Kyphosis

What is Kyphosis?

The human spine is made up of several bones, called vertebrae: seven in the neck (cervical), twelve in the chest (thoracic), five in the lower back (lumbar), five that are fused together in the sacrum, and 3 to 5 small ones fused together at the tail end known as the coccyx. Normally, the spine has a certain amount of forward bend, known as kyphosis, in the thoracic spine and a backward bend or curve, known as lordosis, in the cervical and lumbar spine.

Kyphosis is when the spine has an increased forward curve while if the spine has an increased backward curve, it’s called lordosis. These curvatures are viewed from the side of the body. When the forward curve is more than normal, it is referred to as hyperkyphosis. This shouldn’t be confused with scoliosis, which is a side-to-side curvature as viewed from the front or back of the body.

The shape of the spine is determined by the shape of the vertebrae and the disc in between them. A wedged front edge causes a greater angle of kyphosis. While the complete progression of kyphosis isn’t completely clear, we know that an increased curve in the thoracic spine generally starts at around the age of 40, and progresses faster in women compared to men.

What Causes Kyphosis?

Kyphosis refers to an exaggerated forward curvature of the spine, typically in the upper back. There are three common types: postural kyphosis, Scheuermann disease, and congenital deformities.

Postural kyphosis is most often seen in young people and is more common among girls. It’s caused by slouching, which increases the forward curve of the spine, thereby stretching and weakening the back muscles and ligaments. Despite this, the vertebrae or spine bones in postural kyphosis are usually normal. With age, weaker muscles can lead to poor posture, further stressing the spine. This can lead to compression fractures, particularly in seniors with weak bones due to osteoporosis.

Scheuermann disease, or juvenile kyphosis, is a structural deformity of the spine that usually starts before puberty. It’s thought to be caused by uneven growth and development in the spinal bones, causing them to become wedged. While we aren’t sure how it is passed down, identical twins have been observed to share this condition, suggesting a genetic factor.

Congenital kyphosis, which is inherited at birth, is less common but can be serious, leading to rapid progression of the condition and posing a higher risk of nerve-related complications. There are two types. The first is caused by failure in the formation of one or more spinal bones, leading to increased curvature as the child grows. The second is caused by failure to separate two or more spinal bones, with diagnosis usually occurring once the child starts walking. Except for tuberculosis, congenital kyphosis is the most common reason for pressure on the spinal cord due to spinal deformities.

Besides these three causes, several other factors may contribute to kyphosis, including aging, spinal injuries, osteoporosis, slipped discs, spinal infections, and cancer affecting the spine.

Risk Factors and Frequency for Kyphosis

Hyperkyphosis typically progresses as we grow older, particularly beyond 40 years of age. Around 20 to 40% of adults aged 60 or older are affected by this condition. While both women and men can develop hyperkyphosis, the rate is quicker in women, specifically during the menopause phase. Often, hyperkyphosis can be traced back to underlying conditions like osteoporosis or fractures. However, severe kyphosis is linked to detected spinal fractures in only a third of the cases. A study showed that, on average, the curvature of the upper (thoracic) spine increased by about 3 degrees for every 10 years in people over 50 years old, both males and females.

Scheuermann’s disease is quite rare, impacting between 0.4% and 8% of people in the United States. Males are twice as likely as females to have the disease. The typical age for diagnosis is between 13 and 16 years old, and it’s unusually for it to be detected in children under the age of 10.

Signs and Symptoms of Kyphosis

Hyperkyphosis, a condition where the spine curves excessively forward, shows obvious signs and symptoms. The most visible sign is the appearance of a rounded back, which commonly develops in people older than 40 years in age-related kyphosis and in teenagers with postural kyphosis or Scheuermann disease. Along with this rounded back appearance, symptoms can range from mild to severe back pain, fatigue, an increased forward posture of the head, and uneven shoulder height. In severe cases, individuals might also experience chest pain, breathlessness, weakness, numbness, or even difficulties with bowel and bladder control.

