CHAPTER
Angel E. Macagno
120
Surgical Treatment of
Scheuermanns Kyphosis
INTRODUCTION
Holger Scheuermann described a rigid developmental thoracic
kyphosis for the first time in 1920.17 The condition as we know
still carries his name. In 1964, Sorensen21 further defined the
condition quantitatively by pointing out that the apical verte-
bral bodies are wedged at least 5 per level over three contigu-
ous levels on radiographs (see Figs. 120.1A and B). Others have
suggested that a kyphosis of greater than 45 with one wedged
vertebra constitutes Scheuermanns disease.22 Whatever criteria
are used to describe this entity, it remains a common structural
deformity seen in the adolescent and adult population causing
kyphosis.
The cause for Scheuermanns kyphosis remains unclear.
Scheuermanns kyphosis occurs in 0.4% to 8.3% of the general
population; the original report by Scheuermann suggests that
the entity was found predominantly in males. Bradford et al3
suggested an increased incidence in women. Other literature
has suggested an equal distribution in males and females.21
There is a wide range of normal for thoracic kyphosis across the
population. Normal thoracic kyphosis generally is considered
to be between 10 and 40. However, normal variations with age
may include 50 of thoracic kyphosis in adult patients.6
Early theories regarding the development of Scheuermanns
kyphosis included avascular necrosis of the ring apophysis,
inhibition of enchondral ossification, intravertebral disc herni-
ations and end plate perforations, and persistent anterior vas-
cular grooves. Subsequent studies have not verified these theo-
ries.22 Most investigators agree that mechanical factors have a
significant role in the pathogenesis of Scheuermanns kyphosis.
However, there is a high likelihood that there is a genetic
underpinning to the development of Scheuermanns kyphosis.
Review of the Danish Twin Registry suggests that the prevalence
of Scheuermanns kyphosis is 2.8%. Monozygotic twins were
two to three times more likely than dizygotic twins to have both
individuals express kyphosis. There was a predominance of
male patients (3.8%) having the disorder compared with
females (2.1%).8 This study suggested that the hereditability of
Scheuermanns disease was 74%. Histopathologic studies have
suggested the presence of disorganized enchondral ossification
similar to Blounts disease. Reduction in collagen and increase
in mucopolysaccharide in the vertebral end plates were also
identified. Mechanical factors inducing vertebral body wedging
LWBK836_Ch120_p1295-1311.indd 1295
Michael F. OBrien
Harry L. Shufflebarger
have also been implicated in the development of Scheuermanns
kyphosis. Whether the wedging is primary or secondary is still
unclear. Likewise tight hamstrings have been implicated as pos-
sible etiologic forces in the development of Scheuermanns
kyphosis by preventing forward tilt of the pelvis. This has been
postulated to cause increased bending stress at the thoracic
level instigating kyphosis.22 Tight hamstrings may suggest a lim-
itation in postoperative compensatory mechanisms if the pelvis
is not able to flex forward. This would suggest that most of the
postoperative compensation will come from the lumbar spine.
In this case, care should be taken to limit lumbar fusion.
Scheuermanns disease is a benign condition. It rarely leads
to neurological deficits or severe limitations. However, recent
studies have suggested that patients with Scheuermanns dis-
ease have more back pain and are employed in jobs that tend to
require lower activity levels and less range of motion. In spite of
this, there was no significant difference identified for patients
with Scheuermanns disease with regards to level of education,
days absent from work, and the degree to which pain interfered
with activities of daily living. There also did not appear to be
any significant difference in self-esteem, self-consciousness, the
use of pain medications, or level of recreational activities in
comparison to control patients. Of note, however, the average
kyphosis for this group was only 71.
CLINICAL EVALUATION
There are many kyphotic entities that can masquerade as
Scheuermanns disease (see Figs. 120.2A and B). In both the ado-
lescent and adult patients, kyphosis can be attributed to poor
posture. Careful evaluation of the patient both clinically and
radiographically is necessary to document the presence of
Scheuermanns kyphosis. Postural kyphosis, postlaminectomy
syndromes, tumors, fractures, and neurological and congenital
conditions can all create significant kyphosis requiring treatment.
Kyphosis attributed to Scheuermanns disease typically makes its
clinical presentation in early adolescence. Unlike postural kypho-
sis, the deformity associated with Scheuermanns disease remains
visible with hyperextension of the spine owing to the angular
changes at the apex of the deformity. In addition, patients with
Scheuermanns disease often will have small thoracolumbar sco-
liosis associated with the primary thoracic kyphosis. The kyphosis
1295
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 1296 Section XI Kyphosis and Postlaminectomy Deformities

