Kyphosis

1 What is Kyphosis?

Kyphosis is a forward rounding of the back.

Though the thoracic spine is supposed to be curved, if the curve in a person's thoracic spine is more than 40 to 45 degrees, it is considered abnormal - or a spinal deformity and the deformity is referred to as kyphosis.

There are several kinds of kyphosis:

Postural kyphosis: the most common type, normally attributed to slouching, can occur in both old and young. In the young, it can be called 'slouching' and is reversible by correcting muscular imbalances.

In the old, it may be a case of hyperkyphosis and called 'dowager’s hump'. About one-third of the most severe hyperkyphosis cases in older people have vertebral fractures.

Otherwise, the aging body does tend towards a loss of musculoskeletal integrity, and hyperkyphosis can develop due to aging alone.

Scheuermann's kyphosis: is significantly worse cosmetically and can cause varying degrees of pain, and can also affect different areas of the spine (the most common being the midthoracic area).

Scheuermann's kyphosis is considered a form of juvenile osteochondrosis of the spine and is more commonly called Scheuermann's disease. It is found mostly in teenagers and presents a significantly worse deformity than postural kyphosis.

A patient suffering from Scheuermann’s kyphosis cannot consciously correct posture. The apex of the curve, located in the thoracic vertebrae, is quite rigid. The patient may feel pain at this apex, which can be aggravated by physical activity and by long periods of standing or sitting.

This can have a significantly detrimental effect on their lives as their level of activity is curbed by their condition; they may feel isolated or uneasy amongst peers if they are children, depending on the level of deformity.

Whereas in postural kyphosis, the vertebrae and disks appear normal, in Scheuermann’s kyphosis, they are irregular, often herniated, and wedge-shaped over at least three adjacent levels.

Fatigue is a very common symptom, most likely because of the intense muscle work that has to be put into standing and/or sitting properly. The condition appears to run in families. Most patients who undergo surgery to correct their kyphosis have Scheuermann's disease.

Congenital kyphosis: can result in infants whose spinal column has not developed correctly in the womb. Vertebrae may be malformed or fused together and can cause further progressive kyphosis as the child develops.

Surgical treatment may be necessary at a very early stage and can help maintain a normal curve in coordination with consistent follow-ups to monitor changes. However, the decision to carry out the procedure can be very difficult due to the potential risks to the child.

A congenital kyphosis can also suddenly appear in teenage years, more commonly in children with cerebral palsy and other neurological disorders.

Nutritional kyphosis: can result from nutritional deficiencies, especially during childhood, such as vitamin D deficiency (producing rickets), which softens bones and results in curving of the spine and limbs under the child's body weight.

Gibbus deformity: is a form of structural kyphosis, often a sequela to tuberculosis.

Post-traumatic kyphosis: can arise from untreated or ineffectively treated vertebral fractures.

2 Symptoms

The symptoms of kyphosis can range from causing pain to severely affecting the function of the lungs and heart. Kyphosis can be painful and cause pain primarily in the area of the kyphosis.

If the curve is severe it can begin to put pressure on the spinal cord and cause problems due to the compression of the nerves of the spinal cord. This can cause weakness in the lower extremities.

Finally if the kyphosis is in the thoracic spine the curve can make it difficult to breath and affect the function of the heart as well.

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3 Causes

In adults, kyphosis can be caused by:

  • Degenerative diseases of the spine (such as arthritis or disk degeneration)
  • Fractures caused by osteoporosis (osteoporotic compression fractures)
  • Injury (trauma)
  • Slipping of one vertebra forward on another (spondylolisthesis)

Other causes of kyphosis include:

4 Making a Diagnosis

If kyphosis is suspected in an adult, a diagnosis must be made before an appropriate treatment plan can be developed.
In order to make a proper diagnosis and rule out other possible conditions, the first step is to take a history.