• Rounded back appearance
• Back pain ranging from mild to severe
• Fatigue
• Increased forward posture of the head
• Uneven shoulder height
• Chest pain (in severe cases)
• Shortness of breath (in severe cases)
• Weakness (in severe cases)
• Loss of sensation (in severe cases)
• Bowel/Bladder incontinence (in severe cases)

A physical examination for hyperkyphosis often involves observation, palpation, and range of motion testing. In severe cases, the upper back may have a noticeable rounded ‘hump’. The surrounding muscles might also be tender upon touch. People with Scheuermann disease are associated with tight hamstrings, which cause overcompensation affecting balance. In hyperkyphosis, there’s also noticeable stiffness and a reduction in the range of spinal movements.

One feature that differentiates postural kyphosis from structural kyphosis such as Scheuermann disease is the flexibility of the curve. In cases of postural kyphosis, the spine straightens when the patient lies down, indicating a postural issue rather than a structural one where the curved spine remains rigid.

It’s also essential to check the neurological system in people with hyperkyphosis. Although most cases do not show neurological problems, the most severe cases of kyphosis can present with numbness, tingling, weakness, and difficulties with bowel and bladder control, warranting an MRI to rule out cord compression.

Testing for Kyphosis

Small amounts of kyphosis, or curvature of the spine, are normal due to the shape and structure of our spine and the discs in-between the bones. However, if the angle of the curve is more than 40 degrees, this is outside of the norm for most adults. In this case, we term the condition as hyperkyphosis.

Normally, to check if someone has kyphosis or hyperkyphosis, doctors can use a standing side view X-ray of the spine. For older people who may feel uncomfortable standing, they can lie down for the X-ray. In the X-ray, the doctor will look at the angle between the top and bottom of the curve in your spine, this is known as the Cobb’s angle.

When checking specifically for a condition called Scheuermann disease, doctors will look not only for a Cobb’s angle greater than 40 degrees but also signs that three or more neighboring spinal bones have a forward-facing wedge-shaped curve of 5 degrees or more.

If an X-ray is not possible, there are other tools that can be used. The Debrunner kyphometer and the flexicurve ruler are two such medical devices that can help measure the curve of the spine. The kyphometer is like a protractor that measures the angle of the curve on your back. On the other hand, the flexicurve ruler is a moldable plastic device that’s positioned along your spine. Doctors then calculate the kyphosis index by dividing the width of the curve by its length then multiplying by 100. If the value is more than 13, it’s considered hyperkyphotic. Simply put, a larger angle of curvature results in a wider curve and a shorter spine, which increases the index value.

Treatment Options for Kyphosis

Kyphosis, or the abnormal curvature of the spine, is typically managed first with less invasive treatments with surgery considered as the last option if the less extensive measures don’t improve the patient’s symptoms or if the curve in the spine is too severe.

The first steps in treatment usually involve monitoring, physical therapy, and taking anti-inflammatory drugs. This approach is suitable for those with a kyphosis curve of less than 60 degrees. Regular visits to the doctor and x-rays are used to monitor the progression of the curve. Physical therapy strengthens the back and abdominal muscles to lessen the strain on the spine, which helps improve posture and decrease discomfort. It usually includes stretching exercises and cardio activities to help with back pain and fatigue. Non-surgical treatment methods are often recommended for postural kyphosis. Importantly, although medications for osteoporosis can help prevent spine fractures in people with hyperkyphosis, they don’t fix the kyphosis itself.

For young people with kyphosis greater than 50 degrees, the use of back braces is often considered. The idea is that the brace will guide the growth of the spine and straighten it out. Research suggests that those with a kyphosis curve between 55 degrees to 80 degrees when treated with bracing before reaching full growth, were almost always successful. In adults, however, bracing won’t fix the curvature, but it can provide support and help with pain. The Milwaukee brace is a popular choice and is typically worn for 16 to 24 hours a day annually.

