Kyphosis

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Overview
Kyphosis (Greek - kyphos, a hump), in general terms, is a curvature of the upper spine. It can be either the result of bad posture or a structural anomaly in the spine.

Many radiologists will detect kyphosis with a scolie or an AP-Lateral — two types of X-ray. A scolie (pictured to the right) is an X-ray taken from the rear. An AP-Lateral is taken from the side, where the X-ray machine is programmed to show the spine with high definition.

In the sense of a deformity, it is the pathological curving of the spine, where parts of the spinal column lose some or all of their lordotic profile. This causes a bowing of the back, seen as a slouching posture. Symptoms of kyphosis, that may be present or not, depending on the type and extent of the deformity, include mild back pain, fatigue, appearance of round back and breathing difficulties. Severe cases can cause great discomfort and even lead to death.

Classification
There are several kinds of kyphosis (ICD-10 codes are provided):

Postural kyphosis (M40.0)
The most common type, normally attributed to slouching, can occur in both the old and the young. In the young, it can be called 'slouching' and is reversible by correcting muscular imbalances. In the old, it may be called hyperkyphosis or dowager’s hump. About one third of cases have vertebral fractures. Otherwise, the aging body tends towards a loss of musculoskeletal integrity, and kyphosis can develop due to aging alone.

Scheuermann's kyphosis (M42.0)
Scheuermann's kyphosis is significantly worse cosmetically and can cause pain. It is considered a form of juvenile osteochondrosis of the spine, and is more commonly called Scheuermann's disease. It is found mostly in teenagers and presents a significantly worse deformity than postural kyphosis. A patient suffering from Scheuermann’s kyphosis cannot consciously correct posture. The apex of the curve, located in the thoracic vertebrae, is quite rigid. The patient may feel pain at this apex, which can be aggravated by physical activity and by long periods of standing or sitting. This can have a significantly detrimental effect on their lives, as their level of activity is curbed by their condition; they may feel isolated or uneasy amongst peers if they are children, depending on the level of deformity. Whereas in postural kyphosis the vertebrae and disks appear normal, in Scheuermann’s kyphosis they are irregular, often herniated and wedge shaped over at least three adjacent levels. Fatigue is a very common symptom, most likely because of the intense muscle work that has to be put into standing and/or sitting properly. The condition seems to run in families.

Congenital kyphosis (Q76.4)
Congenital kyphosis can result in infants whose spinal column has not developed correctly in the womb. Vertebrae may be malformed or fused together and can cause further progressive kyphosis as the child develops. . Surgical treatment may be necessary at a very early stage and can help maintain a normal curve in coordination with consistent follow ups to monitor changes. However, the decision to carry out the procedure can be very difficult due to the potential risks to the child. A congenital kyphosis can also suddenly appear in teenage years, more commonly in children with cerebral palsy and other neurological disorders.

Nutritional kyphosis
Nutritional kyphosis''' can result from nutritional deficiencies, especially during childhood, such as vitamin D deficiency (producing rickets), which softens bones and results in curving of the spine and limbs under the child's body weight.

Gibbus deformity
Gibbus deformity is a form of structural kyphosis, often a sequela to tuberculosis.

Orthosis (brace)


Body braces showed benefit in a randomised controlled trial.

The Milwaukee brace is one particular body brace that is often used to treat kyphosis in the US. Modern CAD / CAM braces are used in Europe to treat different types of kyphosis. These are much easier to wear and have better in-brace corrections than reported for the Milwaukee brace. Since there are different curve patterns (thoracic, thoracolumbar and lumbar) different types of braces are in use. The advantages / disadvantages of different braces are discussed in a recent review article.



Specialised physical therapy
In Germany, a standard treatment for both Scheuermann's disease and lumbar kyphosis is the Schroth method, a system of physical therapy for scoliosis and related spinal deformities.

Surgery
Surgical treatment can be used in severe cases. In patients with progressive kyphotic deformity due to vertebral collapse, a procedure called a kyphoplasty may arrest the deformity and relieve the pain. The procedure is serious and consists of fusion and can cause a risk to the abnormal vertebrae.

Complications
The risk of undergoing spinal fusion surgery for kyphosis, like in scoliosis, is estimated to be 5%. Possible complications may be inflammation of the soft tissue or deep inflammatory processes, breathing impairments, bleeding, and nerve injuries. However, according to the latest evidence, the rate of complications is far beyond that rate. As early as five years after surgery another 5% require reoperation and today it is not yet clear what to expect from spine surgery in the long-term. Taking into account that signs and symptoms of spinal deformity cannot be changed by surgical intervention, surgery remains to be a cosmetic indication. Unfortunately, the cosmetic effects of surgery are not necessarily stable. In case one decides to undergo surgery, a specialised centre should be preferred.

Clinical Images
Images shown below are courtesy of Cafer Zorkun MD PhD and copylefted.