The Spine Journal 2 (2002) 4956

Scheuermann kyphosis: long-term follow-up

C.L. Soo, MD, Philip C. Noble, PhD, Stephen I. Esses, MD*
Barnhart Department of Orthopedic Surgery, Baylor College of Medicine, 6560 Fannin, Suite 1900, Houston, TX 77030, USA Received 3 October 2000; accepted 12 October 2001

Abstract

Background context: There is considerable controversy as to the optimal treatment of Scheuermann kyphosis. Proposed modalities have included exercise, bracing and surgery. Purpose: The purpose of this study was to document the functional capacity and radiographic findings in adults who have been previously treated for Scheuermann kyphosis. Study design: A cohort study of all patients with Scheuermann kyphosis treated in a single institution using three different treatment modalities: exercise and observation, Milwaukee bracing and surgical fusion using the Harrington Compression System. Patient sample: Sixty-three patients were evaluated at a mean of 14 years after treatment (10 to 28 years). Outcome measures: Two different functional evaluation instruments were used. Radiographic evaluation was carried out in 38 patients (60%). Methods: Patient interviews were conducted using a specially designed questionnaire. Patients were then asked to undergo standing radiographs. Patients were divided into groups depending on the location of their kyphosis and the manner in which they had been treated. Standard statistical analysis was then carried out. Results: At time of follow-up evaluation there were no differences in marital status, general health, education level, work status, degree of pain and functional capacity between the various curve types, treatment modality and degree of curve. Patients treated by bracing or surgery did have improved self-image, which they attributed to their treatment. Patients with kyphotic curves exceeding 70 degrees at follow-up had an inferior functional result. At time of final follow-up there were no statistical differences in degree of kyphosis and mode of treatment. Conclusions: By carefully selecting the appropriate treatment for patients with Scheuermann kyphosis on the basis of the patients age, spinal deformity and the severity of back pain, it is possible to achieve a similar functional result at long-term follow-up. Despite different treatment protocols, patients with Scheuermann kyphosis tend to achieve a similar functional result at long-term followup. 2002 Elsevier Science Inc. All rights reserved.
Scheuermann kyphosis; Exercise therapy; Bracing; Spinal fusion

Keywords:

Analysis of outcome by method of treatment Patients receiving each of the three treatment modalities differed in terms of their age and sex and the anatomic location of their deformity, but not with respect to their marital status, general health or educational background. Male patients predominated in the groups treated with observation and exercise (78%) and bracing (66%), whereas approximately half (54%) of those treated with surgery were feFDA Device/drug status: Not applicable. Nothing of value received from a commercial entity related to this research. * Corresponding author. Barnhart Department of Orthopedic Surgery, Baylor College of Medicine, 6560 Fannin, Suite 1900, Houston, TX 77030, USA. Tel.: (713) 986-5740; fax: (713) 986-5741.

male. Patients treated with bracing were younger (12.2 years) than those receiving observation and exercise (13.6 years, p.01) and those treated surgically (13.5 years, p.02) at both the time of onset of the deformity and at the time of initial treatment (14.0 years vs. 19.9 years, p.002, and 21.1 years, p.0001). Most patients (53, 84%) presented with deformities of the thoracic spine. Only two patients had lumbar curves; both were treated with surgery. Of the eight patients with thoracolumbar kyphoses, four (50%) were treated with bracing and three (38%) with surgery. There were also significant differences among the three treatment groups with respect to the severity of the spinal curvature and the effect of each treatment on the kyphotic deformity. Before treatment, patients in the exercise group had an average kyphotic curvature of 57.52.3 degrees,

1529-9430/02/$ see front matter 2002 Elsevier Science Inc. All rights reserved. PII: S1529-9430(01)00 1 6 8 - 1