Surgery becomes a consideration when other treatment methods fail to alleviate pain, the curve keeps getting worse, there’s nerve damage, or other serious health problems arise such as those affecting the heart and lungs. Usually, this pertains to those with a kyphosis curve greater than 75 degrees. For older adults with kyphosis due to osteoporotic fractures of the spine, two surgical methods- kyphoplasty and vertebroplasty – can be useful to treat persistent pain from fractures in the vertebrae (the individual bones that make up the spine). In patients with Scheuermann disease, the usual surgical procedure involves a combination of releasing the front part of the spine and then using fusion (a surgical process of joining two bones together) supplemented with posterior instruments with fusion. However, a new method, the “posterior only approach”, that gives better correction rates is becoming more popular.

For those with congenital kyphosis, which is present at birth, surgery may be necessary because of the aggressive progression of the disease. Less invasive treatments won’t prevent the grave spinal deformity and potential nerve damage in these patients. The best surgical approach would typically be posterior fusion for kids younger than 5 years old, and a curve less than 50 degrees, whereas a combination of anterior and posterior fusion would be used for those over 5 years old with a degree of over 60. For those already with cord pressure, an anterior cord decompression with fusion is the standard procedure.

What else can Kyphosis be?

Vertebral instability typically comes from a triggering event or the gradual worsening of a degenerative disease. In patients with this condition, the spine is assessed based on its flexibility and the strength of the surrounding muscles.

Scheuermann’s disease is a condition that affects young people, usually before they hit puberty. It’s characterized by the presence of an over-curvature or ‘humpback’ condition of the spine, known as kyphosis.

Ankylosing Spondylitis, or AS, is an inflammatory condition often found in conjunction with other disorders like psoriasis, inflammatory bowel disease, or reactive arthritis. Unique signs visible on x-ray images can help doctors identify this particular condition.

Osteoporosis is a progressive degenerative disease that causes a loss of bone mineralization, affecting all bones to varying extents. Tools like bone scans, X-rays, and MRIs can help diagnose and measure the severity of osteoporosis.

Finally, vertebral fractures can also cause kyphosis. These fractures can occur from traumatic events or even cancer which can result in the loss of bone integrity. A careful review of the patient’s medical history and medication use can help determine the cause of the kyphosis.

What to expect with Kyphosis

Normal variants, or differences in the body, usually don’t cause any problems or limit how the body functions. If the curve in your back is extreme, it might result in back pain, issues with breathing, and reduce the quality of your life. This situation might get better on its own, improve with physical therapy, or be fixed surgically with spine surgery.

Possible Complications When Diagnosed with Kyphosis

A curved spine can result in back pain and can impact your quality of life. In more severe situations, it can even harm your heart and lungs and affect your nervous system.

When it comes to treating kyphosis – a condition where the spine is excessively curved – the most common complications after the operation are infections around the surgery area and bleeding.

Common Post-operation Complications:

• Infections at the surgical site
• Bleeding around the surgical site

Preventing Kyphosis

Teaching patients about their condition is a key part of treating kyphosis (an excessive outward curvature of the spine, causing hunching of the back), especially if it’s causing problems with daily activities. Patients should concentrate on non-surgical treatments such as physical therapy, maintaining a good posture, and proper movement techniques. Building up the strength of the muscles in your core (the area around your stomach and back) can help support and stabilize the spine.

In cases of kyphosis that develop as a person gets older, it’s particularly important for females to avoid flexion exercises, which are exercises where you bend your body forward. Research shows that these movements can increase chances of bone fractures, especially if your bones are already weak. Instead, the focus should be on extension exercises, which involve straightening and stretching your body, to strengthen the back extensor muscles (the muscles that help keep your back straight). These muscles are often weak in individuals with an excessive curve in their upper back, also known as hyperkyphosis.