Kyphosis

Kyphosis is a convex posterior curvature and lordosis a convex anterior curvature of

the spine, both occurring in a sagittal plane.

From: Clinical Imaging (Third Edition), 2014

Related terms:

Body of Vertebra, Surgery, Spine, Injury, Deformity, Pain, Scoliosis, Lordosis, Frac-
ture

View all Topics

Learn more about Kyphosis

DISORDERS OF ALIGNMENT
In Imaging in Spine Surgery, 2017

Diagnostic Checklist
• Image entire spine (particularly in children) to exclude additional bone or cord
abnormalities, Chiari 1 malformation
Lateral radiograph demonstrates smoothly curved thoracic kyphosis with premature
upper thoracic degenerative disc disease in this patient with degenerative kyphosis.

Lateral chest radiograph (idiopathic kyphosis) reveals diffuse upper thoracic kypho-
sis with a round-back deformity. There is no underlying cause of kyphosis (e.g.,
Scheuermann disease, prior trauma, congenital anomaly, or infection).

Lateral radiograph (repaired high myelomeningocele, congenital vertebral segmen-

tation failure with kyphosis) depicts severe focal lumbosacral kyphotic curvature.
There is also posterior spinal dysraphism and segmentation failure of the lumbar
and sacral vertebra associated with kyphosis.
Sagittal T2WI MR (same patient) reveals distal spinal cord attenuation at the thora-
columbar junction myelomeningocele repair site. Note extensive congenital verte-
bral anomalies.

> Read full chapter

Impaired posture
Carleen Lindsey PT, MScAH, GCS, in Geriatric Physical Therapy (Third Edition), 2012

Thoracic kyphosis
Thoracic kyphosis remains fairly constant in adult men and women until somewhere
about age 40 years. After age 40 years, thoracic kyphosis begins to increase in both
men and women, with a more marked increase in women across the remainder of
the life span. Excessive thoracic kyphosis (hyperkyphosis) is a commonly observed
postural dysfunction in older adults, particularly older women. A thoracic kyphosis
angle greater than 40 degrees exceeds the 95th percentile value of thoracic kyphosis
angle in young adults17,18 and, thus, may serve as a possible cutoff for hyper-
kyphosis. Multiple researchers4,5,7,11,13,14,19-25 have associated clinically symptomatic
hyperkyphosis with advancing age, often linking increasing kyphosis with increas-
ing functional limitations,4,7,11,18,23 decreased participation in outside activities,4,18
and lower self-reported health and life satisfaction.18 In addition, significant
correlations have been demonstrated between fall risk and kyphosis.15,26 Although
clinical kyphosis alone is not linearly predictive of either osteoporosis or vertebral
fractures, an association does exist, 7,11,14,26,26a and has been demonstrated to be most
prominent in women with multiple thoracic vertebral compression fractures (VCF).7
It has also been demonstrated that a composite risk score using calcaneal qualitative
ultrasonometry and kyphosis had better discriminatory power than low dual-energy
x-ray absorptiometry bone mineral density to predict prevalent vertebral fractures in
community-dwelling women.26a

> Read full chapter

Congenital and Neuromechanical Ab-

normalities of the Skeleton
DONALD J. ORTNER, in Identification of Pathological Conditions in Human Skeletal
Remains (Second Edition), 2003

Kyphosis
Kyphosis is the pathological increase in the normal slight anterior concave curvature
of the thoracic spine that results in the abnormal forward bending of the spine.
This is in contrast with the less common lordosis, which is an abnormal curvature
of the posterior spine that results in a saddle-back deformity. Kyphosis is caused
by changes either in the intervertebral disks (primary kyphosis) or in the vertebrae
themselves (secondary kyphosis) (Putschar 1937:675–681). Primary kyphosis is di-
vided into juvenile and senile forms.

Juvenile Kyphosis (Scheuermann's Disease)

This deformity develops in adolescents with great predilection of the male sex
(Scheuermann 1921). The apex of the curvature in this deformity usually falls in
the area of the eighth to tenth thoracic vertebra. The underlying cause is probably
extrusion of nucleus pulposus material of the cartilage disk, mostly into the adjacent
vertebral bodies (Schmorl's nodes) followed by anterior narrowing of the disk space
and subsequent growth disturbance in this area of the end plate. This tends to result
in diminished growth of the anterior vertebral body and a wedge shape of that
body (Schmorl 1930; Schmorl and Junghanns 1971:345–354). The location of the
wedge vertebrae usually coincides with the apex of the curvature. In a disarticulated
skeleton, abnormalities in the curvature of the spine are difficult to assess; the
presence of one or several adjacent wedge vertebrae and of round or oblong defects
near the center of the vertebral end plate, corresponding to the location of the disk
herniation, would be crucial in diagnosis. If this type of deformity is long survived,
secondary sclerotic changes and marginal anterior lipping may be added to the
abnormal findings mentioned previously.

Senile Kyphosis
This is a very common spinal deformity, typically developing in the fifth decade and
increasing in frequency and degree with age. The underlying cause is degeneration
and attrition of the intervertebral disks, particularly of their anterior portions, in
the physiologically kyphotic thoracic segments. The apex of the curvature in senile
kyphosis is in the upper thoracic spine, and wedging of vertebral bodies is either ab-
sent or slight. The main features recognizable on skeletal material are osteosclerosis
of the anterior portions, especially the end plates, of affected vertebrae with marginal
lipping and, sometimes, anterior fusion of several segments (Figure 18-21, left).
Disk herniations are not a characteristic part of this condition. The anterior marginal
lipping, in contrast to spondylosis deformans, arises directly from the vertebral end
plate and is usually rather moderate. In advanced cases the anterior portions of the
intervertebral disk may be replaced by continuous bone trabeculae and the lipping
may be completely smoothed down by remodeling resorption.

FIGURE 18-21. Kyphosis. Two bisected spines. Left: Senile kyphosis with ante-
rior compression of intervertebral disks and bony bridging. Right: Severe post-
menopausal osteoporosis with kyphosis, showing biconcave “codfish” vertebrae.

