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Kyphosis or hunching
over is normal in the thoracic spine. If you
look at your child from the side, you will
notice that there is a curve in the upper back
where they are "hunched over," and a curve in
the lower spine ("sway back"). Some kyphosis is
normal. When the doctor measures it on an x-ray,
the normal range for kyphosis is quite broad,
between 20 to 50 degrees. However, when kyphosis
is greater than 50 degrees, it becomes easy to
see and is considered abnormal. Most parents
will attribute this to "poor posture," but
become concerned that despite their persistent
reminders, their child will not stand up
straight.
The evaluation of
kyphosis begins by viewing the child from the
side. There are no clear visual clues that
distinguish normal from abnormal kyphosis. The
doctors experience is usually the best indicator
for when the amount of kyphosis is abnormal. The
kyphosis may be accentuated with forward
bending. One should look for concomitant
scoliosis and other spinal problems as a routine
part of the kyphosis examination.
If excessive kyphosis is
suspected, then x-rays are required in order to
measure the degree of kyphosis. The x-ray should
be taken in the standing position. The
examination requires that the x-ray be done on a
long x-ray cassette so that your doctor can
accurately measure the amount of kyphosis and
look at the overall balance of the spine.
There are two common
forms of kyphosis encountered in the teenage
population: Scheueremann's kyphosis and postural
roundback. Scheueremann's kyphosis is most
common in teenage boys. It is characterized by a
short, sharp kyphosis in the middle part of the
upper spine, and may be associated with aching
back pain. The kyphosis tends to be rigid on
clinical examination. There are x-ray criteria
that establish a diagnosis of Scheueremann's
kyphosis that can be seen on the x-ray. A mild
degree of scoliosis is common in adolescents
with Scheueremann's kyphosis.
Postural roundback is
noted by a smooth, flexible kyphosis that is not
typically associated with pain. The curve is
easily corrected by asking the child to stand up
straight. Radiographically, the criteria for the
diagnosis of postural roundback are kyphosis
greater than 50 degrees, but without the other
x-ray findings seen with Scheueremann's
kyphosis. These curves tend to be mild in
severity and extend over a longer number of
vertebral segments when compared to
Scheueremann's kyphosis.
Treatment decisions
regarding kyphosis are based upon the expected
natural history, the degree of deformity, the
risk of progression during and after growth, and
the severity of symptoms associated with the
kyphosis.
Treatment options for
kyphosis include observation, bracing or
surgery. Kyphosis below 50 degrees requires no
treatment. Kyphosis between 50 and 75 degrees,
where there is significant growth remaining or
persistent back pain, may be managed in a brace.
Kyphosis bracing is technically difficult, and
the brace must be custom made to properly fit
the child. It requires a three-point bend to
achieve correction of the curve while wearing
the brace. Unlike scoliosis bracing, kyphosis
bracing may produce sustainable correction of
the curve if worn consistently during
growth.
Surgery is reserved for
curves greater than 75 degrees, where there is
concern that there will be gradual progression
after the completion of growth or in late adult
life when there is a progressive loss of bone
mass. Surgical treatment consists of both a
correction of the deformity using spinal
instrumentation and fusion of the involved
portion of the spine to prevent progression
later in life.
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