The Scheuermann’s disease is the most common cause of structural kyphosis, most frequently diagnosed during puberty. The etiology and pathogenesis of this condition are probably related to biomechanical factors, but its cause remains unknown.
Increased growth hormone levels have been documented, so patients with this deformity are higher than average for their age. Genetic factors or avascular necrosis of the vertebral apophyseal ring are conditions defined by other researchers, but also without unanimity.
What is Scheuermann’s Disease
The Scheuermann’s disease is a problem in the development of the spine, producing an abnormal arching of the back (kyphosis), responsible for causing a very painful bad posture.
This is the main cause of structural kyphosis, usually detected during puberty. It affects individuals of both sexes and at any age.
It is likely that the etiology of this condition is related to biomechanical factors; However, its cause has not yet been elucidated. Some factors have been related to this disease , such as increased levels of growth hormone, so that individuals with this disease are taller than the average for their age. Other possible causes raised by other researchers are avascular necrosis of the vertebral pituitary ring and genetic factors.
The natural evolution of the condition has not been well described yet. Some researchers have reported that patients with this disease often had back pain, lower amplitude and trunk extension strength when compared to the normal population for the same age and gender.
Among the clinical manifestations, besides kyphosis that can be thoracic or thoracolumbar, there is pain in almost all patients. Retraction of the pectoral, hamstring and hip flexor muscles may also be observed. In severe cases, breathing may also be present. The onset of neurological changes is uncommon.
Symptoms of Scheuermann’s Disease
Deformity is the most common presenting complaint. And about 50% among those seeking medical attention have pain in the region, but higher percentage (78%) if the lumbar spine is involved. Some patients have lumbar spondylolysis later.
Causes of Scheuermann’s Disease
The exact cause of Scheuermann’s disease is not yet known, but it is believed to be due to a growth abnormality in the vertebral body in which the growth plate stops growing earlier but continues to grow later. This is basically due to a medical condition called osteochondrosis.
The Scheuermann’s disease is a medical condition that usually occurs in years of an individual ‘s growth. The Scheuermann’s disease is more common in men than in women.
Treatment For Scheuermann’s Disease
Treatment of Scheuermann’s disease is based on the severity and progression of the curve, as well as the age and neurological condition of the patient. There is no consensus on the stratification of treatment modalities, due in large part to the ignorance of the natural evolution of this disease . In the following, some therapeutic aspects based on the presented criteria will be discussed.
Adolescents with kyphosis up to 50 ° without evidence of curve progression should be followed clinically every 6 months, including control radiographs. There is no need for follow-up after skeletal maturity in these cases. Indications for intervention in Scheuermann’s kyphosis are: pain, progressive deformity and aesthetic impairment. Treatment varies with the degree of deformity and its flexibility.
Specific criteria for wearing a vest include a patient with a curve between 50 and 80 ° and at least 40% correction by passive extension. Physical therapy with postural exercises and strengthening of the trunk and hamstring extensors should be encouraged. Lumbar hyperlordosis also deserves attention, being treated with abdominal exercises .
Curves greater than 80 ° tend to respond less favorably to the vest, and surgery should be considered in these cases. Vests may be cervicotoracolumbosacral (eg Milwaukee) worn when the deformity apex is proximal to T7, or thoracolumbosacral (eg OTLS) when the apexes are distal to T7. The vest regime includes an initial period of full use (23 hours / day), which should be maintained for 12 to 18 months.
As the patient develops and the curve is corrected after anterior vertebral growth, part-time use is initiated (12 hours / day to skeletal maturity). The removal of the vest should be gradual, usually taking from 8 to 12 months. For a vest to be effective, the patient must have at least 12 to 18 months of remnant growth. Finally, 15 to 30% of the initial correction is expected to be lost after some time without the vest.
Surgery is indicated in cases of progressive kyphosis despite the use of a vest, chronic pain not responsive to conservative treatment even in patients with smaller curves (<80 °), neurological impairment or severe aesthetic changes.
Surgical techniques have been undergoing profound evolution with the use of new implants and resources, such as the application of pedicle screws. Strictly speaking, kyphosis represents a relative shortening of the anterior column.
Thus, surgical correction aims at restoring the anterior spine length and / or shortening the posterior spine. These goals can be achieved through anterior access to the spine, via thoracotomy or thoracoscopy, associated with posterior osteotomies.
Shortening of the posterior spine can be achieved by resection of intervertebral articular facets and adjacent lamina margins in the kyphotic area, in order to gain space for application of compression instruments. Among the main complications of surgical treatment of Scheuermann’s disease are:
Failure and / or loosening of implants;
Particular attention should be given to the latter situation due to excessive surgical correction of the deformity or inappropriate choice of arthrodesis levels.