(IPAZ 6017: left, 71-year-old female, autopsy 385 from 1955; right. 65-year-old
female, autopsy 403 from 1955.)

Copyright © 1955

Secondary Kyphosis
This deformity is secondary to lowered mechanical resistance of the vertebrae. A
variety of conditions, especially osteoporosis (Figure 18-21, right), osteomalacia,
hyperparathyroidism, and Paget's disease, may exhibit this complication. In this con-
dition, wedge vertebrae, due to compression fractures, are common. The intrinsic
changes of the underlying bone disease would help in recognition of the deformity
as secondary. This is especially true of kyphosis due to a congenital anomaly of the
spine, such as dorsal hemivertebra.

> Read full chapter

Osteoporosis
Caitlyn Dowson MBChB FRCP, Rachel Lewis MCSP SRP HT, in Rheumatology, 2010

POSTURAL CORRECTION
Kyphosis can be due to a combination of muscle weakness and muscle imbalance.
Patients with vertebral fracture have a further biomechanical alteration with a reduc-
tion in anterior vertebral height in comparison to the posterior height, increasing
with multiple fractures (Genant et al 1993, Myers & Wilson 1997). Fractures can
exacerbate muscle imbalance and a vicious cycle of muscle pain and weakness can
perpetuate increasing kyphosis and further fracture (Huang et al 2006).

By addressing posture correction and giving ergonomic advice, a more muscle-ef-

ficient posture can be adopted, pain can be reduced and overall biomechanics
improved. This is often demonstrated by an increase in patient activities of daily
living and improvement in metrology. Advice should be given regarding sleeping
positions with particular attention to the cervical spine and hips, which are common
sites of discomfort. The use of lumbar rolls for the spine should be advised for
sitting and travelling to improve posture and relieve discomfort. Ergonomic advice
regarding sitting positions should be given as basic information, and advice on office
seating and armchair design should be highlighted. Patients should be made aware
of their local resource centres, e.g. the Disabled Living Foundation.

Osteoporosis does not only affect retired post-menopausal women, therefore occu-
pational therapists may need to perform fit-for-work assessment. Further self-man-
agement advice on postural correction is applicable in some cases, e.g. the Alexander
technique, Pilates etc.

> Read full chapter

SPECIFIC PROBLEM AREAS
Crispian Scully CBE PhD MD MDS MRCS FDSRCPS FFDRCSI FDSRCS FDSRCSE
FRCPath FMedSci DSc, ... Navdeep Kumar PhD FDSRCS, in Special Care in Den-
tistry, 2007

General anaesthesia
Kyphosis and other deformities affecting respiration may make general anaesthesia
hazardous. The glottic opening may be narrowed and the cords' mobility reduced. A
goitre may further embarrass the airway.

Table 3.1. Key considerations for dental management in acromegaly (see text)

Management modifications* Comments/possible complica-

tions
Risk assessment 2 Blindness, diabetes, hyperten-
sion, arrhythmias
Preventive dentistry and educa- 1 Carpal tunnel syndrome, en-
tion larged tongue
Pain and anxiety control
– Local anaesthesia 0
– Conscious sedation 0
– General anaesthesia 1/4 Kyphosis, narrow glottis
Patient access and positioning
– Access to dental office 0
– Timing of treatment 1 Sleep apnoea, fatigue
– Patient positioning 1 Longer dental chair
Treatment modification
– Oral surgery 0
– Implantology 0
– Conservative/Endodontics 0
– Fixed prosthetics 0
– Removable prosthetics 0
– Non-surgical periodontology 0
– Surgical periodontology 0
Hazardous and contraindicated 0
drugs

* 0 = No special considerations. 1 = Caution advised. 2 = Specialised medical ad-

vice recommended in some cases. 3 = Specialised medical advice mandatory.
4 = Only to be performed in hospital environment. 5 = Should be avoided.

> Read full chapter

Volume 2
Christopher M. Boxell, ... Mitchell Martineau, in Schmidek and Sweet Operative
Neurosurgical Techniques (Sixth Edition), 2012

Limiting Complications of Laminoplasty

Kyphosis and large posterior projection of osteophytes are known factors for poor
improvement of myelopathy after laminoplasty. If osteophyte or OPLL occupies
more than 60% of the canal, then an anterior approach would offer a higher
statistical chance of patient improvement.75 In cases of myelopathy caused by OPLL,
it has been observed that the improvement from laminoplasty is low in cased where
the K-line is negative. The K-line for kyphosis is a measurement of these two factors.
The K-line is measured by taking the midpoint of the spinal canal at C2 and C7 and
connecting these two points with a line. If the K-line contacts the posterior projection
of the OPLL, then the K-line is defined to be negative, and 85% of patients in this
group do not improve with laminoplasty76 (Fig. 157-14).

FIGURE 157-14. K-line measurements.

Laminoplasty complications are frequently associated with damage of posterior

cervical musculature. Electrocautery-based dissection lateral to the facet complex
frequently results in denervation of the adjacent muscle, this may lead to increased
neck pain and kyphotic deformity of the spine. This complication can be lessened
by limiting electrical dissection to the middle of the facet complex. Some surgeons
have advocated a muscle splitting technique in open door laminoplasty so that on
the hinged side of the construct the cervical musculature is spared.77,78 It is well
established that removal of the C2 lamina in laminoplasty worsens postoperative
alignment. If the semispinalis Cervicis is removed from C2 during dissection, it
should be reattached. If laminoplasty includes C2 then efforts should be undertaken
to reattach the semispinalis cervicus and the rectus capitus to the C2 spinous
process. If it is impossible to reattach these muscles to the spinous process of C2,
then it is recommended that a bilateral repair be performed where the rectus capitus
be attached to the contralateral semispinlis cervicus.79,80 Dissection and damage to
any of the facet capsules are to be avoided.

