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What is kyphosis, what types are there, and how is it treated?

09 November 2021
Dr. Elviz Qasımov

What is kyphosis?

“Sit up straight! Stand up straight! Don’t bend your back!” You’ve probably heard this expression quite often, so now reading it again immediately straightened your back.

Kyphosis is the pathology of the spinal column in which its upper part appears more rounded than it should and can occur among people of every age group. The position of the curves of the spinal column changes throughout life. In a newborn baby, the spinal column is kyphotic from the first cervical vertebra to the coccyx. But as the child gets older, there is first a forward bend in the lumbar region (lordosis) and then a backward bend in the thoracic vertebrae (kyphosis). As a result of these changes, the spine takes on an “S” shape in lateral projection. This structure allows the spine to support the head on the shoulders and the balance of the body. If the curvature at the thoracic vertebrae becomes greater than normal, the patient is diagnosed with kyphosis.

The angle of normal kyphosis is in the range of 20-40 degrees. If the angle of curvature will be more than 40 degrees, then such the pathology is called hyperkyphosis.

This disease occurs more often among women than men. During puberty in girls, due to an increase in the size of the mammary glands, begins the progression of curvature of the thoracic part of spinal column. This may also be due to the tightness of the girls or the large size of the mammary glands.

Figure shows an image of kyphosis and the normal spine

Symptoms

Generally, the presence of kyphosis of the spine is manifested by back pain, as well as the presence of a bulge in the thoracic region. Other common symptoms include:

  • A noticeable difference in the height of the shoulders
  • Tilt of the head forward in relation to other parts of the body
  • Convexity of the back (rounded back) when the patient leans forward
  • Soreness in the muscles of the spine
  • Numbness in the legs due to nerve entrapment
  • Misbalance of body
  • Fatigue (especially due to increased strain on the lower limb muscles that support the body in an abnormal posture)
  • Stooping

Complicated kyphosis can lead to pain that is not relieved by medication and breathing problems due to excessive pressure.

Causes

Causes of kyphosis include: trauma and developmental abnormalities, degenerative diseases of the intervertebral discs, inflammatory and infectious diseases. In addition to the above causes, some neuro-muscular disorders can also lead to the development of kyphosis. Such conditions include:

  • Cerebral palsy.
  • Muscular dystrophy.
  • Atrophy of the spinal muscles
  • Spina bifida, myelocele, meningomyelocele, and similar congenital pathologies
  • Paget’s disease
  • Aging
  • Weakness of the muscles that support the spine
  • Scheuermann-Mau disease (juvenile kyphosis), the cause of which has not yet been identified
  • Dislocation of the vertebrae, as a result of trauma
  • Tumors of the spine
  • Infections affecting the spine (spondylitis, spondylodiscitis, etc.)
  • Connective tissue diseases

Postural kyphosis

This form is the most common. As the name suggests, this form of kyphosis is associated with slouching, which results in a rounded back. Constant stooping and carrying heavy backpacks lead to stretching of the muscles and ligaments that support the spine, resulting in postural kyphosis in patients. Among adolescent girls, this disorder is relatively more common and develops faster than in boys. The degree of the lesion can be reduced with a special set of exercises, and most importantly through a straight posture. In some cases, when wearing a corset, kyphosis may disappear completely.

The figure shows the correct position of the back while sitting on a chair

Congenital kyphosis

This type of kyphosis is the rarest. It develops in the womb and is detected at birth of the baby. With congenital kyphosis, there is a fusion of the vertebrae. Three forms of congenital kyphosis are distinguished:

  1. Half vertebra formed as a result of the presence of only the posterior part of the vertebral body
  2. Spinal segmentation disorder due to fusion of parts of the vertebrae
  3. Both causes can occur

Pictured: vertebral abnormalities that cause congenital kyphosis, hemivertebrae and spinal segmentation disorder

Patients with the congenital form of kyphosis may also have abnormalities of other systems of organs. For this reason, the doctor advises clinical tests to identify abnormalities of systems of organs. Treatment of this disease requires surgical intervention, since conservative treatment is not effective.

Scheuermann-Mau disease

This type of kyphosis begins to develop during adolescence and is named by the Danish radiologist who first described it. It is most often diagnosed between the ages of 13-16 years, especially among girls. The development of the curvature stops when growth stops. Patients with Scheuermann-Mau disease may be taller than their peers. In Scheuermann-Mau disease, several thoracic vertebrae decrease in height in the anterior regions and become wedge-shaped. This occurs because the back of the vertebrae grows faster than the front, and fusion of more than 3 vertebrae results in kyphosis with a curvature angle of more than 40 degrees. This form is the most severe and can become more severe with age.

The figure shows a healthy spine and a spine with a wedge-shaped deformity

Patients with Scheuermann-Mau disease are treated with a corset and physical therapy. But if the patient complains of increased pain and some kind of deficiency in the neuromuscular system is detected, surgical intervention is required to treat such cases.

Ankylosing spondylitis

Spondyloarthropathy is the chronic systemic inflammatory rheumatic disease. They are divided into five groups:

  1. Ankylosing spondyloarthritis
  2. Pseudarthrosis
  3. Reactive arthritis.
  4. Arthritis associated with inflammatory bowel disease
  5. Idiopathic arthritis

Ankylosing spondylitis, unlike other types of kyphosis, affects all parts of the spinal column (mainly the thoracic and lumbar parts) and impairs balance. In more severe cases, it can also affect other joints of the body. It was first described by Vladimir Bekhterev, after whom it is named.