The clues from history include:

  • Family History - Some types of kyphosis tend to run in families, so it may have a genetic cause. If anyone else in your family has the problem, the cause is likely genetic.
  • Date of Onset - When did you first notice the appearance of your spinal condition? If shortly after birth, the cause is likely congenital, if after trauma than mostly post-traumatic and likewise cause can be traced from the history.
  • Measured Curve Progression - If X-rays have been taken of your spine in the past, the doctor will want to see if the curve is getting worse. This can be measured comparing new x-rays with old ones, measuring the size of the curve, or measuring changes in your height.
  • The Presence or Absence of Pain - Not all cases of kyphosis produces pain. However, if there is a pain, your doctor needs to know where it is, what brings on or intensifies the pain, and if there is any radicular pain - pain that radiates away from the spine itself. This usually comes from irritation of the nerves as they leave the spine.
  • Bowel or Bladder Dysfunction - Are you having problems knowing when you have to urinate or have a bowel movement? This is extremely important because it could signal the presence of serious nerve damage.
  • Motor function - Has there been a change in how your muscles work? This may be the result of pressure on the nerves or the spinal cord itself.
  • Previous surgery - If you have had any surgery on your spine, it may have caused the kyphosis due to weakened muscles or other problems. In order to evaluate your condition properly, it is important that your physician knows about any spinal surgery you have had in the past.

The spine specialist will then perform a physical examination. During the exam, the provider will try to get an understanding of the curve in your back and how it is affecting you. This means first trying to get a "mental picture" of how the spine is curved from examining your back and watching you move about.

Your doctor will look at the flexibility you have bending in certain directions. Finally, your nerves will be tested by checking: your sensation, your reflexes, and the strength of your muscles.
Usually, after the examination, X-rays will be ordered that allow the provider to see the structure of the spine and measure the curve. During the X-rays, you will be asked to hold certain positions while standing or lying on a table.

With kyphosis the following images may be taken:

  • Front view - These are X-rays of the entire spine taken from the front.
  • Lateral view - These are X-rays of the entire spine taken from the side.
  • Lateral bend - These are X-rays taken while you are bending sideways.
  • Traction films - Traction is when your spine is pulled and held in a particular position to take X-rays. These films are only taken occasionally.

Depending on the outcome of your history, physical examination, and initial X-rays, other tests may be ordered to look at specific aspects of the spine.

The most common tests that are ordered are the MRI scan - to look at the nerves and spinal cord; the CAT scan - to get a better picture of the vertebral bones; and special nerve tests - to determine if any nerves are being irritated or pinched.

5 Treatment

Adult kyphosis has a variety of treatment options. Whenever possible, the first choice of treatment for adult kyphosis is always going to be conservative.

Spinal surgery will always be the last choice of treatment due to the risks involved. Conservative treatment that is commonly recommended includes medications, exercise, and certain types of braces to support the spine.

If osteoporosis is present, then treatment of the osteoporosis may slow the progression of the degenerative kyphosis as well. This can be accomplished in several ways.

The current recommendations include: increasing your calcium and vitamin D intake, hormone replacement therapy, and weight-bearing exercises.

The use of a spinal brace may provide some pain relief. However, in adults, it will not cause the spine to straighten. Once you have reached skeletal maturity, bracing is used for pain relief rather than prevention.

If there is a difference in the length of your legs (or if scoliosis causes you to walk somewhat crooked), special shoe inserts, called orthotics, or a simple shoe lift may reduce your back pain.

Physical therapy and exercise is an important part of treating adult kyphosis. A well-designed exercise program can also provide pain relief in many patients. A physical therapist will develop an appropriate exercise routine for your case. It is essential that you stick to the plan.

Typical advice includes:

  • • Learning correct body mechanics to maintain erect posture that counteracts the effects of the kyphosis
  • • Doing regular non-jarring exercises, such as swimming
  • • Maintaining high levels of activity
  • • Doing your daily stretching exercises

Surgery for adult kyphosis carries with it some risks. For this reason, surgery is only recommended when the risks are far outweighed by the expected benefits. Surgery will not be recommended for most cases of kyphosis.

Surgery may be recommended in the following situations:

  • Pain - The most common reason for surgery is pain relief for increasing, chronic discomfort. However, if the pain is manageable through any conservative way, surgery will not usually be recommended.
  • Progression of Curve - Progression of the kyphosis deformity is another reason for considering surgery. Surgery is recommended in this situation to prevent the problems that come from severe kyphosis.
  • Cosmetics - In some cases, the kyphosis causes physical deformity that is unbearable to the patient. In these cases, surgery is the only option for correcting the condition. Most cases of cosmetic kyphosis surgery are young adults that have very noticeable curves.

