Scheuermann's Disease.

Scheuermann's disease is a rigid progressive kyphosis occurring in late childhood to adolescence. It is the most common cause of sagittal imbalance and angular progressive kyphosis in adolescents associated with back pain. The exact etiology of the disease is unclear, but it is characterized by defective growth of the end plate that may result from excessive mechanical stress on a weakened end plate during spinal growth. Several other theories have been proposed, and it is thought to be a multifactorial disease occurring as a result of the interplay of multiple factors. The radiographic features consist of anterior vertebral body wedging, irregular end plates, Schmorl's nodes, and intervertebral disk degeneration. The natural history and evolution of this disease is also unknown. Conservative management with physiotherapy, rehabilitation, and bracing is the first line of treatment. Mechanical bracing helps prevent further progression of the kyphotic deformity. Surgery is mostly indicated in patients with failure of conservative management, with neurologic compromise, and for cosmetic reasons.

Selecting the Vertebra above Sagittal Stable Vertebra as the Distal Fusion Level in Scheuermann's Kyphosis: A Prospective Study with a Minimum of 2-Year Follow-Up.

OBJECTIVE: The proper selection of the lower instrumented vertebra (LIV) remains controversial in the surgical treatment of Scheuermann's disease and there is a paucity of studies investigating the clinical outcomes of fusion surgery when selecting the vertebra one level proximal to the sagittal stable vertebra (SSV-1) as LIV. The purpose of this study is to investigate whether SSV-1 could be a valid LIV for Scheuermann kyphosis (SK) patients with different curve patterns. METHODS: This was a prospective study on consecutive SK patients treated with posterior surgery between January 2018 and September 2020, in which the distal fusion level ended at SSV-1. The LIV was selected at SSV-1 only in patients with Risser >2 and with LIV translation less than 40 mm. All of the patients had a minimum of 2-year follow-up. Patients were further grouped based on the sagittal curve pattern as thoracic kyphosis (TK, n = 23) and thoracolumbar kyphosis (TLK, n = 13). Radiographic parameters including global kyphosis (GK), lumbar lordosis (LL), sagittal vertical axis (SVA), LIV translation, pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were measured preoperatively, postoperatively, and at the latest follow-up. The intraoperative and postoperative complications were recorded. The Scoliosis Research Society (SRS)-22 scores were performed to evaluate clinical outcomes. RESULTS: A total of 36 patients were recruited in this study, with 23 in the TK group and 13 in the TLK group. In TK group, the GK was significantly decreased from 80.8° ± 10.1° to 45.4° ± 7.7° after surgery, and was maintained at 45.3° ± 8.6° at the final follow-up. While in the TLK group, GK was significantly decreased from 70.7° ± 9.2° to 39.1° ± 5.4° after surgery (p < 0.001) and to 39.3° ± 4.5° at the final follow-up. Meanwhile, despite presenting with different sagittal alignment, significant improvement was observed in LL, SVA, and LIV translation for both TK and TLK groups (p < 0.05). Self-reported scores of pain and self-image in TK group and scores of self-image and function in TLK group showed significant improvement at the final follow-up (all p < 0.05). Distal junctional kyphosis (DJK) was observed in two patients (8.7%) in TK group, and one patient (7.7%) in TLK group. No revision surgery was performed. CONCLUSION: Selecting SSV-1 as LIV can achieve satisfactory radiographic and clinical outcomes for SK patients with different curve patterns without increasing the risk of DJK. This selection strategy could be a favorable option for SK patients with Risser sign >2 and LIV translation less than 40 mm.

Combined surgical correction of pectus carinatum and juvenile kyphosis.

Pectus carinatum may rarely be associated with kyphosis. However, the correlation between both conditions is not well reported. Therefore, there are no reports for combined correction of both deformities in the same patient. Moreover, studies estimating the kyphosis prevalence in patients with pectus carinatum are lacking. To our knowledge, this is the first paper to present such a case. We report an 18-year-old boy with both pectus carinatum and kyphosis that were surgically corrected in a combined procedure. The indication of surgery is cosmetic, and the postoperative recovery included pneumothorax but was otherwise uneventful and satisfactory.