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C.L. Soo et al. / The Spine Journal 2 (2002) 4956

compared with 64.51.9 degrees for the brace group (p.02), and 73.63.0 degrees for the surgery group (p.002). Patients treated with exercise and observation experienced a negligible change in deformity (average reduction, 2.0 degrees), whereas bracing reduced the kyphosis by an average of 13.1 degrees, and surgical fusion by 36.4 degrees. As a result, patients in the bracing and the exercise groups had a similar degree of curvature after treatment (51.4 vs. 53.5 degrees, p.64). In comparison, the average postoperative deformity of the surgical group was 37.2 degrees, approximately 20 degrees less than patients in both the brace and exercise groups (p.0008, p.0002), despite the larger preoperative curvature of the surgical patients. At follow-up, a limited number of radiographs were available to document the change in curvature of patients in the brace and exercise groups. Nonetheless, there appeared to be no change in the kyphotic deformity in the exercise group, a minimal increase (1.2 degrees) in the average curvature of the brace group and a substantial loss (20.3 degrees) of correction in the surgery group (Figs. 1 and 2). The loss of surgical correction corresponded to approximately half of the total reduction in curvature achieved intraoperatively. Nonetheless, the average deformities of all three groups at follow-up were relatively similar (exercise group, 57.5 degrees; brace group, 51.1 degrees; surgery group, 59.2 degrees). There were minimal differences among the three treatment groups in terms of their ability to work without restriction, to perform tasks that involved lifting or sitting, the ex-

tent to which back pain interfered with each patients work or the frequency of missing days at work because of back pain (Table 1). The brace group experienced the lowest severity of back pain and the least fatigue with work activities, whereas patients treated with surgery reported the greatest levels of fatigue and back pain. There were few differences among the three groups with respect to impairment of daily living activities because of back pain. The ability of patients to sleep through the night, sit for more than 1 hour, travel long distances by car, climb stairs or bend or kneel posed a similar degree of difficulty to all three groups. In addition, no differences were reported in the patients sexual activities, their ability to perform personal care activities or their level of social activities. However, patients treated with bracing reported the lowest severity of pain in performing daily living activities. They also had the least difficulty in sleeping through the night, and running, turning or twisting, whereas the surgery group had the greatest tolerance of standing. Patients treated with exercise or bracing also reported approximately one third as many days of restricted activity because of back pain compared with the surgery group. Sixty percent of patients believed that the severity of their spinal deformity had not changed during the period since treatment. This perception did not vary significantly with the method of treatment. In addition, 44% percent of patients believed their height had not changed, especially those who had undergone surgery. Patients treated with surgery or brace believed there was a perceptible improvement

Fig. 1. (Left) Standing lateral radiograph of patient with Scheuermann kyphosis before bracing. The kyphotic deformity measures 60 degrees. (Middle) Standing lateral radiograph of the same patient in a Milwaukee brace. The curve has been reduced to 37 degrees. (Right) Follow-up standing lateral radiograph at 10 years after treatment. The curve now measures 56 degrees.

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Fig. 2. (Left) Preoperative standing lateral radiograph of patients with Scheuermann kyphosis. The curve measures 79 degrees. (Middle) Postoperative radiograph of same patient. Curve measures 36 degrees. (Right) Follow-up lateral radiograph at 10 years after treatment. The curve again measures 79 degrees.

in physical appearance and self-image as a result of their treatment. Patients in all three treatment groups reported no difference in difficulty buying clothes or problems wearing any kind of clothes. Analysis by anatomic location of the deformity Patients with thoracic, thoracolumbar or lumbar kyphoses did not differ in terms of gender or education level of the patient, their age at onset of the deformity and at the time of their initial visit. The small subgroup of eight patients with thoracolumbar curves reported worse general health than those with thoracic or lumbar deformities (p.004). The current work status of the patients was not related to the level of curvature. Similarly, the ability to lift objects, to walk, stand, sit or to perform work tasks requiring reaching or bending did not vary with curve level. No differences were reported in the severity of pain or fatigue resulting from work or the number of days missed from work because of back symptoms. The number of days on which activity was limited by back pain was also similar for each group. The patients ability to perform physical activities were also unaffected by the type of Scheuermann kyphosis. These activities included the ability to sleep through the night, to sit or to stand for more than 1 hour, to walk more than a mile, to climb several flights of stairs, to run or to turn or twist. In addition, the patients reported no significant differences in their social life, their personal care and their ability to perform sexually. The degree of deformity did not correspond to the ability of patients to perform any of the activities of daily liv-

