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Background

Kyphosis refers to the normal apical-dorsal sagittal contour of the thoracic and sacral spine. As a pathologic
entity, kyphosis is an accentuation of this normal curvature. Kyphosis can occur as a deformity solely in the
sagittal plane, or it can occur in association with an abnormality in the coronal plane, resulting in
kyphoscoliosis. Many potential etiologies of kyphosis have been identified.

Problem
Normal kyphosis is defined as a Cobb angle of 20-40 measured from T2-T12. [1, 2]
Pathologic kyphosis can affect the cervical and lumbar spine as well the thoracic spine, but cervical and lumbar
involvement is uncommon. Any kyphosis in these areas is abnormal.
Kyphosis can cause pain and potentially lead to neurologic deficit and abnormal cardiopulmonary function

Etiology
Many potential causes of kyphosis have been described.[3] Scheuermann disease and postural round back are
often identified in adolescents.[4, 5, 6] Congenital abnormalities, such as failure of formation or failure of
segmentation of the spinal elements, can cause a pathologic kyphosis. Autoimmune arthropathy, such as
ankylosing spondylitis, can cause rigid kyphosis to develop as the spinal elements coalesce. Kyphosis can also
develop as a result of trauma, a spinal tumor, or an infection. Iatrogenic causes of kyphosis include the effects
of laminectomy and irradiation, which lead to incompetence of the anterior or posterior column. Finally,
metabolic disorders and dwarfing conditions can lead to kyphosis.
This article focuses on kyphosis due to Scheuermann disease and postural, postinfectious, posttraumatic, or
iatrogenic etiologies

Pathophysiology
The pathophysiology of kyphosis depends on the etiologic factor. The exact cause of Scheuermann disease is
still imprecisely defined. Scheuermann postulated that the condition resulted from avascular necrosis of the
apophyseal ring. Other theories include histologic abnormalities at the endplate, osteoporosis, [7] and mechanical
factors that affect spinal growth.[8] A Danish study demonstrated an important genetic component to the entity.[9]
Postural kyphosis is present when accentuated kyphosis is observed without the characteristic 5 of wedging
over 3 consecutive vertebral segments that defines Scheuermann kyphosis. [10] This is felt to be due to muscular
imbalance leading to the round-back appearance of these individuals.
When focal kyphosis occurs after a fracture, more height is lost in the anterior aspect than in the posterior
aspect; this is the typical fracture pattern. The angulation can increase as the fracture heals, placing pressure
on the spinal cord. Patients with fractures have historically been treated with laminectomy alone, especially in
the thoracic spine, and they often had progressive kyphosis at the fracture site. [11, 12]
Postinfectious kyphosis occurs in a manner similar to that just described. Mechanical integrity of the anterior
column is lost due to the infectious process. Bending forces then accentuate the normal sagittal contour

Presentation

Patients with a symptomatic kyphosis often present with axial back pain. They may also be concerned about
the cosmesis of their rounded back.
Patients with kyphosis should be carefully questioned about and examined for neurologic problems, especially
myelopathy. Difficulty with gait and hyperreflexia should prompt further investigation of the kyphosis.
A 10- to 42-year, natural-history study of Scheuermann disease revealed that patients, as compared with a
control group, tended to have increased back pain.[13]However, they were not more likely than the control group
to take pain medication, to have sedentary jobs, or to lose motion of the spine. The investigators found no
differences in educational level, absenteeism, self-consciousness, or reports of numbness in the legs. Of
interest, restrictive lung disease was observed in patients with a curve greater than 100.

Indications
Indications for treatment of kyphosis include unremitting pain, neurologic changes, progression of deformity,
[14]
and cosmesis.[8] Indications for surgical treatment of Scheuermann kyphosis have changed fairly substantially;
however, precise indicators have not been elucidated.
Authors from early clinical series simply cited pain or deformity as reasons to perform fusion. Proposed
indications more specific than these are kyphosis greater than 75, kyphosis greater than 65 with pain, and an
unacceptable appearance of the trunk.[15]
Other possible indications in severely affected patients are problems with balance while sitting and skin
problems due to pressure at the apex of the deformity.
Surgical intervention for posttraumatic kyphosis is recommended if the patient's neurologic status changes, if
the condition progresses, if the kyphosis is 30 or more, or if the loss of anterior vertebral height is more than
50%

Laboratory Studies
See the list below:

Standard laboratory results should be evaluated whenever surgical intervention is being considered.
The laboratory workup should include determination of a complete blood count, coagulation studies, and
routine chemical analyses.
Autodonation of blood can be recommended to the patient in anticipation of the need for intraoperative
transfusion.
In patients with a known or suspected infectious etiology, the sedimentation rate and C-reactive protein
level should be measured to help identify a potential infection or to help track the progress of treatment.
Before a major operation, the patient's nutritional status might also be checked, because it
considerably influences a patient's ability to heal.

Imaging Studies
Radiography
Radiographs are crucial for both diagnosing kyphosis and for planning treatment.