Figure 120.1. (A) AB is a 45-year-old man

showing a classic large Scheuermanns kyphosis
with apex at disc T7-T8. The curve is 95 across
the Cobb angle measurements from T4 to T11.
The apical four vertebras are wedged. (B) Close
up view shows the elongated anterior to posterior
dimension of the apical vertebral bodies, the
wedging, and the anterior osteophytic deforma-
A B
tions typical of Scheuermanns deformity.

in Scheuermanns disease can either be high, centered in the
mid-thoracic region or low, centered in the thoracolumbar lum-
bar region. The degree and the location of the kyphosis are best
visualized on the Adams forward bend test.
Clinically, patients will often complain of pain, which is
aggravated by standing or increasing activity. Although symp-
toms may be worst at the site of the maximum deformity, that is,
the apex of the kyphosis, referred or adjacent segment pain is
very common in the hyperlordotic cervical and lumbar regions.
Pain in these segments is likely caused by hyperlordotic posi-
tion of the spine with increased contact forces in the facet joints
posteriorly. Neurological deficits as a result of Scheuermanns

A B C

Figure 120.2. (A) Not all clinical kyphosis represents Scheuermanns disease. Careful attention to clinical
and radiographic details is sometimes necessary to differentiate a clinical kyphosis, potentially Scheuermanns
disease, from other ideologies such as in this case of neurofibromatosis. (B) The lateral radiograph shows a
110 kyphosis measured from T5-T8. This is secondary to an intrinsic deformity caused by neurofibromatosis
superimposed on a postlaminectomy segment of the thoracic spine. (C) This magnetic resonance image shows
the morphologic abnormalities typical of neurofibromatosis as it affects the vertebral bodies at the apex.

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 Chapter 120 Surgical Treatment of Scheuermanns Kyphosis 1297

disease are unusual. Associated comorbidities are not typical of

Scheuermanns disease either unlike in other conditions result-
ing in spinal deformity.16 Although neurological compromise is
uncommon, myelopathy can develop due to thoracic disc her-
niations. Structural cardiac or pulmonary complications are
not intrinsic to Scheuermanns disease, although, as with all
deformities, both coronal and sagittal, larger deformities may
result in restrictive pulmonary disease by affecting the mechan-
ical function of the rib cage.