Axial neck pain is a frequently reported complication of laminoplasty. It is thought

that by limiting the dissection from C3 to C6 instead of C7 that the incidence of
neck pain is lessened. This appears to be an acceptable practice as long as more
than 1 mm of subarachnoid space surrounds the cord at C7.81-83 One class II study
found that performing a C3 laminectomy while sparing the muscular insertion to C2
combined with a C4–C7 laminoplasty greatly reduced the incidence of postoperative
axial neck pain as compared to C3–C7 laminoplasty.84-86 A class I study determined
that sparing the C7 spinous process and nuchal ligament significantly reduced axial
neck pain over a 2-year period as compared to C3–C7 laminoplasty group.87

Patients with hypermobility of the cervical spine and the elderly tend to do poorly
with laminoplasty. Other techniques should be considered should be given consid-
eration in these cases.88

> Read full chapter

Back, Hip, and Knee Disorders

James R. Ebert MD, MBA, in Adolescent Medicine, 2008

Kyphosis
Kyphosis is posterior curvature of the thoracic spine that exceeds the normal range
of 20–45 degrees. Scheuermann kyphosis is characterized by anterior wedging of
the vertebral bodies and irregularities of the vertebral end-plates at three or more
levels, with consequent inability to correct the round back by active hyperexten-
sion. This is in contrast to postural round back, which is characterized by normal
vertebrae and disc spaces, temporary correction with active hyperextension, and
long-term improvement with hyperextension exercises of the back. The prevalence
of Scheuermann kyphosis is 4–8%. Males are twice as likely to be affected as females,
and the risk of severe disease appears particularly high in tall males. The cause
remains unknown, although there is some evidence that transient osteoporosis
following prolonged immobilization may result in vertebral compression fractures
with subsequent wedging.
Pain is the usual presenting complaint of patients with Scheuermann kyphosis.
It is gradual in onset, has no clear precipitating event, is worse with activity, and
improves with rest. When the adolescent bends forward at the waist, examination
from the side reveals sharp angulation of the thoracic spine. The most commonly
affected vertebrae are T7–T9 and T10–T12. Radiographic examination of the entire
spine should be performed with standing lateral and posteroanterior views. Oblique
views should also be considered because of the association of Scheuermann kyphosis
with spondylolysis (see below). All patients with Scheuermann kyphosis warrant
orthopedic consultation. Observation may be all that is required for adolescents
with non-progressive curves that are less than 50 degrees. Bracing or surgery
is indicated for larger or rapidly progressive curves to prevent chronic pain and
impaired pulmonary function.

> Read full chapter

Myelomeningocele Spinal Deformities

VINCENT ARLET, JEAN OUELLET, in Surgical Management of Spinal Deformities,
2009

CLASSIFICATION
Spinal deformities in myelomeningocele can be one of three types: congenital
kyphosis, scoliosis, and lordosis.

Congenital kyphosis is observed at birth, generally develops in the middle or upper

lumbar spine, and usually progresses to approximately 100 degrees. Untreated, it
progresses 5 to 12 degrees per year.

Scoliosis has several causes, some occurring together. Flaccid scoliosis is the most
classic, with a typical C-shaped curve and a collapsing spine with an element of
kyphosis. These curves are most often progressive. Congenital anomalies such as
hemivertebrae, congenital bars, and jumbled spine with defect of segmentation
or formation are often present at the thoracic or lumbosacral level. An element
of spasticity is often present. A tethered cord can also play a role in the patho-
genesis of scoliosis. Tethered cord syndrome can result from a lipomeningocele,
a diastematomyelia, or a thick filum terminale. It may be associated with pain,
decreased neurologic function or change in bladder habit (increased bladder spas-
ticity), and lumbar lordosis. Finally, hydromyelia can account for scoliosis. Screening
with magnetic resonance imaging can allow for early treatment (shunting or Chiari
decompression), and in mild or moderate scoliosis (less than 30 degrees), treatment
of the hydromyelia can stop the progression of the curve.
Scoliosis is common in high-level paraplegia, observed in almost 100% of cases.
Scoliosis is observed in 60% of cases of L4 paraplegia, with 40% of patients requiring
surgery.

> Read full chapter

Radiologic Imaging of Spinal Deformi-

ties
RENATA LA ROCCA VIEIRA, ... MARK E. SCHWEITZER, in Surgical Management of
Spinal Deformities, 2009

KYPHOSIS
The term kyphosis is used to refer to excessive curvature in the thoracic spine. Kypho-
sis can be the result of many causes (e.g., trauma, developmental problems, degen-
erative disc disease, infection). When viewed from one side, a kyphosis deformity can
be gradual and smooth, as in postural roundback, or it can be a sharp and angular
(gibbus) deformity, as in congenital kyphosis, Potts disease, or, to a lesser extent,
Scheuermann's kyphosis. Other causes of spinal kyphosis include those that occur
with disorders of the nervous system and muscle disorders (cerebral palsy, muscular
dystrophy, spinal muscular atrophy, and myelomeningocele), neurofibromatosis,
connective tissue disorders, Paget's disease, tumors, and after surgery. Kyphosis can
also be seen in association with scoliosis. In these cases, kyphosis is usually related
to an underlying cause of the scoliosis, such as neurofibromatosis. In idiopathic
scoliosis, there is more often straightening rather than accentuation of the kyphosis.

In the postoperative correction of kyphosis, it is important to assess the spine

curvature on the frontal views and the sagittal balance on the lateral views of the
patient's spine. Flat-back syndrome results from an iatrogenic loss of lumbar lordosis
with forward inclination of the trunk and is frequently recognized as a complication
following placement of thoracolumbar instrumentation.

Scheuermann's Disease
Scheuermann's disease is a structural deformity of the spine that develops prior
to puberty and becomes most prominent during the adolescent growth spurt. The
cause is unknown.

Initial descriptions focused on thoracic kyphosis; however, it was noted that thora-
columbar and lumbar variants also occur. A minimal scoliosis may be associated
in about one third of cases. Classic radiographic descriptions (Fig. 3-12) include
irregular vertebral end plates, narrowing of the intervertebral disc spaces, three or
more vertebrae wedged 5 degrees or more, and an increase in normal thoracic
kyphosis to greater than 45 degrees.

Figure 3-12. Lumbar Scheuermann's disease. Sagittal T1-weighted MR image

demonstrates multiple Schmorl's nodes throughout the lumbar spine.