ing. The level of the deformity was also unrelated to each patients perception of the cosmetic appearance of their back or their assessment of their change or self-image. Analysis by the severity of the kyphotic deformity At the time of most recent follow-up, 30 patients had curves of less than 70 degrees (mean, 50 degrees; range, 29 to 68 degrees) and 8 patients had curvatures greater than 70 degrees (mean, 78 degrees; range, 70 to 90 degrees). Patients with larger curves at follow-up tended to have more deformity before treatment, although this effect was not statistically significant because of the small number of cases and the variability of the data. There was no difference regarding sex distribution, marital status, general health and educational level between patients with deformities greater than or less than 70 degrees at follow-up. At follow-up, the functional capacity of patients with curves greater than 70 degrees was highly variable. Consequently, it was not possible to identify an association between the severity of the kyphotic deformity and the ability of patients to perform lifting, standing, sitting, reaching or bending in their work activities. Moreover, there was no difference in the extent to which both groups required adjustments to their work environment or the difficulty experienced in performing occupational tasks. Patients with curves of more than 70 degrees did report greater difficulty in standing, lifting and carrying, and activities necessitating turning and twisting. During work activities, they also experienced twice the severity of back pain as the less kyphotic

52 Table 1 Demographic and Outcome Measurement Demographic

C.L. Soo et al. / The Spine Journal 2 (2002) 4956

Name: _________________________________________________Address: _________________________________________________ D.O.B.: _____________________ Sex: __________ Phone: ________________________________ W ________________________________ H ________________________________ Marital status: ___________ General health: ___________ Age of onset: ___________ Age at initial visit: ___________ Education level (a) Above college ___________ (b) College ___________ (c) High school ___________ (d) Below high school ___________ Radiographs Type of Scheuermanns: ___________________________________ (From to ) Apex of curve: ___________________________________ Wedging: ___________________________________ Degree of curve (thoracic kyphosis/lumbar lordosis) Pre RxPost RxNow __________________________________________ Rx: _____(a) OBS exercise (b) Milwaukee brace (c) Spinal fusion Pain and function Work What is your current work status? (a) ___Unrestricted, working (b) ___Unrestricted, unemployed (c) ___ Restricted due to back pain, working (d) ___Restricted due to back pain, unemployed (e) ___Not able to work at all due to back pain The extent that your work involves lifting, walking, standing, sitting, reaching or bending (a) How much of your work involves lifting _____% (b) How much of your work involves walking _____% (c) How much of your work involves standing _____% (d) How much of your work involves sitting _____% (e) How much of your work involves reaching or bending _____% Do you have back pain at work? _____(yes); _____(no) To what extent does your back pain interfere with your work? (a) No interference _____ (b) Small amount _____ (c) Moderate amount _____ (d) Totally incapable of work _____ To what extent has your back pain caused you to modify your work so that you can do your job? (a) No adjustment to work _____ (b) Mild adjustment _____ (c) Moderate adjustment _____ (d) So much adjustment that you have to change your job _____ During the past 4 weeks, have you had any of the following problems with your work due to back pain? (a) Cut down the amount of time you spent on work _____ (b) Accomplished less than you would like _____ (c) Were limited in the kind of work you could do _____ (d) Had difficulty performing your work _____ (e) Had no problems _____ In the past 4 weeks, how many days of work have you missed due to back problems? _____ Severity of back pain related to work_____(010) (0 no pain; 10 intolerable pain) Treatment for this back pain Type of treatment (a) Narcotics (b) Prescription (c) OVC (d) None Frequency_____(times/day) Relief_____(yes/some/no) (continued)