RADIOGRAPHIC EVALUATION
The radiographic evaluation of patients with Scheuermanns
disease requires at least an anteroposterior (AP) and lateral
long cassette scoliosis radiograph. The AP film should be evalu-
ated for the commonly associated small but significant scoliosis.
The end instrumented vertebra of the construct treatment of
the primary thoracic deformity may have to be adjusted based
on the end vertebra of the scoliotic deformity. The normal sag-
ittal measurements from T2 to T12 are considered to be 10 to
40. The thoracolumbar region T10-L2 is generally straight
(i.e., 0) or slightly lordotic. These thoracic and thoracolumbar
measures are balanced by lumbar lordosis, which is approxi-
mately 50 to 70. In the sagittal plane, the plumb line that
from C7 ideally should pass through the posterior superior cor-
ner of S1 (see Fig. 120.3). Aside from hyperkyphosis in the tho-
racic or thoracolumbar spine, radiographic criteria for
Scheuermanns disease also include wedging of three contigu-
ous apical vertebral bodies of more than 5 each.
Two distinct but subtle curve patterns present themselves in
Scheuermanns kyphosis: thoracic and thoracolumbar (see
Figs. 120.4A and B). The more common of these two is thoracic
kyphosis with an apex at approximately T8 or T9. The thora-
Figure 120.3. Sagittal global alignment is important for the over-
columbar/lumbar version of Scheuermanns typically has its
all functioning of the spine. In spite of the fact that Scheuermanns
apex between T10 and T11. The curves with a thoracic apex kyphosis results in a large thoracic kyphosis it is often balanced by
(T8, T9) generally are rigid while the thoracolumbar apex hyperlordosis in the lumbar spine. This typically results in an accept-
curves (T10, T11) are more flexible. Lumbar Scheuermanns able overall sagittal balance with C7 plum line (C7PL) passing
disease while a distinct entity often mimics a degenerative flat through the posterior/superior corner of the sacrum. (Reproduced
back. Lumbar Scheuermanns presents with multilevel degen- with permission from OBrien MF, Kuklo TR, Blanke KM, et al. (eds).
erative disc disease as the primary radiographic appearance SDSG radiographic measurement manual. Memphis, TN: Medtronik
rather than vertebral wedging, which is the more typical expres- Sofamor Danek, 2005:89.)
sion for thoracic Scheuermann. A preoperative magnetic reso-
nance imaging (MRI) evaluation is important in patients with
thoracic Scheuermann. This is necessary to evaluate the consis- brace. Hence, a practical guideline for dividing operative from
tency and health of the disc at the intended lowest instru- nonoperative treatments would suggest that curves less than
mented level and also to inspect for any thoracic stenosis or 75 in the growing adolescent could be considered for brac-
thoracic disc herniation, which could result in spinal cord com- ing.1 When bracing is the treatment of choice it should be
pression during corrective maneuvers. accompanied with an exercise program. As with scoliosis brace
wear, braces should be used at least 18 hours per day. Patients
may be out of the brace at night for sleep if necessary. Although
TREATMENTS
NONOPERATIVE TREATMENT
Indication for Nonoperative
The treatment of Scheuermanns disease is primarily nonop- TABLE 120.1
Care
erative (see Table 120.1). Asymptomatic deformities do not
need to be treated. Symptomatic thoracic kyphosis greater than Painless deformity
75 or 80 may require treatment. In the past, curves greater Kyphosis 80
than 50 in the skeletally immature patients have been man- Stable asymptomatic kyphosis of any size in adult
Acceptable cosmetic appearance
aged in a Milwaukee brace.3 However, high failure rates have
No neurologic deficit
been noted in curves greater than 74 that were treated with a

