusion
Surgical indications for Scheuermann’s kyphosis should
be assessed on a case-by-case basis, but in general
patients with pain, a rigid deformity, a curve of more
than 70–758, and an unacceptable cosmetic appearance
are surgical candidates. Newer technologies such as third
generation segmental instrumentation in combination
with compression rod techniques have nearly eliminated
the need for combined anterior–posterior procedures.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
When an anterior procedure is deemed to be necessary,
prone VATS anterior release and fusion is an attractive
alternative to formal open anterior release. Proper level
selection, avoidance of posterior ligamentous tension
band resection, and preventing overcorrection will limit
postoperative complications associated with junctional
kyphosis.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
 of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 615).
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This is an excellent review on the prevention of surgical complications associated
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techniques to avoid junctional kyphosis.

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