Treatment for Scheuermann's kyphosis depends on the patient's age, severity of the curve and, if there are any neurological problems (very uncommon). However, the course of treatment is generally the following:
Bracing. If the curve progresses or for more severe cases, a back brace may be needed to help straighten the spine. The brace is designed to hold the spine straight with shoulders pulled back and the chin upright. Bracing helps take pressure off the vertebrae, allowing for growth of the bony area in the front of the vertebrae to catch up with the growth in the back.
Back braces for Scheuermann's kyphosis are usually worn for 16-24 hours a day for one year. Stretching exercises and cardiovascular activities are also prescribed to help alleviate back pain and fatigue. Bracing is only used in patients who are still growing and is not effective for adults.
Bracing for Scheuermann's kyphosis is somewhat similar to bracing for scoliosis, but the brace needs to extend up higher proximally than for idiopathic scoliosis to control the kyphosis. So the brace either needs to go up very high in the thoracic region or extend up over the shoulders and to the base of the neck.
Adolescents may find bracing difficult because the brace can be uncomfortable, hot, rigid, unattractive, and may make them self-conscious. However, consistent use of the brace can reverse or prevent the progression of the kyphosis.
In the past, the Milwaukee brace was considered to benefit patients with Scheuermann's kyphosis. However, the Milwaukee brace is seldom used as most teenage patients simply refuse to wear this style brace.
Physical Therapy. When used along with bracing, physical therapy can be helpful to build strength, flexibility, and increase range of motion. Emphasis is on increasing the flexibility of the back and hamstring muscles, increasing back strength, and improving posture.
Surgery may be needed if the kyphosis is more than 70 degrees, neurological problems (very, very uncommon) are present, or if pain is severe and cannot be successfully alleviated using non-surgical treatments. The most common surgical technique for Scheuermann's kyphosis is fusion. The procedure is usually done in this fashion:
Posterior: The surgeon approaches the spine from the back. Specialized instrumentation such as rods and screws are used to fuse vertebrae together to straighten and stabilize the spine and reduce pain.
Anterior: The surgeon reaches the spine through the chest (thoracotomy), releases tightened ligaments along the front of the spine, and removes damaged discs (discectomy). This allows for easier straightening of the spine.
Surgeries used to always include an anterior operation before the posterior operation for Scheuermann's kyphosis. But now with resection of the facet joints posteriorly (a variant of Smith-Petersen osteotomies) and the use of pedicle screw implants posteriorly, the anterior operation is needed less often. We now do an anterior operation only 10% of the time or less. This is only needed if the curve is particularly sharp, angular and stiff.
In most cases, a one-staged posterior-only procedure can be used. Recent advancements in fixation techniques and instrumentation systems have made this possible.
This is a young adult female with several failed surgeries for Scheuermann's kyphosis (Figures 2A and 2B). She presented to us with a fixed deformity and pseudarthrosis. There was no correction of her deformity on supine hyperextension radiographs. She was treated with Smith-Petersen osteotomies at all levels and then reconstruction with pedicle screw implants. Smith-Petersen osteotomies means cutting through the fusion mass at the level of the facet joints at each segment. See at ultimate follow-up that the correction has been substantial and maintained with time.
Her preop kyphosis measured 98°. Normal is between 20-40°. At 4 years, 11 months postop her kyphosis measured 45°
Figure 2 (A): Composite standing radiographs on the patient with Scheuermann's kyphosis.
Figure 2 (B): Composite clinical photos on the patient with Scheuermann's kyphosis.
Know the Risks
Surgery to correct Scheuermann's kyphosis is a demanding procedure. While all surgeries carry a risk of complications such as infection, excessive bleeding, and reactions to anesthesia, these procedures also carry risks of paralysis, which are not prohibitively high (maybe as high as 1 in 100), but are higher than with idiopathic scoliosis (probably 1 in 1000). The decision to have surgery to correct Scheuermann's kyphosis should be made carefully. Be sure you understand all of the possible complications.
Talk to Your Spine Specialist
Most cases of kyphosis are postural and mild. However, if your child exhibits some of the symptoms discussed above, see your physician or a spine specialist. If you need to find a spine specialist in your area, visit Find a Doctor.
Dr. Bridwell provides a wealth of experience to this topic. Both non-operative and surgical treatment is discussed in his article. One comment to add is that in addition to the surgical indications of curve progression, pain, and the rare neurological deficit, deformity itself is a relative indication for operative treatment. Often, the kyphosis, even if 60 or 70 degrees, is not evident to others. On the other hand, in some patients, deformity of the back with the head thrust forward is so significant that it may result in emotional and psychological difficulties for the patient. In addition to the excellent x-ray results shown by Dr. Bridwell, patients are typically highly satisfied with their outcome.