The prevalence of Scheuermann's disease varies depending on inclusion criteria and

has been reported to be between 0.4% and 8%.

Imaging

RADIOGRAPHY.

A standard radiographic evaluation of a patient with Scheuermann's disease or other

causes of kyphosis includes anteroposterior and lateral standing radiographs on
long films, which would incorporate the entire thoracolumbar spine on one film. The
patient should be standing in a neutral position with hips and knees fully extended
to allow for a true evaluation of the sagittal balance. The lateral view should be taken
with the arms elevated at 90 degrees in front of the subject to prevent the bony
outlines of the upper extremities from obscuring the vertebral body images.

The diagnosis of Scheuermann's kyphosis is confirmed on the lateral radiographs

(Fig. 3-12). The angle between the end plates of each respective vertebral body
should be measured by using the Cobb technique. The presence of three adjacent
vertebral bodies with 5 or more degrees of anterior wedging confirms the diagnosis
of Scheuermann's kyphosis.

The Cobb technique should be used to measure the overall degree of kyphosis of
the thoracic spine. The end vertebral bodies, which are defined as the last vertebral
body tilting into the kyphotic deformity, should be selected both proximally and
distally. The levels of these particular vertebral bodies should be noted, as they are
the same vertebral bodies that should be selected on subsequent films to ensure
that the examiner is consistent with follow-up evaluations.

Secondary changes of Scheuermann's kyphosis should be noted, such as the nec-

essary presence of Schmorl's nodes, irregular vertebral end plates, and disc space
narrowing. Scoliosis and spondylolisthesis have been associated with Scheuermann's
kyphosis. These should be documented on plain radiographs and treated as separate
entities.

Other entities that share the differential diagnosis of Scheuermann's kyphosis can
be excluded radiographically as well. Congenital kyphosis, ankylosing spondylitis,
multiple compression fractures, tumor, infection, tuberculosis, and postlaminecto-
my kyphosis can be distinguished by clinical history and confirmed by radiographic
evaluation.

The dynamic quality of the kyphosis should be assessed to distinguish Scheuer-

mann's kyphosis from postural kyphosis. A lateral radiograph can be obtained in
hyperextension. Should the deformity correct entirely, postural kyphosis is the most
likely diagnosis, rather than Scheuermann's kyphosis.

It is necessary to account for the rigidity of the curve in treatment decisions, as the
ability for correction with bracing and surgical intervention will be affected.

MAGNETIC RESONANCE IMAGING, COMPUTED TOMOGRAPHY, AND CT MYELOGRAPHY.

MRI, CT scan, and CT myelography can be helpful adjunctive studies in planning

the care of a patient with Scheuermann's disease or other types of kyphosis. MRI,
in particular, helps the surgeon to further define the local anatomy. In particular,
attention should be given to the coexistence of thoracic spinal stenosis, syrinx, or
any other intrathecal abnormalities that would affect surgical care.

Additionally, an anatomic assessment of the lumbar discs can be made, and it may
affect surgical decision making in terms of which levels to incorporate in the fusion.

Postlaminectomy Kyphosis
Traumatic kyphosis is a traumatic compression of one or more vertebrae and may
occur in the cervical, thoracic, thoracolumbar, or lumbar spine. The most commonly
affected location is the thoracolumbar junction. It may lead to either cosmetic or
symptomatic kyphosis. This may be prevented by early stabilization of high-grade
unstable traumatic spinal injuries. Although the majority of posttraumatic deformi-
ties usually occur after spinal column trauma, which is initially treated nonoperative-
ly, several miscellaneous causes of posttraumatic deformity may occur after surgery.
These include nonunion, implant failure, Charcot spine, and technical error.

In the thoracic spine, an injury to the anterior column resulting from a flexion-com-
pression injury will produce a decrease in the height of the anterior portion of the
vertebral body, resulting in a focal kyphosis at this level. This deformity will cause
hyperextension of adjacent spinal regions, resulting in altered facet joint motion,
instability, and worsening of the degenerative process.

Each year in the United States, there are more than 1 million acute injuries to
the spine, approximately 50,000 of these resulting in fractures to the bony spinal
column. The improvements in emergency medical services and the increased safety
standards have been increasing the trend for improved patient survival with incom-
plete and complete spinal cord injuries. Ironically, this has been associated with a
greater number of patients presenting with symptoms related to loss of normal
spinal alignment or worsening of spinal deformity.

Imaging

Plain radiographs, including anteroposterior and lateral views, are essential. Flexion
and extension lateral and anteroposterior bending views are important in assessing
the flexibility of any spinal deformity.

CT offers detailed evaluation of spinal bony architecture, and multislice CT has

added advantages for spinal trauma imaging, including volume imaging, the ability
to acquire multiplanar reconstructions, three-dimensional images, and thick-slice
(wedge) multiplanar reconstructions that mimic conventional radiographs. This
allows the visualization of subtle structural abnormalities, especially involving the
posterior element bony structures that are often difficult to visualize on plain
radiography.

Imaging postoperative patients with metallic implants often presents a challenge.

Metal causes artifacts such as beam hardening. The metal artifacts depend on the
composition of the hardware (titanium produces the least amount of artifact, and
cobalt chrome alloys produce the most). Artifacts also depend on the geometry of
the implant (its thickness and orientation) and are most severe in the direction of the
thickest portion of the implant. Metal artifacts also depend on peak kilovoltage and
current, the reconstruction algorithm, and the slice thickness and orientation of the
 multiplanar reconstruction. Optimization of these parameters can help to reduce
metal artifacts.

MRI is useful in visualizing spinal soft tissue structures in detail and to evaluate the
canal and neural structures but can be limited by susceptibility to artifacts related to
hardware.

Infectious Kyphosis
The term infectious kyphosis refers to septic destruction of vertebral bodies, which
can lead to severe kyphosis. In particular, tuberculous vertebral osteomyelitis can
produce soft-tissue abscess, high-grade kyphosis, and a sharp gibbus deformity with
an exaggerated kyphosis epicentered in the lower thoracic spine.

> Read full chapter

ScienceDirect is Elsevier’s leading information solution for researchers.

