History
Scheuermann kyphosis (Scheuermann disease) may be entirely asymptomatic. However, patients with Scheuermann kyphosis who present for medical attention generally have problems that fall under one of the following five categories:
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Pain
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Progressive deformity
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Neurologic compromise
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Cardiopulmonary complaints
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Cosmetic issues
When present, pain should be highly concordant with the location of the spinal deformity in Scheuermann kyphosis. Pain may be present in either adolescence or adulthood, though it is a more typical presenting complaint in adults. Characteristically, the pain is located just distal to the apex of the deformity and then radiates laterally in a paraspinal pattern. The pain also is activity related and often abates with rest.
Address atypical pain, particularly in adolescents, with further diagnostic studies. Adults with pain often have low back pain, secondary to hyperlordosis below the Scheuermann kyphosis and subsequent degenerative disk disease and facet arthropathy, or the pain may be due to associated spondylolisthesis. Note that pain is the presenting complaint in 20-60% of patients with Scheuermann kyphosis.
Progressive deformity in the absence of radiographic conformation is difficult to document, though the history of the deformity should be queried. Patients and, particularly, family members often note a deformity that worsens over time. Clothes fit differently, shoulders appear more rounded, and it may appear that the length of the arms is increasing out of proportion to the rest of the body. Radiographic confirmation of progressive deformities is ideal.
If progression of the curve is documented, particularly in an adolescent, consider more aggressive treatment options.
Neurologic risk related to Scheuermann kyphosis is quite rare, but when it is present, it typically mandates a surgical approach. A short-segment severe deformity generally is considered to be a curve that is at highest risk secondary to the cord being draped over the deformity with anterior compression.
Lonstein et al demonstrated an average kyphosis of 95° in patients who presented with neurologic compromise. [19] However, Ryan and Taylor presented three patients with Scheuermann kyphosis and neurologic compromise with an average kyphosis of only 54°. [20]
Spinal stenosis of the lumbar spine below the deformity may lead to neurogenic claudication in the adult patient, and although it is not directly attributable to Scheuermann kyphosis, it may complicate the clinical picture.
Congenital thoracic stenosis has been reported in association with Scheuermann kyphosis and may lead to myelopathy or intraoperative complications during correction of the deformity.
Cardiopulmonary compromise as a presenting complaint for patients with Scheuermann kyphosis is quite rare. Restrictive lung disease was documented by Murray et al, [16] though this was in curves of more than 100°, with the apex of the curve located in the upper thoracic region. Sorensen reported earlier that chest-wall abnormalities in patients with Scheuermann kyphosis had no negative effect on cardiopulmonary function. [1]
Finally, cosmetic issues should not be underestimated in the evaluation of a patient with Scheuermann kyphosis. Address these concerns specifically and aggressively with the individual patient, because they ultimately prove to be the driving force behind the patient's decision process. When cosmesis is the isolated indication for treatment, particularly for surgical care, exercise caution.
Physical Examination
After the history has been well documented, a physical examination completes the initial clinical evaluation. Scheuermann kyphosis must be differentiated from postural kyphosis. On physical examination, this difference is made on hyperextension. Patients with Scheuermann kyphosis, even adolescents, demonstrate a structural deformity that only partially corrects on hyperextension. Patients with postural kyphosis, by contrast, have flexible deformities.
Forward flexion delineates the deformity quite well, with shorter angulated curves presenting as an A-frame deformity. Overall, sagittal alignment usually is maintained, secondary to compensatory hyperlordosis of both the cervical and lumbar spine. Perform a lower-extremity neurologic evaluation, paying particular attention to any signs of upper motor neuron compromise. Findings typically are normal. [21]
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Preoperative lateral radiograph of patient with 85° thoracic deformity secondary to Scheuermann kyphosis.
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Postoperative lateral radiograph demonstrating two-rod leverage technique after anterior release allowing reduction of deformity to 47°.