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 1298 Section XI Kyphosis and Postlaminectomy Deformities
A B
Milwaukee braces have been favored in the past, a thoracolum-
bar sacral orthosis (TLSO) brace is probably sufficient in most
curves except those with a high thoracic apex.
OPERATIVE TREATMENT
Operative management of symptomatic Scheuermanns kypho-
sis in either the adult or pediatric patient is intended to improve
spinal balance, both at the operated and the adjacent compen-
satory levels of the cervical and the lumbar spine. The main
goals in surgical treatment are to relieve pain at the affected
site, improve overall sagittal alignment, cosmesis, and to
improve health-related quality of life issues.13 Indications for
operative treatment include progressive deformity, painful
curve, unacceptable cosmetic appearance, restrictive pulmo-
nary disease, and neurologic deficits (see Table 120.2). Symp-
tomatic curves greater than 75 usually require surgery.
The potentially significant impact of the clinical spinal
deformity on a patients self-esteem and self-perception can be
measured by health outcome questionnaires. In a study by
Murray et al,23 patients with Scheuermanns disease were more
often single compared with control patients. This suggests that
Indications for Operative
TABLE 120.2
Treatment
Progressive curve
Painful curve
Unacceptable appearance
Restrictive pulmonary disease
Neurologic deficit
LWBK836_Ch120_p1295-1311.indd 1298
Figure 120.4. Subtle differences may exist between
Scheuermanns kyphosis. Scheuermanns kyphosis may be
represented as a high thoracic apex (A) as shown in this
case with the apex of the disc between T7 and T8. On the
other hand, a lower thoracic apex in B is shown at T11.
Thoracic apexes at higher levels tend to represent stiffer
curves, while thoracolumbar lumbar apexes tend to be
more flexible curves. Lower apex may also suggest some
additional difficulty in obtaining and maintaining distal
alignment and fixation.
there may be a relationship between posture, self-image, self-
confidence, and socialization, which is critical for social interac-
tion. Although objective radiographic criteria are important
for treatment decision making, the patients perception of his
or her condition and deformity is a significant part of the clini-
cal scenario and should play an important part in the decision
to perform surgery.
The surgical technique for the treatment of Scheuermanns
kyphosis has evolved over the last several decades. Initial instru-
mentation techniques using Harrington compression and dis-
traction instrumentation presented significant limitations in
achieving and maintaining correction. Since then, the instru-
mentation used to achieve kyphosis correction has included
Harrington nonsegmental hook instrumentation, segmental
hook instrumentation, sublaminar wires, and hybrid constructs
using hooks and screws. Both anterior and posterior techniques
have found favor at various times. Current treatment is per-
formed primarily via a posterior approach.15,16 The authors
preferred technique is to use segmental bilateral pedicle screw
fixation over the instrumented levels. The key to achieving cor-
rection, however, is performing adequate osseousligamentous
releases. These releases are performed using various osteotomy
techniques. Posterior column osteotomies in the form of Smith-
Peterson or Ponte osteotomies in the thoracic spine and wide
posterior releases as described by Shufflebarger in the lumbar
spine are the most useful and standard release technique for
Scheuermanns disease.14,19,20 Although improvement in the
instrumentation allows more effective force application to the
spine for deformity correction, the ultimate success of the
reduction relies most on the effectiveness of the release. Ponte
osteotomies in the thoracic spine are usually sufficient for
posterior release; however, intraoperative evaluation of spinal
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TABLE 120.3 Preferred Surgical Technique
Posterior-only approach
Bilateral segmental pedicle screw fixation
Ponte osteotomies across the apex of kyphosis
Deal in width of osteotomy to achieve desired correction
Intraoperative assessment for PSO
Would suggest PSO when:
Apex very rigid
Severe wedging at apex
Kyphosis 100
Osteoporosis
PSO, pedicle subtraction osteotomy.
flexibility will be the determinant as to whether or not more
aggressive techniques such as a pedicle subtraction osteotomy
(PSO) are required5 (see Case 120.3 and Table 120.3). In curves
that are stiff, have many levels with significant vertebral wedg-
ing, or in curves greater than 100, the treating surgeon should
embark on the surgery, willing and ready to add a PSO at one
or two levels to achieve the final correction. The PSO is an
extension of the Ponte procedure. After completion of the
Ponte osteotomies, the lamina and then the pedicles bilaterally
of the level requiring the PSO are excised. This is followed by
removal of a wedge-shaped piece of the vertebral body directly
beneath the resected pedicles. This will result in an osseous