Complications Following Surgery for Adult Scheuermann's Kyphosis: A 2-Year Follow-Up in 22 Patients.

AIM: To determine the rate of postoperative complications following surgery for Scheuermann?s kyphosis (SK) and ascertain whether restoration to an ideal Roussouly spine type reduced the incidence of postoperative proximal junctional kyphosis (PJK). MATERIAL AND METHODS: We retrospectively screened all patients undergoing SK surgery at our institution (2010?2017) and excluded patients with less than two years of follow-up. Postoperative complications were identified as early or late and minor or major. Successful restoration of Roussouly spine type was assessed and patients were classified as ?restored? or ?non-restored.? Associations between ideal Roussouly restoration and postoperative PJK were evaluated using logistic regression analysis. RESULTS: The study included 22 patients with a median age of 23 (IQR, 20.0?43.8) years. Postoperative complications developed in 17 (77%) of these cases. All 17 patients developed minor complications; seven (32%) patients also exhibited major complications. PJK was diagnosed in 55% of the patients with an 18% overall two-year revision rate. Forty-four percent of the patients in the restored group developed PJK compared to 83% in the non-restored group (p=0.162). Multivariable logistic regression analysis revealed a trend towards an increased incidence of PJK in the non-restored group, albeit without statistical significance (OR, 9.4; 95% CI, 0.7?122.5, p=0.087). CONCLUSION: Our study revealed that 77% of patients undergoing surgery for SK developed at least one complication with a two-year revision rate of 18%. PJK was detected less frequently in patients who were restored to their ideal Roussouly spine type, although this finding did not achieve statistical significance.

Selection of the optimal distal fusion level for Scheuermann kyphosis with different curve patterns: when can we stop above the sagittal stable vertebra?

PURPOSE: To investigate the optimal lowest instrumented vertebra (LIV) in the treatment of Scheuermann kyphosis (SK) with different curve patterns. METHODS: Fifty-two SK patients who underwent posterior surgery between January 2010 and December 2017 with a minimum follow-up of 2 years were retrospectively reviewed. Patients were divided into two groups based on the curve pattern: the Scheuermann thoracic kyphosis (STK group) or Scheuermann thoracolumbar kyphosis (STLK group). Based on the relationship between the sagittal stable vertebra (SSV) and LIV, both groups were further divided into the SSV group and SSV-1 group. Radiographic parameters, distal junctional kyphosis (DJK) incidence and SRS-22 questionnaire scores were evaluated. RESULTS: In STK and STLK groups, there were no significant differences in most pre- and postoperative radiographic assessments between SSV and SSV-1 subgroups. DJK incidence showed no significant differences between groups during follow-up (P > 0.05). LIV-PSVL was significantly more negative in the SSV-1 group than that in the SSV group (P < 0.001). Within the SSV-1 group, patients with DJK showed a more negative LIV-PSVL (P = 0.039). Moderate correlation was observed between preoperative LIV-PSVL and DJK with a Spearman coefficient of - 0.474 (P = 0.035). Receiver operative characteristic curve analysis showed that the threshold value of preoperative LIV-PSVL to predict DJK was - 37.35 mm (area under the curve 0.882). CONCLUSION: Shorter fusion stopping at SSV-1 achieved comparable clinical outcomes and did not increase the risk of DJK for both STK and STLK patients. For patients whose preoperative LIV-PSVL < - 37.35 mm, extending fusion to SSV is an acceptable solution to prevent DJK.

Surgical Procedures Used for Correction of Scheuermann's Kyphosis: A Meta-Analysis.