The first symptoms of this disease are pain and stiffness, as well as decreased flexibility, due to increased rigidity of the spine. The disease first affects the sacroiliac joint, then spreads to all parts of the spinal column, hip and knee joints. With time Bekhterev’s disease leads to deformations of the physiological curves of the spine (cervical lordosis, thoracic kyphosis, and lumbar lordosis). After a certain period of time, the cervical and lumbar lordosis straightens due to fusion of the vertebral bodies, and the thoracic kyphosis further increases in size, which leads to difficulty in movement. During the movement, the pain in these patients decreases, but at night these pains increase and can wake the patient up.

Figure shows the spine of a healthy person and a patient with ankylosing spondylitis

Other symptoms:

  1. Unbearable joint pain that may wake the patient up
  2. Sense of stiffness and pain after long periods of rest and sleep
  3. Stiffness of movements
  4. The formation of a pathological forward tilt in the patient’s spine over time
  5. Patient’s inability to look forward

Figure shows normal posture and posture of a patient with ankylosing spondylitis

Treatment with medications and physical therapy is recommended for these patients. However, if conservative treatment is not effective: pain syndrome is not controlled, constant progression of spinal deformity, and most importantly: if respiratory disorders occur, surgical treatment must be performed.

Neuromuscular kyphosis

This type of kyphosis develops as a result of diseases of the brain, spinal cord and muscles. The deformity of the spinal column in neuromuscular kyphosis is caused by a weakening of the muscles that support the spine. Other conditions that cause neuromuscular kyphosis include:

  1. Metabolic and mitochondrial muscle diseases
  2. Duchenne muscular dystrophy
  3. Spinal muscular atrophy
  4. Friedreich’s ataxia
  5. Myotubular myopathy
  6. Charcot-Marie-Tooth disease
  7. Other muscular dystrophies

Diagnosis of kyphosis

Patients with pain in the thoracic and lumbar parts of spinal column should have a complete physical and neurological examination with collection of family and personal history. After palpation of the muscles supporting the spine, the patient should be asked to bend forward and examine his back from the side. By performing certain tests, it is possible to determine if the patient has a balance disorder. During the examination of patients with kyphosis, it is necessary to pay special attention to the evaluation of neurological status. We conduct an assessment of muscle strength and sensitivity, reflexes.

X-ray

X-ray examination is performed to measure the angle of kyphosis, as well as to obtain information about the condition of the spinal column. Pictures are taken in straight and lateral projections, on the basis of which the doctor identifies possible anomalies of the vertebrae and measures the angle of kyphosis. Normally, the angle of kyphosis in the thoracic part of spinal column ranges from 25 to 40 degrees. If the kyphosis angle exceeds 40 degrees, the diagnosis is hyperkyphosis.

Patients undergoing conservative treatment need to undergo X-rays once every few months, because it is necessary to compare the images to clarify the size (increase/decrease) of the angle of curvature of the spine.

MRI and CT scans

If severe pain, muscle and nerve dysfunction are detected during the patient’s examination, the MRI (magnetic resonance imaging) or CT (computed tomography) examination should be performed to find out the cause of the symptoms.

How is kyphosis treated?

The treatment methods for hyperkyphosis depend on the patient’s age, the angle of curvature and the level of its progression, the cause of occurrence, pain syndrome, and other possible symptoms.

Conservative treatment and monitoring

If a patient is diagnosed with postural kyphosis, which is most common in adolescents, you should come for a follow-up examination after 3-6 months to determine the degree of curvature (increase/decrease in the degree of curvature). In addition, the patient is prescribed physical therapy to strengthen the back muscles. For patients in the middle age group, the doctor prescribes certain medications to decrease back pain.

Corset

This method is often used to treat hyperkyphosis. It is an effective method of treatment for adolescent patients and those in whom the kyphosis angle is progressing. The purpose of using the corset is primarily to prevent the kyphosis angle from increasing during a period of increased growth, and secondarily to maintain control.

The kyphosis straps are custom made to measure. The corsets (TLSO or Boston) are created on prescription by the doctor. This is made for the purpose of applying pressure to certain areas of the spinal column. The corset can be worn under clothing and is also suitable for sports exercises and other activities. It must be worn for 16 hours a day, but this treatment is not suitable for middle-aged patients.

Surgical treatment

Surgical treatment is resorted to when conservative methods of treatment prove ineffective. The surgical method is chosen depending on the age of the patient, the cause of kyphosis, the degree and progression of the curvature. There are 3 methods of surgical treatment.

Smith-Peterson osteotomy (Posterior column wedge osteotomy with opening of anterior column)

After placement of the transpedicular screws, osteotomy of the posterior elements is performed. First, the anterior column is opened, then an angle equal to the anatomical shape of the kyphosis is given using titanium sticks, and then, after placing the screws, the posterior osteotomy sites are closed with bolts, fixed, and the operation is completed.

The figure shows the Smith-Peterson Osteotomy

Ponte osteotomy (Posterior Closing Wedge Osteotomy)

After placement of the transpedicular screws, a bilateral osteotomy is performed on the facet joints of the vertebrae that are subject to the kyphotic deformity. The deformity is then brought to the anatomically correct size, and then the spine is fixed in the correct position.

Vertebral Column Resection Pedicle Subtraction Osteotomy (Three-Column Closing Wedge Posterior Osteotomy)

In this surgery, the contents of the vertebral body are removed while leaving its sheath, which resembles an “egg shell.” After forming an angle that is equal to the anatomical angle of kyphosis, it is fixed, completing the operation.

The figure shows the Pedicled subtractive osteotomy

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