Kyphosis - Lecture 2013

8/13/2019 Kyphosis - Lecture 2013

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KyphosisDr. Dibyendunarayan Bid


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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
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Definition / Description

Kyphosis refers to the normal apical-dorsal sagittal contourof 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 sagittalplane, or it can occur in association with an abnormality inthe coronal plane, resulting in kyphoscoliosis.

Many potential etiologies of kyphosis have been identified.


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Classification of Kyphosis

Winter and Hall have classified kyphosis into 15 majorgroups:3

I. Postural disorders

II. Scheuermannskyphosis

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)


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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)


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IX. Inadequate fusion A. Too short

B. Pseudoarthrosis

X. Postirradiation A. Neuroblastoma

B. Wilmstumor

XI. Metabolic A. Osteoporosis (juvenile or senile)

B. Osteogenesis imperfecta


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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


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Problem

Normal kyphosis is defined as a Cobb angle of 20-40 measured from T2-T12.

Pathologic kyphosis can affect the cervical andlumbar spine as well the thoracic spine, butcervical and lumbar involvement is uncommon.Any kyphosis in these areas is abnormal.

Kyphosis can cause pain and potentially lead toneurologic deficit and abnormal cardiopulmonaryfunction.


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Etiology

Many potential causes of kyphosis have been described.

Scheuermann disease and postural round back are oftenidentified in adolescents.

Congenital abnormalities, such as failure of formation orfailure of segmentation of the spinal elements, can cause apathologic kyphosis.

Autoimmune arthropathy, such as ankylosing spondylitis,can cause rigid kyphosis to develop as the spinal elementscoalesce.


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Kyphosis can also develop as a result of trauma, aspinal tumor, or an infection.

Iatrogenic causes of kyphosis include the effectsof laminectomy and irradiation, which lead toincompetence of the anterior or posteriorcolumn.

Finally, metabolic disorders and dwarfingconditions can lead to kyphosis.


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Pathophysiology

The pathophysiology of kyphosis depends onthe etiologic factor.

The exact cause of Scheuermann disease isstill imprecisely defined.

Scheuermann postulated that the conditionresulted from avascular necrosis of theapophyseal ring.


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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.


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Postural kyphosis is present when

accentuated kyphosis is observed without the

characteristic 5 of wedging over 3

consecutive vertebral segments that definesScheuermann kyphosis.

This is felt to be due to muscular imbalanceleading to the round-back appearance of

these individuals.


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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.


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Presentation

Patients with a symptomatic kyphosis often presentwith axial back pain.

They may also be concerned about the cosmesis of

their rounded back.

Patients with kyphosis should be carefully questionedabout and examined for neurologic problems,

especially myelopathy.

Difficulty with gait and hyperreflexia should promptfurther investigation of the kyphosis.


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A 10- to 42-year, natural-history study of Scheuermanndisease revealed that patients, as compared with acontrol group, tended to have increased back pain.

However, they were not more likely than the controlgroup to take pain medication, to have sedentary jobs,or to lose motion of the spine.

The investigators found no differences in educationallevel, absenteeism, self-consciousness, or reports ofnumbness in the legs.

Of interest, restrictive lung disease was observed inpatients with a curve greater than 100.


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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 havenot been elucidated.


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Authors from early clinical series simply cited pain ordeformity as reasons to perform fusion.

Proposed indications more specific than these arekyphosis greater than 75, kyphosis greater than 65with pain, and an unacceptable appearance of thetrunk.

Other possible indications in severely affected patientsare problems with balance while sitting and skinproblems due to pressure at the apex of the deformity.


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Surgical intervention for posttraumatic

kyphosis is recommended:

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%.


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Contraindications

Contraindications to surgery for kyphosis

include a clinically significant cardiopulmonary

risk and medical unfitness for surgery.


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Laboratory Studies

Standard laboratory results should be evaluatedwhenever surgical intervention is being considered.

The laboratory workup should include determination ofa complete blood count, coagulation studies, androutine chemical analyses.

Autodonation of blood can be recommended to thepatient in anticipation of the need for intraoperativetransfusion.


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In patients with a known or suspected infectiousetiology, the sedimentation rate and C-reactiveprotein level should be measured to help identify

a potential infection or to help track the progressof treatment.

Before a major operation, the patient's

nutritional status might also be checked, becauseit considerably influences a patient's ability toheal.


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Measurements are made on radiographs by using thestandard Cobb technique for scoliosis, which has beenadapted to the measurement of kyphosis.

Thoracic kyphosis is measured from T1-T12, though theupper thoracic vertebral endplates are often difficult tosee.

Normal measurements for thoracic spine vary widely,but the accepted definition of normal according to theScoliosis Research Societyis 20-40.

A plumb line dropped from C7 should pass through orjust anterior to S1 on a lateral full-length image. Thistechnique helps in assessing and quantifying thepatient's overall sagittal alignment.
http://www.srs.org/http://www.srs.org/http://www.srs.org/http://www.srs.org/


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Radiographs obtained with the patient in a supinelateral hyperextension position over a bolster can beused to determine the flexibility of the curve.

This information is useful in surgical planning.

A flexible curve is best corrected with only posteriorfusion, whereas an anterior only or combined anteriorand posterior procedure may be needed for a stiffcurve.

A curve that corrects to 50 or less on hyperextensioncan be treated with posterior-only fusion.

Postural kyphosis is rarely more than 60, and it shouldcorrect to normal with hyperextension.


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Magnetic resonance imaging

MRI can be a useful adjunct in planningtreatment for patients with kyphosis. If aneurologic abnormality is present, MRI may aid inlocalizing impingement on neural structures.

If surgery is being planned for the treatment ofpostinfectious kyphosis, an MRI helps in planningan anterior approach with regard to the amountof resection needed (if any) to remove diseasedbone.