C.L. Soo et al. / The Spine Journal 2 (2002) 4956 Table 1 Continued Degree of back fatigue related to work_____(010) (0 no fatigue at all; 10 the back is so tired you can only lie down) Daily activity How much difficulty do you experience, due to back pain, in performing the following tasks? (On a scale of 05; 0 not difficult at all; 1 minimally difficult; 2 somewhat difficult; 3 fairly difficult; 5 unable to do) Not difficult (a) Sleep through the night 0 1 (b) Sitting more than 1 hour 0 1 (c) Stand more than 1 hour 0 1 (d) Sex (N/A) 0 1 (e) Walking more than a mile 0 1 (f) Walking a few blocks 0 1 (g) Walking one block 0 1 (h) Traveling in a car 0 1 (i) Personal care 0 1 (j) Climbing several flights of stairs 0 1 (k) Climbing one flight of stairs 0 1 (l) Lifting or carrying grocery 0 1 (m) Moderate activity (moving a table; house cleaning) 0 1 (n) Running 0 1 (o) Social life (dancing, games, going out, etc.) 0 1 (p) Turning and twisting 0 1 (q) Bending, kneeling, reaching 0 1 How many days a week are your activities limited by back pain?_____ How severe is your back pain in performing daily activities?_____(010) (0 no pain; 10 intolerable pain) To what degree do you rely on pain medications for you to be comfortable while performing daily activity? (a) None_____ (b) Some_____ (c) All the time_____ Type_____ (a) Narcotics (b) Prescription (c) OVC Relief_________(yes/some/no) Most sports involvement (a) Golf (b) Jog (c) Tennis, baseball, soft ball (d) Walk (e) Weight lifting (f) Swimming (g) Skiing (h) Bowling, Ping-Pong (I) Fishing (j) Football, basketball (k) Hiking (l) Others Frequency of sports_________(times/week) Back pain related to sport_________ (yes/some/no) Severity_____(010) (0 no pain; 10 intolerable pain) Treatment for this back pain Type_____ (a) Narcotics (b) Prescription (c) OVC (d) None Frequency_________(times/day) Relief_________(yes/some/no) Cosmesis Since the last visit to the Methodist Hospital, has your curve changed? (a) Increased_____ (b) Remained the same_____ (c) Decreased_____ 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Very difficult 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

53

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

(continued)

54 Table 1 Continued

C.L. Soo et al. / The Spine Journal 2 (2002) 4956

Since the last visit to the Methodist Hospital, has your height: (a) Increased_____ (b) Remained the same_____ (c) Decreased_____ As a result of treatment for your round back, do you feel your physical appearance is: (a) Worse_____ (b) Unchanged_____ (c) Moderately improved_____ (d) Greatly improved_____ As a result of treatment for your round back, do you feel your self-image is: (a) Worse_____ (b) Unchanged_____ (c) Moderately improved_____ (d) Greatly improved_____ Since the treatment for your round back, how has the cosmetic appearance of your back changed? (a) A lot worse_____ (b) A little worse_____ (c) No change_____ (d) Moderately improved_____ (e) Greatly improved_____ Since the treatment for your round back, do you feel buying clothes is: (a) No change_____ (b) Less difficult_____ (c) More difficult_____ Before the treatment for your round back, did you have a problem wearing clothes? (a) Yes_____ (b) No_____ Would you recommend the type of treatment you received for your round back to your friends who had a similar condition? (a) Yes_____ (b) No_____ If not, why? (a) Cannot tolerate it_____ (b) Not helpful_____ (c) Painful_____ (d) Better option_____

group and reported that their pain had a greater influence on their working ability. The frequency of missed days was 0.88 days in 4 weeks for patients who had a curve greater than 70 degrees, and 0.0 for those less than 70 degrees. Discussion Scheuermann kyphosis is characterized by wedging of three adjacent vertebrae of 5 or more degrees, irregularity in the vertebral end plates, narrowing of intervertebral disc spaces, Schmorl node formation, detachment of the epiphysial ring anteriorly, and an apparent kyphosis [12]. Most authors agree that the upper limit of the normal thoracic kyphosis is 40 to 45 degrees [39]. This kyphosis, however, is derived as an average value and is only indicative and not normative [10,11]. Therefore, the degree of kyphosis should not be used as the only consideration in selecting an appropriate treatment for Schuermann disease. The natural history of Scheuermann kyphosis has not been clearly defined. It has been thought that a kyphosis of greater than 65 degrees may continue to increase even after skeletal maturity [5]. Sorenson reported that 50% of patients with Scheuermann kyphosis had thoracic back pain during their adult life [12]. However, this pain did not influence the