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Kyphosis
Kyphosis is a convex posterior curvature and lordosis a convex anterior curvature of
the spine, both occurring in a sagittal plane.

From: Clinical Imaging (Third Edition), 2014

Related terms:

Body of Vertebra, Surgery, Spine, Injury, Deformity, Pain, Scoliosis, Lordosis, Frac-
ture

View all Topics

Learn more about Kyphosis

DISORDERS OF ALIGNMENT
In Imaging in Spine Surgery, 2017

Diagnostic Checklist
• Image entire spine (particularly in children) to exclude additional bone or cord
abnormalities, Chiari 1 malformation
Lateral radiograph demonstrates smoothly curved thoracic kyphosis with premature
upper thoracic degenerative disc disease in this patient with degenerative kyphosis.

Lateral chest radiograph (idiopathic kyphosis) reveals diffuse upper thoracic kypho-
sis with a round-back deformity. There is no underlying cause of kyphosis (e.g.,
Scheuermann disease, prior trauma, congenital anomaly, or infection).

Lateral radiograph (repaired high myelomeningocele, congenital vertebral segmen-

tation failure with kyphosis) depicts severe focal lumbosacral kyphotic curvature.
There is also posterior spinal dysraphism and segmentation failure of the lumbar
and sacral vertebra associated with kyphosis.
Sagittal T2WI MR (same patient) reveals distal spinal cord attenuation at the thora-
columbar junction myelomeningocele repair site. Note extensive congenital verte-
bral anomalies.

> Read full chapter

Impaired posture
Carleen Lindsey PT, MScAH, GCS, in Geriatric Physical Therapy (Third Edition), 2012

Thoracic kyphosis
Thoracic kyphosis remains fairly constant in adult men and women until somewhere
about age 40 years. After age 40 years, thoracic kyphosis begins to increase in both
men and women, with a more marked increase in women across the remainder of
the life span. Excessive thoracic kyphosis (hyperkyphosis) is a commonly observed
postural dysfunction in older adults, particularly older women. A thoracic kyphosis
angle greater than 40 degrees exceeds the 95th percentile value of thoracic kyphosis
angle in young adults17,18 and, thus, may serve as a possible cutoff for hyper-
kyphosis. Multiple researchers4,5,7,11,13,14,19-25 have associated clinically symptomatic
hyperkyphosis with advancing age, often linking increasing kyphosis with increas-
ing functional limitations,4,7,11,18,23 decreased participation in outside activities,4,18
and lower self-reported health and life satisfaction.18 In addition, significant
correlations have been demonstrated between fall risk and kyphosis.15,26 Although
clinical kyphosis alone is not linearly predictive of either osteoporosis or vertebral
fractures, an association does exist, 7,11,14,26,26a and has been demonstrated to be most
prominent in women with multiple thoracic vertebral compression fractures (VCF).7
It has also been demonstrated that a composite risk score using calcaneal qualitative
ultrasonometry and kyphosis had better discriminatory power than low dual-energy
x-ray absorptiometry bone mineral density to predict prevalent vertebral fractures in
community-dwelling women.26a

> Read full chapter

Congenital and Neuromechanical Ab-

normalities of the Skeleton
DONALD J. ORTNER, in Identification of Pathological Conditions in Human Skeletal
Remains (Second Edition), 2003

Kyphosis
Kyphosis is the pathological increase in the normal slight anterior concave curvature
of the thoracic spine that results in the abnormal forward bending of the spine.
This is in contrast with the less common lordosis, which is an abnormal curvature
of the posterior spine that results in a saddle-back deformity. Kyphosis is caused
by changes either in the intervertebral disks (primary kyphosis) or in the vertebrae
themselves (secondary kyphosis) (Putschar 1937:675–681). Primary kyphosis is di-
vided into juvenile and senile forms.

Juvenile Kyphosis (Scheuermann's Disease)

This deformity develops in adolescents with great predilection of the male sex
(Scheuermann 1921). The apex of the curvature in this deformity usually falls in
the area of the eighth to tenth thoracic vertebra. The underlying cause is probably
extrusion of nucleus pulposus material of the cartilage disk, mostly into the adjacent
vertebral bodies (Schmorl's nodes) followed by anterior narrowing of the disk space
and subsequent growth disturbance in this area of the end plate. This tends to result
in diminished growth of the anterior vertebral body and a wedge shape of that
body (Schmorl 1930; Schmorl and Junghanns 1971:345–354). The location of the
wedge vertebrae usually coincides with the apex of the curvature. In a disarticulated
skeleton, abnormalities in the curvature of the spine are difficult to assess; the
presence of one or several adjacent wedge vertebrae and of round or oblong defects
near the center of the vertebral end plate, corresponding to the location of the disk
herniation, would be crucial in diagnosis. If this type of deformity is long survived,
secondary sclerotic changes and marginal anterior lipping may be added to the
abnormal findings mentioned previously.

Senile Kyphosis
This is a very common spinal deformity, typically developing in the fifth decade and
increasing in frequency and degree with age. The underlying cause is degeneration
and attrition of the intervertebral disks, particularly of their anterior portions, in
the physiologically kyphotic thoracic segments. The apex of the curvature in senile
kyphosis is in the upper thoracic spine, and wedging of vertebral bodies is either ab-
sent or slight. The main features recognizable on skeletal material are osteosclerosis
of the anterior portions, especially the end plates, of affected vertebrae with marginal
lipping and, sometimes, anterior fusion of several segments (Figure 18-21, left).
Disk herniations are not a characteristic part of this condition. The anterior marginal
lipping, in contrast to spondylosis deformans, arises directly from the vertebral end
plate and is usually rather moderate. In advanced cases the anterior portions of the
intervertebral disk may be replaced by continuous bone trabeculae and the lipping
may be completely smoothed down by remodeling resorption.

FIGURE 18-21. Kyphosis. Two bisected spines. Left: Senile kyphosis with ante-
rior compression of intervertebral disks and bony bridging. Right: Severe post-
menopausal osteoporosis with kyphosis, showing biconcave “codfish” vertebrae.

