Access Keys:
Skip to content (Access Key - 0)

Scheuermann's kyphosis


  • 1st described by Holger Scheuermann in 1921, a Danish physician
  • Structural deformity characterized by anterior wedging of ³5° of three adjacent thoracic vertebrae (Sorensen, 1964); ³50° thoracic kyphosis abnormal
  • Secondary radiographic findings of Schmorl's nodes, endplate narrowing, irregular endplates
  • Adolescents typically present secondary to cosmetic deformity; adults secondary to pain
  • Etiology unclear, indications for treatment debatable

Normal Thoracic Kyphosis

  • Curvature extends from T2-T12 w/ T7 most dorsal vertebrae
  • Anterior elements of spinal column resist compressive forces, posterior ligamentous structures resist tensile forces
  • Kyphotic deformity may occur if anterior column unable to withstand compression, causing shortening of anterior column
  • Typically increases throughout life; sagittal alignment of the thoracic spine displays a range of normal that is dynamic
  • Scoliosis Research Society:
    1. Normal range thoracic kyphosis for growing adolescent 20-40°
    2. Any kyphosis at thoracolumbar or lumbar area abnormal


  • Prevalence of 0.4 to 8.3% (Sorensen, 1964)
  • Two studies that Sorensen cited in 1951, 1955 reported prevalence of 0.4% - may have contained inherent bias as included only men rejected for military service
  • Prevalence of 7.4% in subsequent review of 1,384 cadavers (Scoles, 1991)
  • Prevalence approximately equal in males and females
  • Radiographic findings c/w Scheuermann's not visible until age 12-13 (puberty); Hence, adolescent girls typically evidence findings 1st 


  • Many theories proposed but has yet to be elucidated
  • Scheuermann hypothesized that AVN of ring apophysis (ring of cartilage about developing vertebral body) leads to premature cessation of growth anteriorly à vertebral body wedging
  • Schmorl postulated that herniations of disk material through vertebral endplates lead to loss of disk height and anterior wedging
  • Underlying genetic factor suggested (Halal, 1978; Skogland, 1985)
  • Correlation with height and increased levels of growth hormone (Ascani, 1990)
  • Gross anatomic findings: thickened ALL, narrowed vertebral disks, wedged vertebral bodies
  • Histologic abnormality: decreased collagen to proteoglycan ratio in matrix of endplate à ?alteration in ossification and thus altered vertical growth
  • Early osteoporosis may be an etiologic factor
  • Mechanical factors: Scheuermann found high incidence in industrial workers

Clinical Evaluation

  • Indications for treatment can be grouped into five categories: pain, progression of deformity, neurologic compromise, cardiopulmonary compromise, cosmesis
  • Pain 50% (Sorensen, 1964)- Adolescents often p/w cosmetic or postural complaints; adults - pain
    - Usually paraspinal, just distal to apex of deformity
    - Often activity-related, relieved by rest; sometimes simply early fatigue
  • Progression of deformity- Pay attention to h/o curve; delays in Dx possible if ignored, thought to be just poor posture
  • Neurologic compromise- Cord compression mandates surgical treatment (rare)
    - Ranges from acute onset unilateral radiculopathy to insidious onset spastic paraplegia
    - 54° (Ryan and Taylor, 1982) to 95° (Lonstein, 1980)
    - Extradural cysts and thoracic disk herniations may contribute
  • Cardiopulmonary compromise      - Extremely rare on initial presentation
            - Sorensen reported no negative effects
            - Murray reported restrictive pulmonary disease in curves >100° w/ apex in upper thoracic region
  • Cosmesis      - Address w/ patient
  • Physical Exam      - Sagittal deformity fairly rigid in hyperextension; in postural kyphosis, more correctable
            - Have patient bend forward, view deformity from side ("A-frame")
            - Typically increased cervical and lumbar lordosis
            - Shoulder girdles often rotated anteriorly
            - Evaluate for hamstring tightness, lower extremity neurologic function

Radiologic Evaluation

  • Routine studies: AP & lateral (standing) XR of entire spine on long films and hyperextension lateral of thoracic spine
  • Lateral XR: Schmorl's nodes, disk space narrowing, irregular endplates, vertebral wedging ³5° of three adjacent bodies (use Cobb technique)
  • Lateral XR: r/o lumbar hyperlordosis, spondylolysis (30-50%), degenerative
  • AP XR: r/o scoliosis (1/3 Scheuermann's kyphosis)
  • Lateral XR in hyperextension: to assess flexibility of kyphosis; r/o postural kyphosis (as much as 60° deformity correctable) - Schmorl's nodes, etc. absent
  • Presence of anterior bar à congenital kyphosis       

Natural History

  • Wide variation in natural history; patients w/ mild deformities have few clinical sequelae but a subset of patients have refractory symptoms
  • Back pain and fatigue in adolescent may improve w/ skeletal maturity
  • Paajaanen et al(1989) reported 55% of disks in young adults w/ Scheuermann's w/ abnormal MRI changes (rate five times that in asymptomatic controls)
  • The Natural History and Long-term Follow-up of Scheuermann Kyphosis (JBJS-A, Murray et al, 1993)      - 67 patients w/ mean kyphotic angle 71° for average 32 years (compared w/ age-            matched controls)
          - Back pain more intense and localized in thoracic spine
    - Had less demanding jobs, less extension of thoracic spine
    - Similar, however, overall quality of life; little preoccupation w/ appearance
          - Higher incidence of restrictive lung disease kyphotic curves >100°
    -           Bradford et al(1977) reported 50% incidence severe pain w/ increased incidence pain when kyphosis centered over upper lumbar spine
    -           Lowe et al(1987) reported severe deformity and back pain as common sequelae in adolescents who went untreated


