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Scheuermann's disease

Scheuermann was a Danish radiologist

Definition

Excessive thoracic kyphosis (Cobb angle greater than 45 degrees) with wedging of 5 degrees or more of at least 3 adjacent apical vertebrae and vertebral end plate irregularities. 20 - 45o of kyphosis is normal in the 15 - 20 year old. SRS has defined less than 20o as abnormal (Hypokyphosis)

Incidence

  • Affects nearly 10% of the population with reports of between 0.4 and 8% of the general population
  • Only 1% ever seek medical attention during their youth
  • Male ~ Female

Aetiology

  • The aetiology of Scheuermann's disease remains unknown
  • There is however a strong family tendency 
  • Enchondral ossification of the vertebral bodies appears to be the abnormal factor contributing to wedging of the bodies
  • Osteochondritis of the vertebral epiphysis has been proposed as the epiphyseal plate is irregularly ossified with growth arrest of the anterior vertebral bodies
  • Traumatic infraction of the end plates in children who out grow their bone strength during the growth spurt is another possibility
  • Tightness of the anterior longitudinal ligament of the spine may contribute
  • Collagen weakness of vertebral end-plates with a decrease in the collagen to proteoglycan ratio in the matrix of the end-plate

Clinically

  • Starts at about puberty
  • Become increasingly round shouldered
  • Seldom painful, unless severe deformity develops and usually subsides once growth ceases
  • May complain of back ache or fatigue especially as they get older (adolescent more likely to complain of thoracic pain and the adult lumbar pain due to compensatory increased lordosis)
  • Patients with Scheuermann's are generally taller than average
  • Smooth thoracic kyphosis develops and a mild or moderate scoliosis is evident in about one third of patients
  • Thoracolumbar Schuermanns: frequently painful and cosmetically unacceptable as the thoracolumbar spine is normally straight
  • Lumbar Scheuermann's is more common in male patients who are competitive athletes and in individuals from rural communities, suggesting it is an injury affecting vertebral growth
  • Most adults who have pain have evidence of moderate or advanced spondylosis on radiographs

X-Rays

  • The bodies of several adjacent vertebral bodies are wedged and have irregular end-plates (at least 3 vertebrae with wedging of 5o or more, Sorensen)
  • Schmorl's nodes may be evident (disc herniation through the vertebral end plate)
  • Epiphyseal plates appear fragmented, especially anteriorly
  • Lateral X-Rays over a bolster at the apex of the curve indicates the structural nature of the curve
  • Lumbar Scheuermann's is characterised by irregularity of the vertebral end plates, the presence of Schmorls nodes and narrowing of the intervertebral discs without wedging of the vertebral bodies

Treatment

  • Analgesics and anti-inflammatories are useful for painful periods and in patients developing degenerative changes
  • Work modification and postural exercises are indicated
  • With kyphosis up to 45 degrees, back strengthening and postural education
  • Bracing
    • Use Milwaukee if there is significant deformity (greater than 45 degrees) and still growing
    • Nearly always results in success (not if curve excessive from the outset of bracing, e.g. greater than 70° or vertebral wedging)
    • Usually within 4-6 weeks the deformity corrects in the brace, if flexible - need to maintain correction
    • Full time bracing for 12 - 18 months, then weaning for another year
    • Monitor during weaning. If any loss of correction, resort ot full time brace for further 6 months
    • Exercise program with bracing to strengthen extensors
    • Average correction with brace is 40% of curve
  • Surgery
    • Rare in Schuermanns
    • Indications
      • Kyphosis greater than 60o in an adult
      • Greater than 75o in an adolescent (bracing not useful )
      • Unacceptable cosmesis
    • If the kyphosis does not correct to less than 50o on a lateral radiograph over a bolster, then combined anterior release and fusion and posterior fusion will be necessary
    • If does correct to less than 50 degrees, posterior fusion is sufficient alone
    • For fractures a kyphosis angle of less than 30o is unlikely to progress

Prognosis

  • Sorensen: good prognosis for thoracic Scheuermann's
  • Moderately good for thoraco-lumbar region 
  • Relatively poor in the lumbar region
  • For skeletally immature patients Risser 4 or lower, posterior fusion alone is adequate and is followed by little loss of correction
  • In Risser 5 patients, combined anterior and posterior surgery is recommended
  • If the resultant deformity remains less than 60°, most patients will have very little long term difficulties

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