patients working ability and rarely required treatment. This is in contrast to the suggestion that untreated kyphosis is not only a psychological handicap but also a source of significant and disabling thoracic back pain [3,4,8]. Murray et al. [13] followed 67 patients to document the natural history of this entity. Nine percent of patients were unemployed because of back pain. They found that patients who were untreated had more intense back pain than the general population. This pain, however, did not interfere with the type of job and days missed from work when compared with the general population. Furthermore, there was no difference in limitation of recreational activity or exercise because of back pain. Neurologic sequelae from untreated Scheuermann kyphosis has been reported only rarely [14,15]. A variety of treatment modalities have been proposed for Scheuermann kyphosis. It has been suggested that observation and exercise should be used for the skeletally immature patient who has a thoracic kyphosis less than 50 degrees [3,4,7,8]. Bracing has been recommended for skeletally immature patients with a thoracic curve less than 70 degrees and with wedging less than 10% [3,4,7,8]. Surgical treatment has been advised for those patients who have completed their growth and who have a structural kyphosis that is large and cosmetically unacceptable [16,17,4,18,6,19,20,21]. Surgery

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has also been recommended for patients who have severe and disabling back pain in the area of the kyphosis when the pain cannot be controlled by nonoperative means [8,16]. In cases in which bracing does not prevent progression of deformity, surgery has been recommended [4,7,8]. For those rare instances in which there are neurologic signs or symptoms secondary to a severe Scheuermann kyphosis, surgery is also indicated. [4,8]. Farsetti et al. [22] reported on 12 patients treated with cast or brace. At long-term follow-up, there was no correlation found between back pain, occupation or degree of kyphosis. Indeed, the amount of back pain was not significantly different from that of the general population. Sachs et al. [9] have reported on patients treated by Milwaukee bracing. Some of these patients showed a progression of the curve despite brace treatment. Some patients subsequently underwent surgery. At time of final follow-up, however, only 16 of 120 patients had mild pain after activity. Only four patients (3%) were unemployed because of back pain. A variety of different surgical approaches have been discussed and used for the treatment of Scheuermann kyphosis. In general, posterior instrumentation and fusion has been carried out for curves less than 70 degrees [8,16]. Curves greater than 70 degrees have been treated with a combined anterior release and posterior fusion with instrumentation [6,3,4,7,8,21]. Kyphosis of less than 75 degrees that is correctable to less than 50 degrees by hyperextension may be treated by a onestage posterior fusion and instrumentation [8,23]. Anterior fusion with instrumentation has also been proposed in treating the skeletally mature patient with a curve greater than 75 degrees or the skeletally immature person with a curve greater than 65 degrees. Most articles documenting results of surgical treatment for Scheuermann kyphosis have a short-term follow-up [16,17,5,18,23,6,14,20,2]. These reports do not allow comparison of patients treated by different methods. Patients treated surgically in this study all underwent a two-stage procedure. Initially, an anterior release was carried out. One week later, they all underwent a posterior Harrington instrumentation and fusion procedure. The small threaded Harrington compression rods were used with number 1259 hooks. This is clearly a much more flexible construct than other systems currently available. The purpose of the present study was to document the long-term functional capacity of individuals treated for Scheuermann kyphosis through selective use of three different treatment modalities: exercise with observation, Milwaukee bracing and surgical fusion with Harrington instrumentation. Given that each modality was prescribed for a group of patients that differed in age, severity of deformity and pain, it is not possible to directly compare the results of each group or to extrapolate to the possible outcome if all patients had been treated with one single modality. Rather, our results show that it is possible to successfully treat patients with Scheuermann kyphosis using a graduated set of interventions if the treatment modality is correctly matched to the severity of the initial pathology. It is interesting to