(IPAZ 6017: left, 71-year-old female, autopsy 385 from 1955; right. 65-year-old
female, autopsy 403 from 1955.)

Copyright © 1955

Secondary Kyphosis
This deformity is secondary to lowered mechanical resistance of the vertebrae. A
variety of conditions, especially osteoporosis (Figure 18-21, right), osteomalacia,
hyperparathyroidism, and Paget's disease, may exhibit this complication. In this con-
dition, wedge vertebrae, due to compression fractures, are common. The intrinsic
changes of the underlying bone disease would help in recognition of the deformity
as secondary. This is especially true of kyphosis due to a congenital anomaly of the
spine, such as dorsal hemivertebra.

> Read full chapter

Osteoporosis
Caitlyn Dowson MBChB FRCP, Rachel Lewis MCSP SRP HT, in Rheumatology, 2010

POSTURAL CORRECTION
Kyphosis can be due to a combination of muscle weakness and muscle imbalance.
Patients with vertebral fracture have a further biomechanical alteration with a reduc-
tion in anterior vertebral height in comparison to the posterior height, increasing
with multiple fractures (Genant et al 1993, Myers & Wilson 1997). Fractures can
exacerbate muscle imbalance and a vicious cycle of muscle pain and weakness can
perpetuate increasing kyphosis and further fracture (Huang et al 2006).

By addressing posture correction and giving ergonomic advice, a more muscle-ef-

ficient posture can be adopted, pain can be reduced and overall biomechanics
improved. This is often demonstrated by an increase in patient activities of daily
living and improvement in metrology. Advice should be given regarding sleeping
positions with particular attention to the cervical spine and hips, which are common
sites of discomfort. The use of lumbar rolls for the spine should be advised for
sitting and travelling to improve posture and relieve discomfort. Ergonomic advice
regarding sitting positions should be given as basic information, and advice on office
seating and armchair design should be highlighted. Patients should be made aware
of their local resource centres, e.g. the Disabled Living Foundation.

Osteoporosis does not only affect retired post-menopausal women, therefore occu-
pational therapists may need to perform fit-for-work assessment. Further self-man-
agement advice on postural correction is applicable in some cases, e.g. the Alexander
technique, Pilates etc.

> Read full chapter

SPECIFIC PROBLEM AREAS
Crispian Scully CBE PhD MD MDS MRCS FDSRCPS FFDRCSI FDSRCS FDSRCSE
FRCPath FMedSci DSc, ... Navdeep Kumar PhD FDSRCS, in Special Care in Den-
tistry, 2007

General anaesthesia
Kyphosis and other deformities affecting respiration may make general anaesthesia
hazardous. The glottic opening may be narrowed and the cords' mobility reduced. A
goitre may further embarrass the airway.

Table 3.1. Key considerations for dental management in acromegaly (see text)

Management modifications* Comments/possible complica-

tions
Risk assessment 2 Blindness, diabetes, hyperten-
sion, arrhythmias
Preventive dentistry and educa- 1 Carpal tunnel syndrome, en-
tion larged tongue
Pain and anxiety control
– Local anaesthesia 0
– Conscious sedation 0
– General anaesthesia 1/4 Kyphosis, narrow glottis
Patient access and positioning
– Access to dental office 0
– Timing of treatment 1 Sleep apnoea, fatigue
– Patient positioning 1 Longer dental chair
Treatment modification
– Oral surgery 0
– Implantology 0
– Conservative/Endodontics 0
– Fixed prosthetics 0
– Removable prosthetics 0
– Non-surgical periodontology 0
– Surgical periodontology 0
Hazardous and contraindicated 0
drugs

* 0 = No special considerations. 1 = Caution advised. 2 = Specialised medical ad-

vice recommended in some cases. 3 = Specialised medical advice mandatory.
4 = Only to be performed in hospital environment. 5 = Should be avoided.

> Read full chapter

Volume 2
Christopher M. Boxell, ... Mitchell Martineau, in Schmidek and Sweet Operative
Neurosurgical Techniques (Sixth Edition), 2012

Limiting Complications of Laminoplasty

Kyphosis and large posterior projection of osteophytes are known factors for poor
improvement of myelopathy after laminoplasty. If osteophyte or OPLL occupies
more than 60% of the canal, then an anterior approach would offer a higher
statistical chance of patient improvement.75 In cases of myelopathy caused by OPLL,
it has been observed that the improvement from laminoplasty is low in cased where
the K-line is negative. The K-line for kyphosis is a measurement of these two factors.
The K-line is measured by taking the midpoint of the spinal canal at C2 and C7 and
connecting these two points with a line. If the K-line contacts the posterior projection
of the OPLL, then the K-line is defined to be negative, and 85% of patients in this
group do not improve with laminoplasty76 (Fig. 157-14).

FIGURE 157-14. K-line measurements.

Laminoplasty complications are frequently associated with damage of posterior

cervical musculature. Electrocautery-based dissection lateral to the facet complex
frequently results in denervation of the adjacent muscle, this may lead to increased
neck pain and kyphotic deformity of the spine. This complication can be lessened
by limiting electrical dissection to the middle of the facet complex. Some surgeons
have advocated a muscle splitting technique in open door laminoplasty so that on
the hinged side of the construct the cervical musculature is spared.77,78 It is well
established that removal of the C2 lamina in laminoplasty worsens postoperative
alignment. If the semispinalis Cervicis is removed from C2 during dissection, it
should be reattached. If laminoplasty includes C2 then efforts should be undertaken
to reattach the semispinalis cervicus and the rectus capitus to the C2 spinous
process. If it is impossible to reattach these muscles to the spinous process of C2,
then it is recommended that a bilateral repair be performed where the rectus capitus
be attached to the contralateral semispinlis cervicus.79,80 Dissection and damage to
any of the facet capsules are to be avoided.

