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Scheuermann Disease

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J. Taylor Mansfield
J. Taylor Mansfield
Matthew Bennett
Matthew Bennett
Matthew Bennett
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8/31/18, 4(21 PMScheuermann Disease - StatPearls - NCBI Bookshelf
Page 1 of 5https://www.ncbi.nlm.nih.gov/books/NBK499966/
Scheuermann Disease
Mansfield JT, Bennett M.
Introduction
Scheuermann kyphosis, also known as Scheuermann disease, juvenile kyphosis or juvenile discogenic disease, is a condition of
hyperkyphosis that involves the vertebral bodies and discs of the spine identified by anterior wedging of greater than or equal to 5 degrees in
3 or more adjacent vertebral bodies. The thoracic spine is most commonly involved, although involvement can include the
thoracolumbar/lumbar region as well.
Most commonly, diagnosis is made in adolescents aged 12 to 17 years who present after their parents notice a postural deformity or
“hunchbacked” appearance. Pain in the affected hyperkyphotic region may also be the cause of initial evaluation.
There is a hereditary component associated with this condition, although the exact mode of transmission is still unclear. This is supported by
the fact that incidence is higher in monozygotic versus dizygotic twins.
Etiology
Definitive and universally accepted etiology of Scheuermann kyphosis remains undetermined. As previously mentioned, a hereditary
component is understood to contribute to this condition's development, although the mode of transmission is still unclear.
One growing theory, supported by histologic findings, suggests discordant vertebral endplate mineralization and ossification during growth
which causes disproportional vertebral body growth and resultant classic wedge-shaped vertebral bodies that lead to kyphosis.
Epidemiology
Prevalence: 1% to 8% in the United States
Sex: Male to female ratio is at least 2:1
Age: Most commonly diagnosed in adolescents 12-17 years
Rarely diagnosed in children less than 10 years.
Classification: Type I (Classic) - Thoracic spine involvement only, with the apex of curve T7-T9Type II - Thoracic and lumbar
involvement, with the apex of curve T10-T12
Pathophysiology
Exact pathophysiology as it relates to Scheuermann kyphosis is still undetermined. Likely, genetic inheritance as well as OR resulting in
discordant vertebral endplate mineralization and ossification during growth, causing disproportional vertebral body growth with the resultant
classic wedge-shaped vertebral bodies that lead to kyphosis.
Suggested components that might explain or partially explain this condition, among many others, include abnormal collagen to proteoglycan
ratios, dural cysts, childhood osteoporosis, biomechanical stressors such as tight hamstrings, and growth hormone hypersecretion.
The most common findings associated with this disease include thoracic spine hyperkyphosis as defined by the diagnostic criteria commonly
associated with irregular vertebral endplates, Schmorl nodes, and loss of disc space height noted on sagittal imaging studies.
Histopathology
Abnormal vertebral endplate cartilage
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Irregular mineralization
Altered endochondral ossification
Decreased collagen to proteoglycan ratios (i.e., increased proteoglycan levels)
History and Physical
The adolescent will present with (1) cosmetic/postural deformity and/or (2) subacute thoracic pain. The deformity is typically appreciated in
the early-mid teenage years by child, parents, or on a school screening exam. With respect to subacute thoracic pain, there is usually no
identifiable inciting event. The pain is worse with activity and improved with rest.
Physical exam shows rigid hyperkyphotic curve, accentuated with forward bending. The hyperkyphosis does not resolve with an extension or
lying prone/supine, further supporting the “rigid” nature of this deformity. Other associated findings on an exam might include cervical or
lumbar hyperlordosis, scoliosis, and tight hamstrings. Although neurologic deficits are uncommon, a thorough neurologic exam must be
completed.
At each visit, the patient’s spinal range of motion should be evaluated in all planes of motion: flexion/extension, right/left lateral bending,
and right/left rotation. The degree of hyperkyphosis should also be followed over time via serial imaging to assess the degree of progression.
Tracking the patient’s functional range of motion as well as the degree of deformity will help guide the appropriate intervention and
prognosis.