note that such an approach maintains all patients at a relatively similar functional level, despite the severity of some of the initial deformities and despite the obvious inadequacies of the stabilization achieved in this series using the Harrington Compression System. The strengths of this study are the large number of patients followed, the length of follow-up, the long-term radiographic evaluation, the detailed and objective functional outcome instrument and the unbiased, nontreating physician status of the primary investigator. We readily acknowledge the weaknesses of the present study. It is retrospective, interviews were carried out by telephone and there was a reliance on old medical records. The latter may bias patient selection to those treated surgically. Twenty-five patients (40%), most of whom had been treated with exercise and observation, or with bracing, did not complete the radiographic evaluation needed for this study. Many patients were busy at work and could not find time to do so. Many patients thought that their back was fine and they did not perceive a reason to spend additional time obtaining X-rays. Irrespective of the method of treatment, 94% of our patients reported a working status without restriction. There was only one patient who required narcotics for pain control during daily activity. All patients scored well in their daily functional capacity and exercise activity. The type of Scheuermann kyphosis, type of treatment and degree of kyphosis at time of final follow-up did not significantly affect functional outcome. At time of final follow-up there was no difference in the marital status, general health or educational level of our patients as a function of the location of their kyphosis, the type of treatment they received and the severity of their residual deformity. In addition, there was no difference in self-image and perception of physical appearance among the three treatment groups as evidenced by the lack of difference in dressing. It is of interest that those patients who had been treated with bracing or surgery believed that their self-image had been improved by their treatment. Nevertheless, there were no objective differences between these two groups of patients and the patients treated only by observation and exercise. Indeed, at the time of final follow-up there was no difference in the degree of kyphosis among the three different groups. This is primarily because of a loss of correction in the surgical group from the time of surgery to final follow-up. One drawback of our study is our inability to know what the outcome of our patients would have been without treatment, because we did not have access to a control group of individuals without spinal deformity or patients with Scheuermann kyphosis who went untreated. Nonetheless, we have demonstrated the long-term success of a three-tiered approach to the treatment and management of Scheuermann kyphosis in which different modalities have been prescribed to address deformities of different severity at initial presentation. The ongoing challenge is to address the relative indications of each of these treatment methods, in view of advances in both the safety and efficacy of newer bracing methods and operative approaches to spinal fixation.

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C.L. Soo et al. / The Spine Journal 2 (2002) 4956 vertebral bodies in a sagittal plane: approach to references for the evaluation of kyphosis and lordosis. Spine 1982;7:33542. Sorenson KH. Scheuermanns juvenile kyphosis. Copenhagen: Munksgaard, 1964. Murray PM, Weinstein SL, Spratt KF. The natural history and longterm follow-up of Scheuermanns kyphosis. J Bone Joint Surg 1993; 75-A:23648. Ryan MD, Taylor TKF. Acute spinal compression an Scheuermanns disease. J Bone Joint Surg 1982;64-B:40912. Yablon JS, Kasdon DL, Levine H. Thoracic cord compression in Scheuermanns disease. Spine 1988;13:8968. Bradford DS, Moe JH, Montalvo FJ, Winter RB. Scheuermanns kyphosis. Results of surgical treatment by posterior spine arthrodesis in twenty-two patients. J Bone Joint Surg 1975;57-A:43948. Herndon WA, Emans JB, Micheli LJ, Hall JE. Combined anterior and posterior fusion for Scheuermanns kyphosis. Spine 1980;6:12530. Lowe TG. Double L-rod instrumentation in the treatment of severe kyphosis secondary to Scheuermanns disease. Spine 1987;12:33641. Sturm PF, Dobson JC, Armstrong GWD. The surgical management of Scheuermanns disease. Spine 1993;18:68591. Taylor TC, Wenger DR, Stephen J, Gillespie R, Bobechko WP. Surgical treatment of thoracic kyphosis in adolescents. J. Bone Joint Surg 1979;61-A:496503. Bradford DS, Ahmed KB, Moe JH, Winter RB, Lonstein JE. The surgical management of patients with Scheuermanns disease. A review of twenty-four cases managed by combined anterior and posterior spine fusion. J Bone Joint Surg 1980;62-A:70512. Farsetti P, Tudisco C, Caterini R, Ippolito E. Juvenile and idiopathic kyphosis. Long-term follow-up of twenty cases. Arch Orthop Trauma Surg 1991;110:1658.

Acknowledgments The authors wish to thank Jesse Dickson, MD, and Wendel Erwin, MD, who treated these patients. References
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