When adult kyphosis requires surgery, many different procedures may be suggested. Each case of kyphosis is somewhat different and each may require a very specialized approach for optimal results.

Surgery is suggested to solve the problems brought on by the kyphosis - not just to straighten the spine.

The goals of most surgical procedures for adult kyphosis are to:

  • Reduce the deformity (straighten the spine as much as possible)
  • Stop the progression of the deformity
  • Remove any pressure from the nerves and spinal cord
  • Protect the nerves and spinal cord from further damage

To succeed at doing these things, the spine surgeon may suggest an operation on the back of the spine, the front of the spine - or both. The goal is to first straighten the spine and then fuse the vertebrae together into one larger bone.

With any surgery, there is a risk of complications. When surgery is done near the spine and spinal cord these complications (if they occur) can be very serious.

Complications could involve subsequent pain and impairment and the need for additional surgery.

In addition, the surgical treatment of adult kyphosis may result in two special complications:

  • Flatback Deformity: The lumbar (lower) spine naturally has a "C"-shaped curve called lordosis. When the vertebrae in the lumbar spine are fused together, this lordosis curve may be lost, leaving the patient with a "flat-back" deformity. However, the loss of curve may not appear right after surgery. In fact, if the surgery it is done in a young person, the loss of lordosis may not appear until sometime between the ages of 30 to 50.
  • Pseudoarthrosis: The term "pseudo" means false and "arthrosis" refers to joint. The term "pseudoarthrosis" then means false joint. A surgeon uses this term to describe either a fractured bone that has not healed or an attempted fusion that has not been successful. A pseudoarthrosis usually means that there is motion between the two bones that should be healed, or fused, together. When the vertebrae involved in a surgical fusion do not heal and fuse together, there is usually continued pain. The pain may actually increase over time. The spinal motion can also stress the metal hardware used to hold the fusion. The screws and rods may break, leading to an increase in pain. A pseudoarthrosis may require more surgery to try to get the bones to heal. Your surgeon may add more bone graft, replace the metal hardware, or add an electrical stimulator to try to get the fusion to heal.

6 Prevention

Kyphosis cannot be prevented in all cases. However, there are ways to prevent its development. Follow certain habits like maintaining good posture, good diet, and exercise.

Periodical weight check- up and adequate intake of calcium in the diet can reduce the risk of osteoporosis and spine fractures that can cause kyphosis. Kyphosis present from birth is not preventable, but it is possible to detect and treat it early to avoid complications later.

Simple Exercise for Kyphosis. With your hands on your waist, stand straight, bend backwards, arching your back as far as you can comfortably maintain your balance. Hold for three to five seconds and repeat.

To maintain a good posture. Be consciousness of maintaining an erect posture in all your activities. Strengthen your abdominal and back muscles by means of exercise. Use a chair with good back support

7 Risks and Complications

Kyphosis can sometimes cause psychological complications related to body image or physical complications such as nerve problems or loss of bladder or bowel control.

Older children with kyphosis may become self-conscious and embarrassed about the effect of kyphosis on their appearance and body image, or the fact that they have to wear a back brace. Anything that makes them 'stand out from the crowd' can be an issue of concern.

This can affect children in different ways and some children may:

  • become socially withdrawn
  • be reluctant to take part in activities that may expose their back or the fact they have to wear a brace
  • become moody
  • be reluctant to discuss issues surrounding their treatment, or argue that they don't need any more treatment

There are no easy answers to these problems, but it can sometimes help to reassure your child that their feelings will improve with time.

Other complications of kyphosis usually only occur in more severe cases. They include:

  • persistent pain that can't be controlled with medication
  • breathing difficulties that are caused by the spine compressing the lungs and airways

Occasionally, people with kyphosis can have difficulties when the nerves that run through the spine become compressed or pinched.

This can disrupt nerve signals and cause symptoms such as:

  • a feeling of numbness or weakness in your arms and legs
  • problems with your sense of balance
  • loss of normal bladder and/or bowel control (urinary incontinence and bowel incontinence)

These serious complications require urgent medical attention and surgery would usually be recommended.

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