  • Ranges from observation to anterior and posterior reconstructive surgery


  • Anti-inflammatory medications - useful short-term adjunct
  • Exercise - extension or postural exercises will not improve or halt progression of fixed deformity, but thoracic extension program combined w/ aerobic exercise may improve physical conditioning and decrease pain
  • Bracing -Typically reserved for patients w/ 1 yr or more of skeletal growth remaining (Risser's stage 3 or below)
    -can provide up to 50% correction of deformity but gradual loss of correction over time
          - 45° can be used as threshold (Sachs, 1987)
          - Milwaukee-style brace (neck ring and anterior and posterior uprights connected to pelvic girdle)
          - Obtain lateral radiograph to confirm proper fit w/ f/u in 3-4 wks for brace check, then every 4-6 mo
    - Sachs et al (1987): 1) 120 patients f/u >5 yrs after brace discontinued, 69% still had improvement 3° or more from initial radiograph  2) When deformity ³74°,         brace treatment failed
          - Role of bracing in skeletally mature patient less clear


  • Adolescent w/ curve ³75° despite appropriate bracing may be candidate
  • Goals of treatment: safely obtain solid arthrodesis throughout length of kyphosis w/ correction of deformity
  • Posterior-only, anterior-only, or combined anterior-posterior approach
  • Abnormal kyphosis corrected by surgically shortening posterior column or lengthening anterior column or both

Anterior-only approach

  • Described by Kostuik (1988), less widely used
  • Anterior diskectomy and interbody fusion and anterior instrumentation w/ Harrington distraction system augmented by postop bracing
  • 36 patients - reduction of mean preop deformity of 75.5° to 60°

Posterior-only approach

  • Advantages: decreased EBL and surgical time, no risks of thoracotomy
  • Disadvantages: higher rate of pseudoarthrosis, less correction
  • Recommended approach for flexible deformity that corrects on hyperextension to <50°; may add segmental fixation and posterior facetectomy for greater deformities

Anterior-Posterior approach

  • For more rigid deformities (>75°) that does not correct to <50° on hyperextension lateral view*;* one sitting or staged
  • Anterior approach open or thoracoscopically, right side to avoid great vessels
  • Anterior release and interbody fusion performed on all levels that are wedged or have a narrowed disk space
  • Posterior correction performed by compression technique or leverage technique
  • Posterior fusion w/ dual rods segmentally attached to compression instrumentation is treatment of choice, preceded by anterior release and interbody fusion
  • Harrington compression system vs. segmental posterior systems (Cotrel-Dubousset, Texas Scottish-Rite Hospital, Isola) that obviate need for postop brace
  • Overall correction should not exceed 50% initial deformity or <40° - reduces risk of proximal and distal junctional kyphosis

Lumbar Scheuermann's disease

  • Less common
  • More often causes back pain on mechanical basis (more common in athletes and manual laborers)
  • Pain often self-limited
  • Same radiographic findings but NOT associated w/ vertebral wedging


  • Scheuermann's Kyphosis in Adolescents and Adults: Diagnosis and Management.  Tribus, C.B.  JAAOS.  1998; 6:36-43
  • Scheuermann's Disorder.  Koop, S.E.  OKU: Pediatrics 2.
  • Review of Orthopaedics, 4th ed.  Miller, M.D.
  • Cambell's Operative Orthopaedics.  

Peer Review

OrthopaedicsOne Peer Review Workflow is an innovative platform that allows the process of peer review to occur right within an OrthopaedicsOne article in an open, transparent and flexible manner. Learn more

Instructions for Authors

Read our Instructions for Authors to learn about contributing or editing articles on OrthopaedicsOne.

Content Partner

Learn about becoming an OrthopaedicsOne Content Partner.

Academic Resources

Resources on Scheuermann's kyphosis from Pubget.

The license could not be verified: License Certificate has expired!
Orthopaedic Web Links

Internet resources validated by

The license could not be verified: License Certificate has expired!
Related Content

Resources on Scheuermann's kyphosis and related topics in OrthopaedicsOne spaces.

Page: Scheuermann's kyphosis (OrthopaedicsOne Articles)
Page: Congenital muscular dystrophy (OrthopaedicsOne Articles)
Page: Congenital myopathies (OrthopaedicsOne Articles)
Page: Congenital vertical talus (OrthopaedicsOne Articles)
Page: Coxa vara (OrthopaedicsOne Articles)
Page: Curly toes (OrthopaedicsOne Articles)
Page: Developmental milestones (OrthopaedicsOne Articles)
Page: Down's syndrome (OrthopaedicsOne Articles)
Page: Ehlers-Danlos syndrome (OrthopaedicsOne Articles)
Page: Enchondral ossification (OrthopaedicsOne Articles)
Showing first 10 of 234 results