release that will facilitate 30 to 40 of angular correction at the
osteotomy site (see Fig. 120.5).4
Choosing the correct levels for instrumentation and fusion
is a key component for success in treating sagittal plane defor-
mity. For high and mid-thoracic apex deformities, the upper
instrumented vertebra will be T2 or T3. The distal fusion level
will be decided by two criteria. First, the sagittal sacral vertical
plumb line should bisect or nearly bisect the vertebra that is
anticipated to be the distal instrumented vertebra. That verte-
bra should also be positioned distal to the first lordotic disc and
rostral to a lordotic disc. Care should be taken to ensure that
Figure 120.5. Schematic representation of a small pedicle sub-
traction osteotomy.
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Chapter 120 Surgical Treatment of Scheuermanns Kyphosis 1299
the first uninstrumented disc is not degenerative. Stopping
instrumentation short will often result in a distal junctional
kyphosis (DJK). DJK may or may not be symptomatic. DJK does
not always require revision surgery. Proximal junctional kypho-
sis is also a potential problem with an unclear etiology. Although
near normalization of the sagittal contours of the spine can be
achieved with a combination of the posterior techniques previ-
ously described, one should be careful trying to achieve too
much correction. In general, 50% to 60% correction of the
deformity is sufficient. Correction greater than 50% may result
in either proximal or DJK (see Figs. 120.6AD)1012 Spontaneous
correction of the compensatory cervical and lumbar curves is
anticipated.
Electrophysiological monitoring of the spinal cord is man-
datory during these surgical cases. All available monitoring
techniques should be used. These should include transcranial
motor evoked potentials (TcMEP), somatosensory evoked
potentials (SSEP), and pedicle screw stimulation. Although
correction of Scheuermanns kyphosis is typically uncompli-
cated, it is not without risk.7 Neurological deficits can be pro-
voked by disc herniation, osseous compressive pathologies, and
vascular insults. During these surgical procedures, particularly
at the time of deformity correction, vascular physiology should
be optimized to protect against neurological deficits. Steps
should be taken to increase the mean arterial blood pressure
greater than or equal to 90 mmHg. The hematocrit should be
optimized to ensure that oxygenation is maximized. If osteoto-
mies are performed that might be accompanied by large angu-
lar corrections such as pedicle subtraction osteotomies or verte-
bral column resections, care must be taken to ensure that the
neural canal remains patent. Any significant changes in neural
monitoring should be addressed immediately. This can be
achieved by optimizing blood pressure, oxygenation, and hema-
tocrit and or by reversing whatever event or surgical technique
preceded the drop in monitoring. Steroids have been touted as
being neuroprotective in the early phase of spinal cord injury.
The literature is more optimistic in this regard than the gener-
ally held belief of deformity surgeons at this time. However, the
incremental risk of giving spinal cord injury doses of steroid
may be acceptable if a spinal cord injury seems possible.2
SURGICAL PROCEDURE (See Table 120.3)
The surgery is performed on a Jackson operating table.9 To
assist with postural reduction, the chest pads and the pelvis
pads are separated a bit more than usual to allow gradual
reduction of the kyphosis via gravity during the exposure. After
complete exposure of the spine (see Figs. 120.7A and B and
120.8), the thoracic and lumbar facets are excised. The facets
should be excised prior to placing pedicle screws to facilitate
their complete removal. The presence of pedicles screws will
make removal of the facet joints difficult (see Fig. 120.9). Pedi-
cle screw instrumentation is placed using the fluoroscopic tech-
nique as described by Shufflebarger.18 The interspinous
ligaments are removed at each level. The spinous processes are
then shortened or excised as necessary to gain access to the
interlaminar space (see Figs. 120.10A and B and 120.11). The
local bone is saved for later use as bone graft. The ligamentum
flavum is exposed and partially resected in the midline with a
wide double action Lexel rongeur. Kerrison rongeurs are then
used to excise the remaining ligamentum flavum proceeding
laterally through the facet joints. The Kerrison rongeur is
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 1300 Section XI Kyphosis and Postlaminectomy Deformities
A B
C D
LWBK836_Ch120_p1295-1311.indd 1300
Figure 120.6. The development of distal (A and
B) and proximal (C and D) junctional kyphosis is an
ever present problem in the surgical treatment of
scoliosis. Typically these junctional kyphosis do not
present with significant clinical sequela and only
result in an unpleasing radiographic appearance.
Occasionally, significant proximal or junctional
kyphosis requires revision surgery.
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 Chapter 120 Surgical Treatment of Scheuermanns Kyphosis 1301