Axial neck pain is a frequently reported complication of laminoplasty. It is thought

that by limiting the dissection from C3 to C6 instead of C7 that the incidence of
neck pain is lessened. This appears to be an acceptable practice as long as more
than 1 mm of subarachnoid space surrounds the cord at C7.81-83 One class II study
found that performing a C3 laminectomy while sparing the muscular insertion to C2
combined with a C4–C7 laminoplasty greatly reduced the incidence of postoperative
axial neck pain as compared to C3–C7 laminoplasty.84-86 A class I study determined
that sparing the C7 spinous process and nuchal ligament significantly reduced axial
neck pain over a 2-year period as compared to C3–C7 laminoplasty group.87

Patients with hypermobility of the cervical spine and the elderly tend to do poorly
with laminoplasty. Other techniques should be considered should be given consid-
eration in these cases.88

> Read full chapter

Back, Hip, and Knee Disorders

James R. Ebert MD, MBA, in Adolescent Medicine, 2008

Kyphosis
Kyphosis is posterior curvature of the thoracic spine that exceeds the normal range
of 20–45 degrees. Scheuermann kyphosis is characterized by anterior wedging of
the vertebral bodies and irregularities of the vertebral end-plates at three or more
levels, with consequent inability to correct the round back by active hyperexten-
sion. This is in contrast to postural round back, which is characterized by normal
vertebrae and disc spaces, temporary correction with active hyperextension, and
long-term improvement with hyperextension exercises of the back. The prevalence
of Scheuermann kyphosis is 4–8%. Males are twice as likely to be affected as females,
and the risk of severe disease appears particularly high in tall males. The cause
remains unknown, although there is some evidence that transient osteoporosis
following prolonged immobilization may result in vertebral compression fractures
with subsequent wedging.
Pain is the usual presenting complaint of patients with Scheuermann kyphosis.
It is gradual in onset, has no clear precipitating event, is worse with activity, and
improves with rest. When the adolescent bends forward at the waist, examination
from the side reveals sharp angulation of the thoracic spine. The most commonly
affected vertebrae are T7–T9 and T10–T12. Radiographic examination of the entire
spine should be performed with standing lateral and posteroanterior views. Oblique
views should also be considered because of the association of Scheuermann kyphosis
with spondylolysis (see below). All patients with Scheuermann kyphosis warrant
orthopedic consultation. Observation may be all that is required for adolescents
with non-progressive curves that are less than 50 degrees. Bracing or surgery
is indicated for larger or rapidly progressive curves to prevent chronic pain and
impaired pulmonary function.

> Read full chapter

Myelomeningocele Spinal Deformities

VINCENT ARLET, JEAN OUELLET, in Surgical Management of Spinal Deformities,
2009

CLASSIFICATION
Spinal deformities in myelomeningocele can be one of three types: congenital
kyphosis, scoliosis, and lordosis.

Congenital kyphosis is observed at birth, generally develops in the middle or upper

lumbar spine, and usually progresses to approximately 100 degrees. Untreated, it
progresses 5 to 12 degrees per year.

Scoliosis has several causes, some occurring together. Flaccid scoliosis is the most
classic, with a typical C-shaped curve and a collapsing spine with an element of
kyphosis. These curves are most often progressive. Congenital anomalies such as
hemivertebrae, congenital bars, and jumbled spine with defect of segmentation
or formation are often present at the thoracic or lumbosacral level. An element
of spasticity is often present. A tethered cord can also play a role in the patho-
genesis of scoliosis. Tethered cord syndrome can result from a lipomeningocele,
a diastematomyelia, or a thick filum terminale. It may be associated with pain,
decreased neurologic function or change in bladder habit (increased bladder spas-
ticity), and lumbar lordosis. Finally, hydromyelia can account for scoliosis. Screening
with magnetic resonance imaging can allow for early treatment (shunting or Chiari
decompression), and in mild or moderate scoliosis (less than 30 degrees), treatment
of the hydromyelia can stop the progression of the curve.
Scoliosis is common in high-level paraplegia, observed in almost 100% of cases.
Scoliosis is observed in 60% of cases of L4 paraplegia, with 40% of patients requiring
surgery.

> Read full chapter

Radiologic Imaging of Spinal Deformi-

ties
RENATA LA ROCCA VIEIRA, ... MARK E. SCHWEITZER, in Surgical Management of
Spinal Deformities, 2009

KYPHOSIS
The term kyphosis is used to refer to excessive curvature in the thoracic spine. Kypho-
sis can be the result of many causes (e.g., trauma, developmental problems, degen-
erative disc disease, infection). When viewed from one side, a kyphosis deformity can
be gradual and smooth, as in postural roundback, or it can be a sharp and angular
(gibbus) deformity, as in congenital kyphosis, Potts disease, or, to a lesser extent,
Scheuermann's kyphosis. Other causes of spinal kyphosis include those that occur
with disorders of the nervous system and muscle disorders (cerebral palsy, muscular
dystrophy, spinal muscular atrophy, and myelomeningocele), neurofibromatosis,
connective tissue disorders, Paget's disease, tumors, and after surgery. Kyphosis can
also be seen in association with scoliosis. In these cases, kyphosis is usually related
to an underlying cause of the scoliosis, such as neurofibromatosis. In idiopathic
scoliosis, there is more often straightening rather than accentuation of the kyphosis.

In the postoperative correction of kyphosis, it is important to assess the spine

curvature on the frontal views and the sagittal balance on the lateral views of the
patient's spine. Flat-back syndrome results from an iatrogenic loss of lumbar lordosis
with forward inclination of the trunk and is frequently recognized as a complication
following placement of thoracolumbar instrumentation.

Scheuermann's Disease
Scheuermann's disease is a structural deformity of the spine that develops prior
to puberty and becomes most prominent during the adolescent growth spurt. The
cause is unknown.

Initial descriptions focused on thoracic kyphosis; however, it was noted that thora-
columbar and lumbar variants also occur. A minimal scoliosis may be associated
in about one third of cases. Classic radiographic descriptions (Fig. 3-12) include
irregular vertebral end plates, narrowing of the intervertebral disc spaces, three or
more vertebrae wedged 5 degrees or more, and an increase in normal thoracic
kyphosis to greater than 45 degrees.

Figure 3-12. Lumbar Scheuermann's disease. Sagittal T1-weighted MR image

demonstrates multiple Schmorl's nodes throughout the lumbar spine.

