This Issue's Rounds Question - " Believe that you apply a superior cast? Tell us why"
(responses to be published in next issue)

In the last issue of Body Cast, Rounds asked: “Describe Scheuermann’s Disease.”

The following responses were received:

From Doug Longphee:

Scheuermann’s disease, or Scheuermann’s kyphosis, is a condition in which the normal round back in the upper spine (called a kyphosis) is increased. Most people with Scheuermann’s disease will have an increased round back (e.g., a hunch back or hump back), but not pain.

The name of this condition comes from Scheuermann, the person who, in 1921, described changes in the vertebral endplates and disc space that can occur during development, and lead to kyphosis, or round back deformity of the thoracic spine (upper back).

There is some confusion in terminology, however as Scheuermann also described changes that occur in the disc spaces of the lumbar spine that can lead to back pain. This is really another condition called juvenile disc disorder, but is often confused with Scheuermann’s kyphosis and is sometimes called Lumbar Scheuermann’s disease. To avoid confusion, the preferred terminology is now:

• Scheuermann’s disease (or Scheuermann’s kyphosis) to describe the condition of adolescent kyphosis.
• Juvenile disc disorder (or juvenile discongenic disorder) to describe the condition of adolescent degenerative disc disease.

Scheuermann’s kyphosis

This condition (also called Scheuermann’s disease) occurs when the front of the upper spine does not grow as fast as the back of the spine, so that the vertebrae become wedge-shaped, with the narrow part of the wedge in front. The wedge-shape of the vertebrae creates an increase in the amount of normal kyphosis (front angulation of the thoracic spine).

The wedging of vertebrae in Scheuermann’s kyphosis is most common in thoracic spine (upper back), with the apex of the curve typically between the T7 and T9 levels of the spine. Although less common, Scheuermann’s kyphosis may also occur in the junction between the thoracic and lumbar spine (thoracolumbar spine) or in the lumbar spine (lower back).

The cause of Scheuermann’s disease is unknown, but is thought to be due to a growth abnormality of the vertebral body. The growth plate anteriorly (in the front) stops growing, but the posterior part of the growth plate continues to grow. This is due to a condition known as osteochondrosis.

Scheuermann’s disease does not spread and is not really a “disease”, but a condition that can arise during growth. It is more common in males and appears in adolescents usually towards the end of their growth spurt.

If the round back deformity is severe, patients are more likely to have discomfort or pain along with the deformity as they age.

From Thelma Odgen:

This is a disorder of the vertebral end plates that affects adolescents, particularly boys.

It produces a progressive rigid forward curvature of the thoracic spine. Less commonly, it can also affect the lumbar spine causing decreased lumbar lordosis. It is often moderately painful. Radiographs show wedging of the vertebral bodies, irregularity of the end plates and kyphosis.

Schmorl’s nodes, characterized by herniation of the disc material at the vertebral end plates, and increased thoracic kyphosis are also seen.

Thoracic involvement with pain or kyphosis of 15 to 20 degrees greater than normal can be managed with a Milwaukee brace. Brace treatment is usually effective in controlling pain and structural correction of the kyphosis.

It is the exception to the rule that spinal bracing must be done during the growth phase to improve deformity, because patients as old as 18 years will show improvement with the Milwaukee brace.

Surgical treatment of kyphosis may be indicated if the curve magnitude increases despite bracing.

Posterior spinal fusion with a variable hook-rod system such as the Cotrel-Dubousset System is the treatment of choice in patients nearing skeletal maturity and with a severe curvature.

Recent reports have described the neural history of Scheuermann’s kyphosis suggesting some functional limitations, but little actual interference with lifestyle. The deformity can worsen over time. Many patients have their symptoms of back pain and deformity improved by surgery. Proper patient education and selection are essential for appropriate treatment of these patients.

From Heather Wong:

This is a disease of the thoracic and lumbar spine, also known as kyphosis of the spine. It is a condition in which the normal round back in the upper (thoracic) spine increases and results in a “hunchback”. It is most common in boys and usually causes no pain. Not to be confused with Juvenile Disc Disorder (a degenerative disc disease), this is actually not a disease, but a condition.

The cause is unknown, but is thought to be a growth abnormality of the vertebral body. The growth plate anteriorly stops growing, but the posterior side keeps growing, a condition called osteochondrosis. This usually occurs during the end of the growth spurt.

Normal curvature of the spine is between 20 and 50 degrees. A curvature greater than 50 degrees, where the spine has three contiguous vertebral bodies that have a wedging of five degrees or more, constitutes Scheuermann’s disease.

Postural round back in teens is most often caused by poor posture and not structural change to the spine. It is easily distinguished by the fact that the deformity goes away when the patient lies down. Typically, a patient with Scheuermann’s disease needs two or three pillows for comfort to sleep. Also, on x-ray, there is usually a mild scoliosis noted.

Treatment is usually conservative for relief of pain, to correct unacceptable cosmetic deformity and to prevent further progression of the curve. Type of treatment relies on the size of the curve, flexibility of the curve, patient age and patient preference.

Conservative treatment for the patient who has at least one year of growth left would be a Milwaukee-type of back brace and exercise to strengthen muscles and help alleviate pain and fatigue.

Surgery is rarely needed, but is considered for severe deformities with curvatures greater than 70 degrees, neurological deficits and moderate/severe pain.