Figure 120.9. Close up three-dimensional representation of pedi-

cle screw placement with Ponte osteotomies as used for treatment in
Scheuermanns disease. It is often difficult to perform the Ponte
osteotomies after placement of pedicle screws due to the small size of
some patients anatomy.
A B

Figure 120.7. Preoperative sagittal alignment (A) and coronal

alignment (B) are represented for typical Scheuermanns kyphosis.

A B
Figure 120.8. This shows three-dimensional representation of the
pertinent anatomy required for pedicle fixation and osteotomies for Figure 120.10. Sagittal (A) and coronal representation (B) of
the treatment of Scheuermanns disease. multilevel Ponte osteotomies through the thoracic spine.

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 1302 Section XI Kyphosis and Postlaminectomy Deformities

Figure 120.11. A three-dimensional close up representation of an

appropriately performed Ponte osteotomy.

Figure 120.13. Closure of the Ponte osteotomy involves proximal

placement of the rods with segmental compression across these osteot-
omy sites achieving closure from proximal to distal of each osteotomy.

Figure 120.14. Final closure of the Ponte osteotomy is achieved

by continued compression of the distal Ponte osteotomies toward the
Figure 120.12. Closure of the Ponte osteotomy involves proximal proximal osteotomies. This in combination with cantilever manipula-
placement of the rods with segmental compression across these osteot- tion of the rod into the distal instrumentation achieves correction of
omy sites achieving closure from proximal to distal of each osteotomy. the kyphosis.

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Figure 120.15. Final closure of the Ponte osteotomy is achieved
by continued compression of the distal Ponte osteotomies toward the
proximal osteotomies. This in combination with cantilever manipula-
tion of the rod into the distal instrumentation achieves correction of
the kyphosis.
continued laterally through the superior articular process of
the inferior vertebrae at that level. The same technique is used
in the thoracic and lumbar spine. The result is a series of
chevron-shaped osteotomies. Rostral and caudal widening of
the osteotomy is performed as dictated by the requirements
of the reduction. The rods are placed in the proximal anchors,
and these anchors are compressed (see Figs. 120.12 and
120.13). The rest of the reduction is achieved by using cantile-
ver maneuvers with the rod while inserting it into the distal
anchors (see Figs. 120.14 and 120.15). Engaging and reducing
the rods in a sequential and bilateral manner is facilitated by
the use of reduction screws below the apex of the deformity.
After rod placement, additional correction can be achieved by
segmental compression (see Fig. 120.16). The final step in con-
struct assembly is torque tightening all the connections. Poste-
rior fusion is completed with gouge decortication of the
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Chapter 120 Surgical Treatment of Scheuermanns Kyphosis 1303
Figure 120.16. Three-dimensional representation showing the
final placement of pedicle screw instrumentation and closure of
osteotomies using the Ponte technique.
posterior elements, and local and iliac crest grafting. Ambula-
tion without a brace is accomplished on the first or second day
after surgery.
CONCLUSION
Scheuermanns kyphosis in the adolescent and adult popula-
tion is a common spinal deformity. Treatment is usually either
observation or conservative care. Occasionally, surgical inter-
vention is warranted. Surgical intervention may be required for
a host of objective and subjective reasons. State-of-the-art surgi-
cal techniques for correction of Scheuermanns kyphosis
include posterior spinal fusion with instrumentation and
posterior-based osteotomies for spinal release and mobiliza-
tion. Using a combination of segmental pedicle screw fixation
and spinal osteotomies, Scheuermanns kyphosis can usually be
corrected satisfactorily. Significant neurological complications
are uncommon but may occur. Careful attention should be
paid to the patients physiological parameters and the surgical
technique during corrective procedures. These cases should
not be undertaken without adequate spinal cord monitoring.
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 1304 Section XI Kyphosis and Postlaminectomy Deformities
CLINICAL CASES
CASE 120.1
MS is a 24-year-old man with a significant clinical
kyphotic deformity as evidenced in Figures 120.17A and
B. The patient has a small associated scoliosis (Fig.
120.17C) as is common in Scheuermanns disease. The
A B
C D
Figure 120.17. (continued)
LWBK836_Ch120_p1295-1311.indd 1304
relatively low thoracic apex is documented in the lateral
radiographs (Fig. 120.17D) but is also suspected when
visualizing the lateral clinical photograph (Fig. 120.17A).
Postoperative clinical photographs (Figs. 120.17E and F)
show excellent realignment of the sagittal plain. Postop-
erative radiographs (Figs. 120.17G and H) show excellent
alignment in the coronal and sagittal projection without
any significant proximal or distal junctional kyphosis.
E
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 Chapter 120 Surgical Treatment of Scheuermanns Kyphosis 1305