Evaluation
History and physical along with AP/lateral radiographs comprise the essential components for evaluating Scheuermann kyphosis. Lateral
radiographs are required for diagnosis, and diagnostic criteria including the following:
Rigid hyperkyphosis, greater than 40 degrees
Anterior wedging, greater than or equal to 5 degrees in three or more adjacent vertebral bodies
Technique for Determining Degree of Kyphosis on Lateral Imaging
Line is drawn along the superior endplate of the most tilted vertebrae on the cephalad portion of the kyphotic curve
Line is drawn along the inferior endplate of the most tilted vertebrae on the caudal portion of the kyphotic curve
The angle formed by the intersection of lines perpendicular to the above-described lines is the measured Cobb angle
Hyperkyphosis is described as, measured Cobb angle greater than 40 degrees
Technique for Determining Degree of Anterior Wedging on Lateral Imaging
Line is drawn from posterior to anterior along the superior endplate
Line is drawn from posterior to anterior along the inferior endplate
The angle formed by the intersection of these lines anteriorly is the measured Wedge angle
Anterior wedging of greater than or equal to 5 degrees in three or more adjacent vertebral bodies, with an associated rigid
hyperkyphosis greater than 40 degrees, is diagnostic for Scheuermann disease
Other Associated Findings Noted on AP/Lateral Radiographs
Irregular vertebral endplates
Schmorl nodes
Loss of disc space height
Scoliosis
Spondylolysis/spondylolisthesis
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Disc herniation
Although typically not a necessity, MRI can be helpful to further evaluate anatomic changes or for pre-operative planning. CT imaging is
usually not needed. There are also no specific laboratory tests or histologic findings necessary for the diagnosis of Scheuermann kyphosis.
Treatment / Management
Nonoperative Management
1. Stretching, lifestyle modification, NSAIDs, plus/minus physical therapy
1. 2. Indication
2. Kyphosis less than 60 degrees and asymptomatic
3. Course
4. Majority of patients fall into this category
Patients typically do well without significant longterm sequelae
3. Extension bracing plus “A”
1. 4. Indication
2. Kyphosis 60 to 80 degrees plus/minus symptomatic
3. Course
4. Bracing typically required for 12 to 24 months
Most effective in skeletally immature patients
Typically, does not improve curve but rather impedes progression
5. Braces
6. Milwaukee brace
Kyphologic brace
Thoracolumbosacral orthosis-style Boston brace
Operative Management
1. Spinal fusion, typically combination of anterior release + fusion as well as posterior instrumentation + fusion
1. 2. Indications
2. Kyphosis greater than 75 degrees causing unacceptable deformity
Kyphosis greater than 75 degrees with associated pain
Neurologic deficit/spinal cord compression
Severe refractory pain
3. Course
4. Majority of patients experience symptomatic improvement as well as improved curve deformity towards normal
Operative/postoperative complications must be considered
Differential Diagnosis
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1.
2.
Postural kyphosis (flexible postural deformity)
Hyperkyphosis attributable to another known disease state
Postsurgical kyphosis
Ankylosing spondylitis
Scoliosis
Prognosis
The majority of patients are successfully treated with conservative measures as previously discussed. Pain in the affected region typically
improves after skeletal maturity is reached, although patients with Scheuermann kyphosis are at increased risk of chronic back pain as
compared to the general population.
Patients with a kyphotic curve less than 60 degrees at skeletal maturity typically have no long-term sequelae.
Complications
Potential complications
Progressive cosmetic deformity
Chronic back pain
Neurologic deficits/spinal cord compression
Postoperative complications
Pseudoarthrosis (most common complication)
Persistent pain
Postoperative and Rehabilitation Care
For surgical patients, inpatient rehabilitation might be necessary for mobility and strength training as well as aggressive postoperative pain
management.
Questions
To access free multiple choice questions on this topic, click here.
