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Chapter: Paediatrics: Bones and joints

Paediatrics: Spine: kyphosis

Definition: from Greek Kyphos, a hump. Increased curvature of the spine in the sagittal plane, visible from the side. Normally there is a 20–40° curvature of the thoracic spine.

Spine: kyphosis

 

   Definition: from Greek Kyphos, a hump. Increased curvature of the spine in the sagittal plane, visible from the side. Normally there is a 20–40° curvature of the thoracic spine.

   History: site, age of onset, rate of progression, associated scoliosis/pain/ neurological symptoms, family history.

 

Examination

 

Assess:

   Flexibility: stand, bend forwards, bend backwards (hyperextension).

   Ability to lie flat: associated lumbar lordosis (more prominent with greater severity of kyphosis).

   Hips for tight hamstrings: limited straight leg raising.

   Full respiratory (pulmonary function) and neurological examination.

 

Investigation 

PA and lateral standing X-rays of entire spine.

 

Diagnosis

 

Three major causes are identified by answers to:

   Is it flexible?

 

   Is it painful?

 

   When did it start?

 

Postural kyphosis (most common)

 

Flexible, usually painless, onset <10yrs old.

   Other findings: tall; girls > boys; poor physical development; flat-footed; poor at games.

 

   Investigations: supine hyperextension lateral radiograph confirms complete correction.

 

   Treatment: physiotherapy to improve posture and provide exercises for dorsal spine, education, occasionally brace.

 

   Outcome: corrects spontaneously by end of adolescence.

 

Congenital kyphosis

 

Rigid, occasionally painful, onset <10yrs old.

   Other findings: severe deformities recognized at birth, associated with congenital spinal abnormality, e.g. spina bifida.

   Cause: may be secondary to failure of vertebral formation +/– segmentation during the first trimester.

 

   Treatment: brace, if progression fusion to prevent paraplegia.

 

   Outcome: can progress rapidly and lead to paraplegia.

 

Scheuermann’s disease

 

   Rigid, aching pain between shoulder blades; onset 10–15yrs (previously normal spine).

   Incidence: unknown (up to 7–8% of population in cadaveric studies).

   Aetiology: osteochondritis.

 

Investigations

 

AP and lateral spine X-rays: >45° kyphosis with >5° anterior wedging at three sequential vertebrae = radiographical definition of Scheuermann’s disease.

May have vertebral body end-plate changes (Schmorl’s nodes—vertical herniations of the intervertebral discs into the vertebral end-plate), spondylolysis (30–50%), scoliosis (33%).

 

Treatment

 

Physiotherapy (extension exercises): bracing may be considered.

 

Medical: NSAIDs.

 

Surgical correction: with severe kyphosis (>70°), the patient is skeletally mature, with severe pain or evidence of cord involvement.

 

Outcome

 

Little evidence that patients with kyphosis <70° experience late progres-sion, disabling pain, or neurological compromise.

 

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Paediatrics: Bones and joints


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