The most useful radiographs are upright posteroanterior and lateral images of the entire spine. These views
enable the reviewer to assess the sagittal balance of the entire spine and to determine if a scoliosis is present.
Measurements are made on radiographs by using the standard Cobb technique for scoliosis, which has been
adapted to the measurement of kyphosis. Thoracic kyphosis is measured from T1-T12, though the upper
thoracic vertebral endplates are often difficult to see. Normal measurements for thoracic spine vary widely, but
the accepted definition of normal according to the Scoliosis Research Society is 20-40. A plumb line dropped
from C7 should pass through or just anterior to S1 on a lateral full-length image. This technique helps in
assessing and quantifying the patient's overall sagittal alignment.
Radiographs obtained with the patient in a supine lateral hyperextension position over a bolster can be used to
determine the flexibility of the curve. This information is useful in surgical planning. A flexible curve is best
corrected with only posterior fusion, whereas an anterior only or combined anterior and posterior procedure
may be needed for a stiff curve. A curve that corrects to 50 or less on hyperextension can be treated with
posterior-only fusion.[17, 18] Postural kyphosis is rarely more than 60, and it should correct to normal with
hyperextension.

Magnetic resonance imaging


MRI can be a useful adjunct in planning treatment for patients with kyphosis. If a neurologic abnormality is
present, MRI may aid in localizing impingement on neural structures.
If surgery is being planned for the treatment of postinfectious kyphosis, an MRI helps in planning an anterior
approach with regard to the amount of resection needed (if any) to remove diseased bone.

Other Tests
Ensuring the adequacy of bone density is imperative when surgical correction of kyphosis is being considered.
Correction of the kyphosis relies on instrumentation to reduce the spine, and considerable forces are placed on
the instrumentation-bone interface. Osteopenic bone can predispose to loss of correction over time, if the
instrumentation cuts through the relatively less dense vertebrae. If a patient's bone density is in question, bone
densitometry can be perform to quantify it. Efforts should be made to a patient's improve bone density before
and following surgery. When bone density is poor, the surgeon must usually increase the number of points of
fixation to reduce the stress at each point

Medical Therapy
Medical therapy for kyphosis consists of exercise, medication, and bracing. [14]Physical therapy, which usually
consists of extension-focused activities, may be of some benefit; however, this has not been proven. [15, 19]
Medications to treat discomfort associated with kyphosis should be limited to nonsteroidal anti-inflammatory
drugs and, possibly, muscle relaxants. Narcotics should be avoided as long-term treatment of pain associated
with kyphosis.
If a patient has an active infection, such as diskitis or vertebral osteomyelitis, appropriate antibiotics based on
culture results should be started as soon as possible.
Bracing is effective in some skeletally immature patients with Scheuermann kyphosis. However, the correction
obtained may diminish as patients approach and pass skeletal maturity. Treatment with a Milwaukee brace
improved deformity in 76 of 120 (63%) patients who wore the brace regularly. Brace treatment seemed to be
least effective when the curve was more than 74 at the beginning of treatment. [20]Bradford et al reported

modest success in treating adults with a brace, with some correction of their deformities. [18] As far as the present
authors are aware, no other reports of brace treatment in adults with kyphosis have been published.

Surgical Therapy
Surgical planning for kyphosis is crucial to a successful operation. The goal of surgery is to correct the
deformity and remove any neural compression, if present. The correction can be done anteriorly, posteriorly, or
both. Posterior surgery is most commonly described and performed. Posterior arthrodesis for kyphosis can be
an extensive operation, with many spinal segments typically included in the fusion mass. [21] This procedure is
most helpful for long, sweeping, flexible curves. In cases of rigid deformity, osteotomies can be performed to
improve the correction. Combined anterior-posterior surgery may be required for severe deformities. [22]

Smith-Peterson osteotomy, pedicle subtraction osteotomy, and vertebral column resection


Specific osteotomies are aggressive facetectomies at each level, Smith-Peterson osteotomy, pedicle
subtraction osteotomy, and vertebral column resection.
Smith-Peterson osteotomy is wedge-shaped resection of posterior elements from the pedicles of the superior
vertebra to the pedicles of the inferior vertebra. When closed posteriorly, the spine hinges on the disk space;
therefore, an open, mobile disk is crucial to the success of this procedure. Smith-Peterson osteotomy can be
performed at 1 or multiple levels, if necessary. This allows for significant correction, approximately 1 mm of
resection yielding 1 of lordosis.[3] Some recommend anterior diskectomy and fusion with Smith-Peterson
osteotomy to decrease the pseudarthrosis rate.[23, 24]
Pedicle-subtraction osteotomy is relatively aggressive resection of a wedge of bone, including posterior
elements, the pedicles, and the vertebral body.[25]
Vertebral column resection entails removal of posterior elements, the vertebral body, and adjacent disk
material. Both anterior and posterior fixation are often required because of the destabilizing effect of this
resection.
As kyphosis becomes notably sharp and/or focal, increasingly aggressive techniques are required for
correction. Cho et al demonstrated that the corrections per segment were 10.7 for Smith-Peterson osteotomy
and 31.7 for pedicle subtraction osteotomy.[26] Procedures involving the anterior column are usually followed by
posterior instrumentation and fusion.

Anterior surgery
Anterior surgery can include single or multiple diskectomies to increase the flexibility of the spine, followed by a
posterior arthrodesis. The transthoracic approach allows for decompression of the neural elements before the
spine is corrected with posterior instrumentation. Anterior-only fusion is most useful in relatively short and focal
kyphosis, such as posttraumatic or postinfectious kyphosis. [17]
A novel technique for single-curve scoliosis may also be used to correct kyphosis. The bone-on-bone technique
involves an anterior-only approach to perform complete annulectomy and diskectomy at each level in the Cobb
angle of the deformity. Then, using sequential compression along 2 rods, which are affixed with a staple and 2
screws in each vertebral level, the surgeon brings the bony endplates into immediate contact. Substantial
correction can be achieved in this manner

Cassidy, R.C. (2015). http://emedicine.medscape.com/article/1264959overview#showall