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Other Tests

Ensuring the adequacy of bone density is imperativewhen surgical correction of kyphosis is beingconsidered.

Correction of the kyphosis relies on instrumentation toreduce the spine, and considerable forces are placedon the instrumentation-bone interface.

Osteopenic bone can predispose to loss of correctionover time, if the instrumentation cuts through therelatively less dense vertebrae.


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If a patient's bone density is in question, bonedensitometry can be perform to quantify it.

Efforts should be made to a patient's improvebone density before and following surgery.

When bone density is poor, the surgeon mustusually increase the number of points offixation to reduce the stress at each point.


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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.


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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.


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Bracing is effective in some skeletally immature patients withScheuermann kyphosis.

However, the correction obtained may diminish as patientsapproach 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 abrace, with some correction of their deformities.


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Surgical therapy

Surgical planning for kyphosis is crucial to asuccessful 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.


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Posterior arthrodesis for kyphosis can be an

extensive operation, with many spinal segmentstypically included in the fusion mass.

This procedure is most helpful for long, sweeping,

flexible curves.

In cases of rigid deformity, osteotomies can beperformed to improve the correction.

Combined anterior-posterior surgery may berequired for severe deformities.


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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.


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Pedicle-subtraction osteotomy is relatively aggressiveresection of a wedge of bone, including posteriorelements, the pedicles, and the vertebral body.[24]

Vertebral column resection entails removal ofposterior elements, the vertebral body, and adjacentdisk material. Both anterior and posterior fixation are

often required because of the destabilizing effect ofthis resection.

As kyphosis becomes notably sharp and/or focal,increasingly aggressive techniques are required forcorrection.

Procedures involving the anterior column are usuallyfollowed by posterior instrumentation and fusion.


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Anterior surgery

Anterior surgery can include single or multiplediskectomies to increase the flexibility of thespine, followed by a posterior arthrodesis.

The transthoracic approach allows fordecompression of the neural elements before thespine is corrected with posterior instrumentation.

Anterior-only fusion is most useful in relativelyshort and focal kyphosis, such as posttraumatic orpostinfectious kyphosis.[16]


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A novel technique for single-curve scoliosis may also beused to correct kyphosis.

The bone-on-bone technique involves an anterior-onlyapproach to perform complete annulectomy anddiskectomy at each level in the Cobb angle of thedeformity.

Then, using sequential compression along 2 rods,which are affixed with a staple and 2 screws in eachvertebral level, the surgeon brings the bony endplatesinto immediate contact.

Substantial correction can be achieved in thismanner.[26]


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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]


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Follow-up

Standing posteroanterior and lateral full-lengthradiographs of the spine should be obtained as soon aspossible after surgery and serially for follow-up.

Full-length scoliosis films obtained yearly allowevaluation of the patient's curve over time.

Comparison of the postoperative and follow-up imageswith the preoperative images helps in defining theamount of correction achieved and in determining ifcorrection is being lost over time.


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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 centimetersof S1.


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Outcome and Prognosis Results of surgical correction vary depending on the etiology

of the deformity.

1. Deformity correctionwas moderate.

2. Pain reliefupto very good extent.

3. Improvement in preoperative neurologic deficit seen.

4. Improvement in pain score and Oswestry Disability

Index seen.


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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 differa lot from what is described in literature.


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Stretching of pectoralis muscels, passive and activeredression of the kyphotic hump are the mainprinciples of physical exercises besides the work on thelower extremity muscles within the Schroth exerciseprogram.

Especially the "two stool" exercise as shown on Figure4and the "door frame exercise" (Fig. 5) showselements of muscle stretching and redression of the

thoracic kyphosis.

[Redress: To compensate or set a situation right.]
http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/


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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, isdirectly related to chronic low back pain in

adulthood.


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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-logicexercises 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 seenin Figure 6and 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 ofevidence there is for in-patient rehabilitation.

In general in-patient rehabilitation does not seem necessary

or even indicated.
http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/


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Future and Controversies

As surgical implants and techniques haveimproved, so have results of surgery.

Patient safety should be the foremost goal ofthe treating physician.

Future prospective trials will help in definingthe best way to care for patients with clinicallysignificant sagittal imbalances.


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Outcome measures

Scoliosis Research Society Scores

Oswestry Disability Index


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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
http://emedicine.medscape.com/article/1264959-overviewhttp://cirrie.buffalo.edu/encyclopedia/en/article/125/http://www.srs.org/patient_and_family/kyphosis/http://www.spineuniverse.com/conditions/kyphosis/kyphosis-description-diagnosishttp://www.spineuniverse.com/conditions/kyphosis/kyphosis-description-diagnosishttp://www.spineuniverse.com/conditions/kyphosis/kyphosis-description-diagnosishttp://www.spineuniverse.com/conditions/kyphosis/kyphosis-description-diagnosishttp://www.spineuniverse.com/conditions/kyphosis/kyphosis-description-diagnosishttp://www.spineuniverse.com/conditions/kyphosis/kyphosis-description-diagnosishttp://www.spineuniverse.com/conditions/kyphosis/kyphosis-description-diagnosishttp://www.spineuniverse.com/conditions/kyphosis/kyphosis-description-diagnosishttp://www.srs.org/patient_and_family/kyphosis/http://www.srs.org/patient_and_family/kyphosis/http://www.srs.org/patient_and_family/kyphosis/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://cirrie.buffalo.edu/encyclopedia/en/article/125/http://emedicine.medscape.com/article/1264959-overviewhttp://emedicine.medscape.com/article/1264959-overviewhttp://emedicine.medscape.com/article/1264959-overviewhttp://emedicine.medscape.com/article/1264959-overview

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Kyphosis - Lecture 2013