Normal spinal column appears to be a straight line on the back view. On a side view, two curvatures can be seen. The upper back extending from shoulders to the chest-rib cage has a curvature called ‘kyphosis’, on contrary the lumbar area has a curvature called ‘lumbar lordosis’. These curvatures enable head and upper body stand balanced over the pelvis.

The normal thoracic spine has a slight kyphosis between vertebrae 1 and 12 with an angle of 20 to 45. It is called ‘hyper-kyphosis’ when the curvature of upper spine is greater than 45 degrees. Scheurmann’s kyphosis is a typical hyper-kyphosis and formed as a result of wedging of vertebrae in adolescence. The cause remains unknown but is believed to be multi-factorial and it is more common in men.

The side view of normal spine on the direct radiography is similar to a rectangular shape. Anterior part of the vertebrae of thoracic spine is smaller than its posterior (to form a kyphosis). Lumbar vertebra has a reverse structure to form a lordosis. In case of congenital kyphosis, the curvature is greater than the expected local kyphosis.

The patients with congenital kyphosis and scoliosis are likely to have a defect in other organ systems. After verification of diagnosis on radiography, additional tests might be required to investigate anomalies of spinal cord, cardiac and gastrointestinal system. MRI (Magnetic Resonance) is useful to evaluate abnormal growth potential and development of spinal deformity.

The strength of child leg and the way h/she walks should be clinically evaluated. Progressed kyphosis causes a strong pressure on the spinal cord and can result in compression of the nerve roots from spinal cord, and myelopathy (deformity of structure of spinal cord). Children with nerve compression can be delayed to start walking.

Patients with congenital kyphosis have segmentation defect of vertebrae or formation defect. The deformity often progresses as the child grows. Progression of deformity is higher in the first year of life in particular depending on the rapid development of skeletal development. Segmentation defect has a lower progress and might not require a surgical intervention until adolescence period.

Treatment

Observation: Observation is the first-line treatment method in children with a spinal deformity. The difference between direct radiographies is measured and significant changes are recorded whenever the patient visits for examination. Serious and progressive congenital kyphosis deformities which are greater than 45 degrees or kyphosis cases accompanied by neurological weakness often require surgical treatment. Early surgical approach usually provides the best result and prevents progression of curvature. Procedure for surgical intervention to be performed is changed based on the nature of deformity

Corseting: Corseting is not recommended for treatment of congenital kyphosis. Clinical studies fail to assess the results of patients who have received this type of treatment.

In situ fusion: Surgical option for progressive kyphotic deformity is full fusion or arthrodesis of deformed vertebra (union of vertebrae). Fusion should also include the two normal vertebrae, the one below and the one above. The bone graft from the patient or tissue bank is placed posteriorly (on the back). In case of a seriously angled curvature, additional bone graft can be placed anteriorly (on the front). 4-6 weeks are needed until full fusion tissue is formed by bone graft. The patient should be supported with plaster or corset in this period until the full fusion is completed.

Instrumented fusion and osteotomy: Progressive kyphotic deformities may require instruments (rods, hooks and screws) in older children. If the spinal cord cannot tolerate lengthening techniques for spine, removal of the vertebra causing the deformity can be considered. The postoperative use of corset and plaster is the same until fusion is detected on the periodically taken direct radiographies.

Your surgeon might also recommend you an osteotomy to re-align the spine. “Pedincule subtraction osteotomy” provides correction by removing the bone in the back of the vertebra. Vertebral resection osteotomy can be applied to remove the front and the back of the vertebra from posterior side. Your surgeon may also recommend different surgeries including from the front and back of the spine. Our center has a worldwide-known experience in interventions of removal of the vertebra from the back.

Hyper-kyphosis (forward bend of the thoracic vertebrae beyond normal limits) is classified as postural or structural. Postural kyphosis will correct when the patient stands up straight. Patients with postural kyphosis have no abnormalities in the shape of the vertebrae.
“Scheuremann’s kyphosis is defined as rigid (structural) kyphosis. It is the most common in the ages between 12 and 15. The abnormal kyphosis is best viewed from the side in the forward-bending position.

Patients with “Scheuremann’s disease” often present with poor posture and complaints of back pain. Back pain is the most common complaint during the early adolescence period and decreases as they approach adulthood. The pain aggravates with daily activities. The kyphosis is usually symptomatic and the apex is in the mid-to-low back instead of upper back.

Treatment

Observation: Observation is often recommended in the following cases:

Postural hyper-kyphosis
Curvatures less than 60 degrees in adolescence
Curvatures with 60-80 degrees in incomplete adolescence

The control involves radiographies taken on long scoliosis cassette every six months when the standing up position. An exercise program will be recommended if the child suffers from pain.

Corset treatment: If the deformity is moderately severe (60-80) and if the patient has not completed skeletal development, the corset treatment can be recommended with an exercise program. The full-day use of (20 h a day) the corset is recommended until maximum correction is achieved. The use of the corset can be reduced to 12-14 hours a day in the final year during the process of completion of skeletal development. The corset should be used for at least 18 months to achieve a total and permanent correction.

Spinal fusion: The surgical treatment may be recommended if kyphotic deformity is serious (greater than 80 degrees) and if the patient’s back pain is increasing. Surgical treatment ensures a significant correction and no postoperative use of corset is needed. The spine is corrected and lengthened by fixing the screws placed in vertebrae with rods. The surgeries are often done from the back. The patients can go back to their normal daily activities within 4-6 months. The change made by surgical correction is visible.