Figure
Sagittal MRI demonstrating anterior wedging of >/= 5 degrees in 3+ adjacent vertebral bodies, as described in the diagnostic criteria for
Scheuermann's kyphosis. Public image without copyright
References
Etemadifar MR, Jamalaldini MH, Layeghi R. Successful brace treatment of Scheuermann's kyphosis with different angles. J
Craniovertebr Junction Spine. 2017 Apr-Jun;8(2):136-143. [PMC free article: PMC5490348] [PubMed: 28694598]
Gokce E, Beyhan M. Radiological imaging findings of scheuermann disease. World J Radiol. 2016 Nov 28;8(11):895-901. [PMC free
article: PMC5120249] [PubMed: 27928471]
8/31/18, 4(21 PMScheuermann Disease - StatPearls - NCBI Bookshelf
Page 5 of 5https://www.ncbi.nlm.nih.gov/books/NBK499966/
3. Patel DR, Kinsella E. Evaluation and management of lower back pain in young athletes. Transl Pediatr. 2017 Jul;6(3):225-235. [PMC
free article: PMC5532202] [PubMed: 28795014]
Publication Details
Author Information
J T. Mansfield ; Matthew Bennett .
Georgetown Medstar NRH
UHS Wilson Medical Center
Publication History
Last Update: April 20, 2018.
Copyright
Copyright © 2018, StatPearls Publishing LLC.
This book is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use,
duplication, adaptation, distribution, and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, a link is
provided to the Creative Commons license, and any changes made are indicated.
Publisher
StatPearls Publishing, Treasure Island (FL)
NLM Citation
Mansfield JT, Bennett M. Scheuermann Disease. [Updated 2018 Apr 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.
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A Holistic Approach to Physiotherapy Treatment for Scheuermann Disease Along With Lumbar Canal Stenosis and Bilateral Lower Limb Radiculopathy: A Case Report
Article
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  • Aug 2024
Scheuermann disease, a structural deformity marked by kyphotic alterations in the thoracic or thoracolumbar spine, is frequently accompanied by back discomfort and spinal wedging. Scheuermann disease predominantly affects the thoracic and thoracolumbar parts of the spine; thus, there is an indirect link between the two conditions. This case report describes a rare form of Scheuermann illness in which lumbar canal stenosis caused bilateral lower limb radiculopathy. A 50-year-old male with a confirmed diagnosis of Scheuermann illness complained of severe back discomfort, developing bilateral lower limb weakness, and sensory impairments. Clinical and radiographic investigations indicated lumbar canal stenosis at multiple levels, resulting in nerve root compression and radiculopathy. MRI reports of the lumbosacral spine were suggestive of severe, multiple-level degenerative changes. Spinal canal stenosis was noted at lumbar levels. Following the investigation findings suggestive of Scheuermann disease, the patient underwent posterior decompression and spinal fixation of L3-L4 and L4-L5. The outcome led to the decompression of the lumbar canal and the stabilization of the affected spinal segments. A personalized postoperative rehabilitation plan was developed based on the patient's complaints of pain, stiffness, and the difficulties he faced associated with the disease. Overall physiotherapy rehabilitation plays an essential role in the overall care of Scheuermann's illness and postoperative lumbar spine disease, aiding in functional restoration, enhancing quality of life, and encouraging long-term spinal health. Although exercise therapy is intense, it shows promising results and is beneficial for these conditions. Physical therapy in the postoperative period plays a significant role in promoting the patient's functional independence.
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Scheuermann's Disease in Young Adults: A Case Report
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  • Nov 2022
Scheuermann kyphosis, also known as Scheuermann disease, juvenile kyphosis, or juvenile discogenic disease, is a condition involving an abnormal, excessive curvature of the spine. It involves both the vertebral bodies and discs of the spine and is characterized by anterior wedging of greater than or equal to 5 degrees in three or more adjacent vertebral bodies. Type 1 Scheuermann's disease involves the thoracic spine, whereas type 2 involves both the thoracic and lumbar spine. Although no definitive cause for Scheuermann's disease has been found, we have reported a case that may explain further about this disease. This article elucidates a case of a 19-year-old boy experiencing pain in the lower back and showing various signs and symptoms of Scheuermann's disease and the diagnosis and steps taken by doctors toward its treatment.
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Clinical Manifestations and Diagnosis of Axial Spondyloarthritis
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Background: Axial spondyloarthritis (axSpA) is a chronic, rheumatic disease characterized by inflammation of the sacroiliac joint, spine, and entheses. Axial spondyloarthritis affects up to 1.4% of adults in the United States and is associated with decreased quality of life, increased mortality, and substantial health care-related costs, imposing a high burden on patients, their caregivers, and society. Summary of work: Diagnosing axSpA can be difficult. In this review, we seek to help rheumatologists in recognizing and diagnosing axSpA. Major conclusions: A discussion of challenges associated with diagnosis is presented, including use and interpretation of imaging, reasons for diagnostic delays, differences in disease presentation by sex, and differential diagnoses of axSpA. Future research directions: The early diagnosis of axSpA and advances in available therapeutic options have improved patient care and disease management, but delays in diagnosis and treatment remain common. Additional research and education are critical for recognizing diverse axSpA presentations and optimizing management early in the course of disease.
