SCHEUERMANN'S DISEASE

K.M.C. MANGALORE
Dept. of Orthopaedics
Presented by:

Moderator:

Dr. Praveen Patil

Dr. K.G. Kamath

Co-Moderator:

Date: 30.06.09

Dr. Ronald Menenzes

Synonyms: Scheuermann's disease, juvenile kyphosis, Scheuermann kyphosis,

humpback disease.
Scheuermann's disease is one of the osteochondroses. It is essentially
osteochondrosis of the vertebrae. It affects the thoracic or thoracolumbar spine in
adolescents, causing increased kyphosis, poor posture and possible backache. It is the
most common cause of structural kyphosis in adolescents.
Pathophysiology

Osteochondroses all involve a defect in ossification. In Scheuermann's disease

there is a defect in the secondary ossification centres of the vertebral bodies. A
few vertebral bodies may be involved or the whole thoracolumbar spine.

Hereditary factors are thought to play a part in the pathophysiology but no

definite mode of inheritance or genetic marker has been established so far.

Other factors including a correlation between Scheuermann's disease and taller

height, as well as an association with increased levels of growth hormone have
also been suggested as possible causes. However, one study has disputed the
increased weight and height in those with Scheuermann's disease as being part of
the pathogenetic mechanism, suggesting that they were secondary results.

Mechanical factors and trauma have also been cited as possible causes.

Epidemiology

Usually presents in children 13-16 years old.

Occurs more commonly in boys.

Presentation
History

Poor posture with increased kyphosis (usually noticed by parents).

Pain is a more common presentation if the disease affects the lumbar spine. Pain
is usually worse on activity.

Neurological symptoms may rarely be the presenting feature.

Cardiorespiratory symptoms can also rarely occur.

Examination

It is normal to have a degree of kyphosis. Any degree of kyphosis of more than 40

degrees is considered abnormal.

Kyphotic deformity may be progressive.

Upper thoracic kyphosis is best seen in the forward flexed position; lower thoracic
kyphosis may be seen at the thoracolumbar junction.

There is reduced flexibility of the spine.

There may be tenderness above and below the apex of the kyphosis.

Scoliosis may also be present and is associated with Scheuermann's disease.

You should carry out a neurological examination but neurological signs are rare.

Differential diagnosis
Includes:

Postural kyphosis (known as postural round back deformity; kyphosis is flexible)

Ankylosing spondylitis

Glucocorticoid-induced osteoporosis in Cushing disease can lead to thoracic

kyphosis

Skeletal dysplasia

Congenital kyphosis (failure of segmentation)

Spinal tuberculosis (consider if atypical presentation)

Investigations

X-ray of spine in a standing position is the mainstay for diagnosis. AP and lateral
views are taken. The whole thoraco-lumbar spine should be imaged. Changes can
include:
Wedge-shaped vertebral bodies with anterior wedging of at least 5 degrees or
more in at least 3 adjacent vertebral bodies (pathognomonic for
Scheuermanns disease)
Hyperkyphosis (greater than 40 degrees)
Narrow intervertebral disc spaces
Irregular upper and lower vertebral endplates
Schmorl nodes - multiple herniations of the nucleus pulposus of the vertebral
plates

MRI and CT scanning may also be used.

Management

The management is controversial. Some think that no treatment is required as the

disease usually follows a benign course with few adverse sequelae. Others believe
that treatment in those who are skeletally immature will prevent future excessive
deformity and pain.

If treatment is carried out, for mild disease, avoidance of strenuous activity and
weight-bearing may be all that is needed. A referral to a physiotherapist may be
helpful. Observation and X-ray follow-up are carried out.

Non-steroidal anti-inflammatory drugs may be used for pain relief provided there
are no contraindications.

Casting, spinal braces (a Milwaukee style brace) and bed rest may be used in
more severe disease. Braces may be advised for several years.

Surgery is usually only used if there is neurological deficit, uncontrolled pain,

unacceptable cosmetic appearance or documented progression.

Cord decompression is carried out for neurological deficit and spinal fusion
techniques are used for kyphosis correction and pain control.

Complications

Chronic back pain

Progressive and permanent deformity

Neurological deficit

Cardiorespiratory problems

Prognosis

The degree of clinical symptoms and signs generally depends on the degree of
deformity. Those with mild deformity tend to have mild symptoms and signs.

Mild to moderate Scheuermann's disease rarely requires bracing or surgery.

A gradual loss of correction can occur after a brace is removed.

Neurological and cardiorespiratory complication risks are very low.

Adolescents with severe deformity and symptoms have had significant deformity
correction after surgery. However, a literature review in 2007 concluded that
clinical outcomes data are not yet available, and the studies available do not have
strong levels of evidence.

REFERENCE
CAMPBELL, 11th edition
TUREK, 4th edition
BRADFORD, D.S & GARCIA, Scheuermanns Disease. JBJS 81-A, 507-1969
THE SPINE, 5th Edition, ROTHAM & SIMONE
KYPHOSIS DORSALIS JUVENLIS .Am.J. Roentgenol 38,681, 1937