The prevalence of Scheuermann's disease varies depending on inclusion criteria and

has been reported to be between 0.4% and 8%.

Imaging

RADIOGRAPHY.

A standard radiographic evaluation of a patient with Scheuermann's disease or other

causes of kyphosis includes anteroposterior and lateral standing radiographs on
long films, which would incorporate the entire thoracolumbar spine on one film. The
patient should be standing in a neutral position with hips and knees fully extended
to allow for a true evaluation of the sagittal balance. The lateral view should be taken
with the arms elevated at 90 degrees in front of the subject to prevent the bony
outlines of the upper extremities from obscuring the vertebral body images.

The diagnosis of Scheuermann's kyphosis is confirmed on the lateral radiographs

(Fig. 3-12). The angle between the end plates of each respective vertebral body
should be measured by using the Cobb technique. The presence of three adjacent
vertebral bodies with 5 or more degrees of anterior wedging confirms the diagnosis
of Scheuermann's kyphosis.

The Cobb technique should be used to measure the overall degree of kyphosis of
the thoracic spine. The end vertebral bodies, which are defined as the last vertebral
body tilting into the kyphotic deformity, should be selected both proximally and
distally. The levels of these particular vertebral bodies should be noted, as they are
the same vertebral bodies that should be selected on subsequent films to ensure
that the examiner is consistent with follow-up evaluations.

Secondary changes of Scheuermann's kyphosis should be noted, such as the nec-

essary presence of Schmorl's nodes, irregular vertebral end plates, and disc space
narrowing. Scoliosis and spondylolisthesis have been associated with Scheuermann's
kyphosis. These should be documented on plain radiographs and treated as separate
entities.

Other entities that share the differential diagnosis of Scheuermann's kyphosis can
be excluded radiographically as well. Congenital kyphosis, ankylosing spondylitis,
multiple compression fractures, tumor, infection, tuberculosis, and postlaminecto-
my kyphosis can be distinguished by clinical history and confirmed by radiographic
evaluation.

The dynamic quality of the kyphosis should be assessed to distinguish Scheuer-

mann's kyphosis from postural kyphosis. A lateral radiograph can be obtained in
hyperextension. Should the deformity correct entirely, postural kyphosis is the most
likely diagnosis, rather than Scheuermann's kyphosis.

It is necessary to account for the rigidity of the curve in treatment decisions, as the
ability for correction with bracing and surgical intervention will be affected.

MAGNETIC RESONANCE IMAGING, COMPUTED TOMOGRAPHY, AND CT MYELOGRAPHY.

MRI, CT scan, and CT myelography can be helpful adjunctive studies in planning

the care of a patient with Scheuermann's disease or other types of kyphosis. MRI,
in particular, helps the surgeon to further define the local anatomy. In particular,
attention should be given to the coexistence of thoracic spinal stenosis, syrinx, or
any other intrathecal abnormalities that would affect surgical care.

Additionally, an anatomic assessment of the lumbar discs can be made, and it may
affect surgical decision making in terms of which levels to incorporate in the fusion.

Postlaminectomy Kyphosis
Traumatic kyphosis is a traumatic compression of one or more vertebrae and may
occur in the cervical, thoracic, thoracolumbar, or lumbar spine. The most commonly
affected location is the thoracolumbar junction. It may lead to either cosmetic or
symptomatic kyphosis. This may be prevented by early stabilization of high-grade
unstable traumatic spinal injuries. Although the majority of posttraumatic deformi-
ties usually occur after spinal column trauma, which is initially treated nonoperative-
ly, several miscellaneous causes of posttraumatic deformity may occur after surgery.
These include nonunion, implant failure, Charcot spine, and technical error.

In the thoracic spine, an injury to the anterior column resulting from a flexion-com-
pression injury will produce a decrease in the height of the anterior portion of the
vertebral body, resulting in a focal kyphosis at this level. This deformity will cause
hyperextension of adjacent spinal regions, resulting in altered facet joint motion,
instability, and worsening of the degenerative process.

Each year in the United States, there are more than 1 million acute injuries to
the spine, approximately 50,000 of these resulting in fractures to the bony spinal
column. The improvements in emergency medical services and the increased safety
standards have been increasing the trend for improved patient survival with incom-
plete and complete spinal cord injuries. Ironically, this has been associated with a
greater number of patients presenting with symptoms related to loss of normal
spinal alignment or worsening of spinal deformity.

Imaging

Plain radiographs, including anteroposterior and lateral views, are essential. Flexion
and extension lateral and anteroposterior bending views are important in assessing
the flexibility of any spinal deformity.

CT offers detailed evaluation of spinal bony architecture, and multislice CT has

added advantages for spinal trauma imaging, including volume imaging, the ability
to acquire multiplanar reconstructions, three-dimensional images, and thick-slice
(wedge) multiplanar reconstructions that mimic conventional radiographs. This
allows the visualization of subtle structural abnormalities, especially involving the
posterior element bony structures that are often difficult to visualize on plain
radiography.

Imaging postoperative patients with metallic implants often presents a challenge.

Metal causes artifacts such as beam hardening. The metal artifacts depend on the
composition of the hardware (titanium produces the least amount of artifact, and
cobalt chrome alloys produce the most). Artifacts also depend on the geometry of
the implant (its thickness and orientation) and are most severe in the direction of the
thickest portion of the implant. Metal artifacts also depend on peak kilovoltage and
current, the reconstruction algorithm, and the slice thickness and orientation of the
 multiplanar reconstruction. Optimization of these parameters can help to reduce
metal artifacts.

MRI is useful in visualizing spinal soft tissue structures in detail and to evaluate the
canal and neural structures but can be limited by susceptibility to artifacts related to
hardware.

Infectious Kyphosis
The term infectious kyphosis refers to septic destruction of vertebral bodies, which
can lead to severe kyphosis. In particular, tuberculous vertebral osteomyelitis can
produce soft-tissue abscess, high-grade kyphosis, and a sharp gibbus deformity with
an exaggerated kyphosis epicentered in the lower thoracic spine.

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