F G H

Figure 120.17. (Continued)

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 1306 Section XI Kyphosis and Postlaminectomy Deformities

CASE 120.2

TF is a 19-year-old woman with a significant clinical kypho-
sis as evidenced by her preoperative clinical photographs
(Figs. 120.18A to C). Radiographs in the frontal projection
(Fig. 120.18D) do not show a significant scoliosis. The lat-
eral radiographs (Fig. 120.18E) show a significant thoracic
kyphosis measuring approximately 90 from T4 to T12.
Postoperative clinical pictures (Figs. 120.18F to H) show
excellent restoration of sagittal profile including lumbar
lordosis and excellent reduction of the thoracic kyphosis
without development of a clinical proximal or distal junc-
tional kyphosis. Postoperative radiographs (Figs. 120.18I
and J) show excellent coronal and sagittal alignment
without proximal or distal junctional kyphosis.

A B

Figure 120.18. (continued)

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 Chapter 120 Surgical Treatment of Scheuermanns Kyphosis 1307

D E F

G
Figure 120.18. (Continued)

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 1308 Section XI Kyphosis and Postlaminectomy Deformities

I J

Figure 120.18. (Continued)

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CASE 120.3
KS is a 16-year-old highly competitive swimmer and volley-
ball player. The patient has increasing back pain and
progressive kyphosis. Clinical anteroposterior (AP) and lat-
eral (Figs. 120.19A and B) and forward bend (Fig. 120.19C)
films show the moderate low apex kyphosis. Preoperative
radiographs in the AP (Fig. 120.19D) and lateral projection
(Fig. 120.19E) show a small associated scoliosis and a low
thoracic apex at T11. For this 88 Scheuermanns kyphosis
measured from T4 to L2, postoperative clinical films
(Figs. 120.19F and G) show excellent coronal and sagittal
A B
Figure 120.19. (continued)
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Chapter 120 Surgical Treatment of Scheuermanns Kyphosis 1309
alignment without any evidence of proximal or junctional
kyphosis. Postoperative radiographs (Figs. 120.19H and I)
verify excellent coronal and sagittal alignment. Please note
that to improve the alignment of the lower aspect of the
kyphosis across the T11 apex, a small pedicle subtraction
osteotomy was performed to obtain additional correction in
the lower end of the construct and to assist in creating thora-
columbar lordosis. Excellent sagittal realignment has been
achieved without the development of any proximal or distal
junctional kyphosis.
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 1310 Section XI Kyphosis and Postlaminectomy Deformities

D E F

G H I

Figure 120.19. (Continued)

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 Chapter 120 Surgical Treatment of Scheuermanns Kyphosis 1311

Annual Meeting, Chicago, 2006. Pediatric Orthopaedic Society of North America, San
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