Paediatrics: Spine: kyphosis

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.