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Successful brace treatment of Scheuermann's kyphosis with different angles
Article
Full-text available
  • Apr 2017
  • J Craniovertebr Junction Spine
Background: Scheuermann's disease is regarded as the most common cause of structural hyperkyphosis within adolescents without any proper treatment. It may lead to progressive deformity and back pain which influences patient's quality of life during adolescence and adulthood. Treatment approach to Scheuermann's kyphosis has not been clearly defined due to its different definitions and obscure natural history. The goal of treatment is not only to prevent progression but also to obtain permanent correction. Bracing, especially Milwaukee brace and physiotherapy are two of the common nonoperative treatment modalities. Hence, the present study intended to evaluate the effectiveness of Milwaukee brace on progression control as well as correction of Scheuermann's kyphosis. Materials and Methods: In a retrospective, observational study, all the patients diagnosed with Scheuermann's kyphosis were reviewed in 2003–2013, who were treated by Milwaukee brace at a single center. There was a minimum of 2-year follow-up after completion of bracing, during which clinical and radiological parameters were identified and recorded. Results: The mean angle of kyphosis in these patients at the presentation was 63.24 ± 9.96 and at the end of this study was 36.5° ± 13.4° (P < 0.001). Moreover, mean improved angle in those patients with
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Radiological imaging findings of scheuermann disease
Article
Full-text available
  • Nov 2016
AIM To find accompanying anomalies of typical and atypical Scheuermann’s disease (SD) is reported in the present study. METHODS Study included 20 patients (16 men and 4 women) who had radiological imaging radiography, magnetic resonance imaging (MRI) and computed tomography, if available, due to back pain, curved back and low back pain in November 2011-February 2016 period. Patients were categorized into typical and atypical patterns based on the region involved. Thoracic kyphosis values were measured using real Cobb angle. Accompanying disc degeneration, herniations and spinal cord pathologies were studied using MRI. RESULTS Age of the patients ranged from 11.0 to 23.0 (mean 17.2 ± 3.0). Typical pattern of SD were detected in 15 patients while atypical pattern were detected in 5 patients. Cobb angle range was 40.2-67.2 (mean 55.5 ± 8.7) in typical Scheuermann’s patients and 24.7-49.9 (mean 36.7 ± 10.8) in atypical ones. Intervertebral level was affected and had the measures of 3-8 (mean 5.3 ± 1.6) and 7-9 (mean 8.2 ± 0.8) in typical and atypical Scheuermann’s patients, respectively. Level of degenerative disc disease in MRI was 1-7 discs (mean 4.1 ± 1.7) in typical patients and 5-10 discs (mean 7.6 ± 1.9) in atypical patients. CONCLUSION SD can be seen in typical and atypical patterns, typical being more frequent. Because degenerative disc diseases, herniations and cord pathologies such as syringomyelia can accompany SD (albeit more common in atypical pattern), it is necessary to evaluate these patients with plain radiography and MRI together.
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Evaluation and management of lower back pain in young athletes
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  • Jul 2017
Lower back pain in young athletes is a common problem. The prevalence of back pain from different causes in adolescent age group is between 20% and 30%. However, the incidence of low back pain in young athletes varies widely in different sports. Overuse injuries are the most common cause of low back pain in young athletes. In case of overuse injuries, the cause and effect relationship between back pain and specific condition is often difficult to establish. In adolescent athletes, the most common underlying identified cause of low back pain is lumbar spondylolysis. During adolescent growth spurt, the severity of the pain generally correlates with adolescent growth spurt. Participation in sports starting at an early age and for a longer duration tends to increase the risk for back pain. Numerous conditions cause low back pain in athletes. These include acute trauma, chronic overuse or repetitive trauma, and referred pain. Our focus in here will be on selected conditions that cause recurrent or chronic low back pain.
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