History

Evaluation of a patient for spine deformity should include a thorough history. Patients presenting with kyphosis may have as much concern about the cosmesis of the deformity as about the pain. Typically, though, the more significant the deformity is, the greater the pain that will be experienced with ambulation and the performance of activities of daily living (ADLs).^[26] The presence of numbness or tingling sensations in the lower extremities, more frequent falls, and balance issues should prompt evaluation of the spinal cord and neural elements, which can be compressed with significant deformity.

It is important to elucidate the etiology and history of the deformity. The Comprehensive Etiology-Base Adult Spine Deformity Classification described the following eight types of adult spinal deformity (ASD) according to etiology:

Type 1 - Idiopathic progressive adult deformity
Type 2 - ASD due to progressive idiopathic adolescent scoliosis (AIS) that was untreated or deformity adjacent to prior surgical fusion
Type 3 - ASD secondary to iatrogenic sagittal imbalance after flat-back deformity following prior AIS surgery related to Harrington rods instrumentation or due to prior fusion with lack of adequate lordosis
Type 4 - Junctional spine deformity due to proximal junctional kyphosis (PJK) after prior fusion surgery or distal junctional kyphosis/failure after prior spine fusion
Type 5 - Posttraumatic, either acute after trauma or showing chronic progression after trauma
Type 6 - Pathologic deformity after either neoplasm or infection
Type 7 - Metabolic-related ASD due to osteoporosis or another metabolic bone disorder
Type 8 - ASD secondary to congenital, neuromuscular, or syndromic etiologies

A 10- to 42-year natural-history study of Scheuermann disease revealed that patients, as compared with control subjects, tended to have increased back pain.^[23] However, they were not more likely to take pain medication, to have sedentary jobs, or to lose motion of the spine. The investigators found no differences between the patient group and the control group with respect to educational level, absenteeism, self-consciousness, or reports of numbness in the legs. Of interest, restrictive lung disease was observed in patients with a curve greater than 100°.

Physical Examination

Examination of a patient should begin with inspection of the coronal and sagittal balance while the patient is standing. Specific attention should be directed at the magnitude of trunk shift in the frontal plane, which would indicate a coronal plane deformity, or scoliosis. Inspection of the patient from the side allows evaluation of the head's position in relation to the pelvis.

The patient should also be asked to walk. Significant hip and knee flexion during ambulation indicates that the patient is compensating for the kyphosis by altering the hip and knee position. Whereas such compensation is effective at allowing better forward gait during ambulation, it carries a significantly higher energy cost, negatively correlates with quality-of-life measures, and may increase the risk of falling.^[27]

A thorough neurologic examination is also critical in evaluation. A wide-based gait pattern could indicate cervical or thoracic spinal stenosis. Increased hip and knee flexion during the swing phase of gait could indicate impairment of the ankle dorsiflexion muscles as a consequence of lumbar nerve compression.

Muscle testing should be done systematically and bilaterally so as not to miss any subtle weakness. Hyperactive reflexes or pathologic reflexes, such as clonus or upgoing Babinski, would indicate upper-motor-neuron dysfunction and signify a problem at the level of the cervical or thoracic spine. Alternatively, diminished or absent reflexes could indicate a lower-motor-neuron issue—specifically, at the level of the lumbar spine or more peripherally.

Workup

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Media Gallery

Preoperative lateral radiograph of patient with 85° thoracic deformity secondary to Scheuermann kyphosis.

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Author

R Carter Cassidy, MD, FAOA Professor, Department of Orthopaedic Surgery, University of Kentucky College of Medicine; Director, UK Good Samaritan Spine and Total Joint Clinic; Spinal Surgeon, Division of Spine Surgery, UK Healthcare Orthopaedic Surgery and Sports Medicine

R Carter Cassidy, MD, FAOA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, Kentucky Orthopaedic Society, North American Spine Society

Disclosure: Nothing to disclose.

Coauthor(s)

Charles-Antoine A Mechas, MD Resident Physician, Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine

Disclosure: Nothing to disclose.

William O Shaffer, MD Former Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons

William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, International Society for the Study of the Lumbar Spine, Kentucky Medical Association, Kentucky Orthopaedic Society, North American Spine Society, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center

Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, AOSpine, Cervical Spine Research Society, International Society for the Advancement of Spine Surgery, International Society for the Study of the Lumbar Spine, Lumbar Spine Research Society, North American Spine Society, Scoliosis Research Society, Society of Lateral Access Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Globus, 3Spine<br/>Received income in an amount equal to or greater than $250 from: Globus, Nuvasive, Surgalign, 3Spine.

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