Kyphosis

Dr. Dibyendunarayan Bid

Contents
1 Definition/Description 2 Clinically Relevant Anatomy 3 Epidemiology /Etiology 4 Characteristics/Clinical Presentation 5 Differential Diagnosis 6 Diagnostic Procedures 7 Outcome Measures 8 Examination 9 Medical Management 10 Physical Therapy Management 11 Key Research 12 Resources 13 Clinical Bottom Line 14 Recent Related Research (from Pubmed) 15 References

Definition / Description
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.

Classification of Kyphosis
Winter and Hall have classified kyphosis into 15 major groups:3

I. Postural disorders II. Scheuermanns kyphosis III. Congenital disorders

A. Failure of segmentation B. Failure of formation

IV. Paralytic
A. Polio B. Anterior horn cell disease C. Upper motor neuron disease (eg, cerebral palsy)

Classification of Kyphosis
V. Myelomenigocele VI. Posttraumatic
A. Acute B. Chronic C. With or without cord damage

VII. Inflammatory
A. Tuberculosis B. Other infections

VIII. Postsurgical
A. Post-laminectomy B. Post-excision (e.g., tumor)

Classification of Kyphosis
IX. Inadequate fusion
A. Too short B. Pseudoarthrosis

X. Postirradiation
A. Neuroblastoma B. Wilms tumor

XI. Metabolic
A. Osteoporosis (juvenile or senile) B. Osteogenesis imperfecta

Classification of Kyphosis
XII. Developmental
A. Achondroplasia B. Mucopolysaccharidosis C. Other

XIII. Collagen disease (e.g., Marie-Strumpell) XIV. Tumor (e.g., histiocytosis X)

A. Benign B. Malignant

XV. Neurofibromatosis

Problem
Normal kyphosis is defined as a Cobb angle of 2040 measured from T2-T12. 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. Scheuermann disease and postural round back are often identified in adolescents.

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 conditions can lead to kyphosis.

and

dwarfing

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, and mechanical factors that affect spinal growth. A Danish study demonstrated an important genetic component to the entity.

 Postural kyphosis is present when accentuated kyphosis is observed without the characteristic 5 of wedging over 3 consecutive vertebral segments that defines Scheuermann kyphosis. 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.

 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.
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, and cosmesis.

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.

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 kyphosis is recommended:

posttraumatic

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%.

Contraindications
Contraindications to surgery for kyphosis include a clinically significant cardiopulmonary risk and medical unfitness for surgery.

Laboratory Studies
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. 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. Physical therapy, which usually consists of extension-focused activities, may be of some benefit; however, this has not been proven. Medications to treat discomfort associated with kyphosis should be limited to NSAIDs 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. Bradford et al reported modest success in treating adults with a brace, with some correction of their deformities.

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. 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.

 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.

 Pedicle-subtraction osteotomy is relatively aggressive resection of a wedge of bone, including posterior elements, the pedicles, and the vertebral body.[24] 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.
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.[16]

 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.[26]

Postoperative Details
Patients usually require clinically significant pain medication after undergoing correction of kyphosis, especially extensive procedures. The amount of narcotics given should be carefully titrated because the drugs may cause ileus, atelectasis, and/or difficulty in mobilizing the patient after surgery. The patient should be monitored for anemia, as blood losses can be substantial. Electrolytes should be checked as well, as notable fluid shifts are common in the perioperative period. Careful postoperative neurologic examination is important to identify any changes from the patient's preoperative status.[31]

Follow-up
Standing posteroanterior and lateral full-length radiographs of the spine should be obtained as soon as possible after surgery and serially for follow-up. Full-length scoliosis films obtained yearly allow evaluation of the patient's curve over time. Comparison of the postoperative and follow-up images with the preoperative images helps in defining the amount of correction achieved and in determining if correction is being lost over time.

 Loss of correction should prompt a careful evaluation for implant pull-out or breakage, for subsidence of an anterior strut (if any), or for the lack of adequate fusion mass. Postoperative measurements of the C7 plumb line should be at or within a few centimeters of S1.

Outcome and Prognosis

Results of surgical correction vary depending on the etiology of the deformity. 1. Deformity correction was moderate. 2. Pain relief upto very good extent. 3. Improvement in preoperative neurologic deficit seen. 4. Improvement in pain score and Oswestry Disability Index seen.

Physiotherapy
Physiotherapy for hyperkyphosis Physiotherapy for patients with thoracic kyphosis has been described at length by Lehnert-Schroth (Lehnert-Schroth and Weiss 1992, Lehnert-Schroth 2000). This kind of exercises, however does not differ a lot from what is described in literature.

 Stretching of pectoralis muscels, passive and active redression of the kyphotic hump are the main principles of physical exercises besides the work on the lower extremity muscles within the Schroth exercise program. Especially the "two stool" exercise as shown on Figure 4 and the "door frame exercise" (Fig. 5) shows elements of muscle stretching and redression of the thoracic kyphosis.
[Redress: To compensate or set a situation right.]

 Thoracolumbar and lumbar curve patterns have to be addressed differently by physiotherapy: loss of lumbar lordosis is the consequence of these curve patterns, which, according to actual knowledge, is directly related to chronic low back pain in adulthood.

 Therefore loss of lumbar lordosis in these curve patterns exercises should aim to correct. Exercises to improve lumbar lordosis have been described at length by Weiss and Klein 2006. These exercises are called physio-logic exercises as they are developed to restore a physiologic lumbar lordosis and by this best possible lumbar function and stability. Examples for exercises from this program can be seen in Figure 6 and Figure 7. In the recent years kyphosis patients were treated with a four week in-patient rehabilitaion program, especially in Germany. In view of the benign character of the disease and the lack of evidence there is for in-patient rehabilitation. In general in-patient rehabilitation does not seem necessary or even indicated.

Future and Controversies

As surgical implants and techniques have improved, so have results of surgery. Patient safety should be the foremost goal of the treating physician. Future prospective trials will help in defining the best way to care for patients with clinically significant sagittal imbalances.

Outcome measures
Scoliosis Research Society Scores Oswestry Disability Index

References
http://emedicine.medscape.com/article/1264959-overview very good article http://cirrie.buffalo.edu/encyclopedia/en/article/125/ - very good article Winter RB, Moe JE. Kyphosis in childhood and adolescence. Spine. 1978;3:285-308. [classification] http://www.srs.org/patient_and_family/kyphosis/ http://www.spineuniverse.com/conditions/kyphosis/kyphosis -description-diagnosis