Pediatric Injuries

Kyphosis (Roundback) of the Spine

Anatomy

The spinal column is made up of small bones (vertebrae) stacked on top of one another, creating the natural curves of the back. Between the vertebrae are flat, round, rubbery pads (intervertebral disks) that act as shock absorbers and allow the back to flex or bend. Muscles and ligaments connecting the vertebrae allow motion while providing support and stability for the spine and upper body. Each vertebra has an opening (foramen) in the center and these line up to form the spinal canal. Protected by the vertebrae, the spinal cord and other nerve roots travel through the spinal canal. Nerves branch out from the spinal column through vertebral openings, carrying messages between the brain and muscles. Facet joints align at the back of the spinal column, linking the vertebrae together and allowing for rotation and movement. Like all joints, cartilage covers the surface where facet joints meet.

The spine contains three segments: lumbar, thoracic and cervical. The lumbar spine consists of five vertebrae located in the lower back; lumbar vertebrae are larger because they carry more of the body's weight. The thoracic spine consists of 12 vertebrae and begins at the upper chest, extending to the middle back and connecting to the rib cage. The cervical spine includes the neck and consists of seven small vertebrae, beginning at the base of the skull and ending at the upper chest. Disks in the lumbar spine are composed of a thick outer ring of cartilage (annulus) and an inner gel-like substance (nucleus). In the cervical spine, disks are similar but smaller in size.

Description

The term kyphosis is used to describe the spinal curve that results in an abnormally rounded back. Although some degree of rounded curvature of the spine is normal, a kyphotic curve that is more than 50° is considered abnormal. There are several types and causes of kyphosis.

• Postural kyphosis—This is the most common type of kyphosis. Often attributed to slouching, postural kyphosis represents an exaggerated, but flexible, increase of the natural curve of the spine that usually becomes noticeable during adolescence. It is found in girls more frequently than boys, and rarely causes pain. Although exercise to strengthen the abdomen and stretch the hamstrings may help relieve any associated discomfort, it is unlikely to result in significant correction of the postural kyphosis. With occasional exceptions, postural kyphosis does not lead to problems in adult life.
• Scheuermann's kyphosis—As with postural kyphosis, Scheuermann's kyphosis often becomes apparent during the teen years; however, the deformity is significantly more severe, particularly in thin individuals. Scheuermann's kyphosis usually affects the upper (thoracic) spine, but it can also occur in the lower back (lumbar) area. If pain is present, it is usually felt at the apex of the curve. Pain can be aggravated by activity, or long periods of standing or sitting. Exercise and anti-inflammatory medication can help ease associated discomfort. In X-rays, vertebrae and disks appear normal in patients with postural kyphosis. In X-rays of patients with Scheuermann's kyphosis, they appear irregular and wedge-shaped.
• Congenital kyphosis—In some infants, the spinal column did not develop properly while still in the womb. The bones may not form properly, or several vertebrae may be fused together. Either of these abnormalities may cause progressive kyphosis as the child grows. Surgical treatment may be needed at a very young age to help maintain a more normal spinal curve. Consistent follow-up is required to monitor any changes.

Diagnosis

A visit to the doctor is typically the result of a scoliosis examination at school, a child's or parent's concern regarding the cosmetic deformity of a rounded back, or pain. The physician's exam may include asking the child to bend forward so that the slope of the spine can be assessed. Spinal X-rays will reveal any bony abnormalities and will help measure the degree of the kyphotic curve.

Nonsurgical Treatment

Recommended treatment will depend on the reason for the deformity. Most teens with postural kyphosis will do well throughout life, and for some, posture may improve over time. An exercise program may help relieve any associated back pain. A spine conditioning program may be recommended. For patients with Scheuermann's kyphosis, an initial program of conservative treatment that includes exercises and anti-inflammatory medications (for discomfort) is recommended. If the patient is still growing, the physician may prescribe a brace, typically worn until skeletal maturity is reached.

Surgery

If the kyphotic curve exceeds 75°, surgery may be recommended to: reduce the degree of curvature by straightening and fusing the abnormal spinal segments together; maintain the improvement over time; and alleviate significant back discomfort, if present preoperatively.

Complications

As with any surgery, there are some risks, and these vary from person to person. Complications are typically minor, treatable and unlikely to affect your final outcome. For most people, surgery can provide relief of symptoms and return to function with relatively low risk of complications. Overall, elderly patients have higher rates of complications from surgery, as do patients who are overweight, diabetics, smokers, or suffering from multiple medical problems. Among the general, potential risks associated with surgery are infection, bleeding and blood clots, and reactions to anesthesia. Be sure to discuss the potential risks and benefits with your surgeon prior to surgery.