OBJECTIVES: Scheuermann's kyphosis can cause severe back pain and cosmetic disorders to patients. Previous studies on surgical procedure selection for correction of Scheuermann's kyphosis have drawn controversial conclusions. Here, a meta-analysis was performed to figure out a better way between anterior-posterior (AP) combined procedures and posterior-only (PO) procedures. METHODS: We searched PubMed database and Ovid database, as well as Cochrane Library (between January 2009 and December 2020, around recent ten years), for studies reporting Scheuermann's kyphosis correction in an anterior way or a posterior way. Random effects meta-analysis regarding correction degrees and incidence of proximal junctional kyphosis (PJK) was performed. RESULTS: Finally, 13 unique studies including 586 patients (AP: 300; PO: 286) were identified and included for this meta-analysis. Overall, 6 AP cohorts and 10 PO cohorts were pooled regarding the correction degrees of kyphosis in the analysis, respectively. Pooled correction degrees in AP cohorts were 33.31 (95% CI: 27.48-39.15; I 2 = 86%, P < 0.001) and in PO cohorts were 31.16 (95% CI: 26.97-35.35; I 2 = 81.1%, P < 0.001). Comparison of correction between AP and PO cohorts did not indicate any significant difference. Likewise, postoperative PJK incidence showed no difference. Back pain can be caused by both AP and PO procedures, but which causes less pain remains to be conclusive. The PO approach showed less blood loss and shorter surgical duration as compared to the AP approach. CONCLUSIONS: In summary, this meta-analysis shows similar treatment effects between AP and PO procedures in correcting Scheuermann's kyphosis, suggesting the advantage of PO procedures due to less blood loss and surgical duration. However, the postoperative complications PJK and distal junctional kyphosis (DJK) cannot be well concluded due to the limitation of existing data.

Long-term follow-up of untreated Scheuermann's kyphosis.

STUDY DESIGN: Long-term cross-sectional study. OBJECTIVES: To investigate the long-term effects of untreated Scheuermann's kyphosis on quality of life, and its relationship to radiographic parameters of spinal deformity. Previous studies reported reduced self-image, increased pain and impaired physical status. Little is known of the long-term impact of sagittal plane deformity in untreated SK. METHODS: One hundred and thirteen consecutive untreated patients with SK were identified from a national service database prior to 2000, when surgery was not offered at this unit. 81 of these patients were available for evaluation; 66 (81%) consented to questionnaire and clinical evaluation, and 47 (58%) consented to additional radiological evaluation. Health-related quality of life (HRQoL) was compared to normative population values. Mean age was 45.1 years (31-65), and mean follow-up was 27 years (16-36). 57 patients had thoracic kyphosis and 9 had thoracolumbar deformity. RESULTS: SRS-22 and SF-36 scores were lower, and ODI was greater in patients with untreated SK compared to normative population values. Kyphosis progressed from mean 66° at skeletal maturity to 78° (p < 0.001) after mean follow-up of 27 years. Long-term progression of untreated SK was 0.45°/year (n = 47). Multilinear regression showed good correlation between increasing SVA and worse ODI scores (r = 0.59; p = 0.001). Increasing SVA also correlated with worse function, pain and mental health scores reported by SRS-22, and with worse physical function and bodily pain scores reported by SF-36. Increasing CL correlated with worse SF-36 physical function scores. Increasing cSVA and increasing TK correlated with worse SRS-22 self-image scores. CONCLUSION: SRS-22 and SF-36 scores were lower, and ODI was greater in patients with untreated SK compared to normative data. Long-term progression of untreated SK was 0.45°/year (n = 47). Increasing SVA correlated with worse SF-36 physical function, SRS-22 function, SRS-22 pain and higher ODI scores. Total kyphosis (TK) and cSVA were independent predictors of low SRS self-image. LEVEL OF EVIDENCE: III.

Relationship between Scheuermann disease and symptomatic thoracic spinal stenosis: A retrospective study.

OBJECTIVE: This study aimed to investigate the possible relationship between Scheuermann disease (SD) and the pathophysiological factors of thoracic spinal stenosis (TSS), including ossification of the ligamentum flavum (OLF), ossification of the posterior longitudinal ligament (OPLL), and thoracic disc herniation (TDH) in patients with symptomatic TSS. METHODS: Demographic and radiological data from 66 consecutive patients diagnosed with symptomatic TSS from 2013 to 2018 were retrospectively collected and divided into 3 groups depending on the underlying pathomechanism of TSS: TDH group (18 patients; 6 women; mean age ± standard deviation [Sd] = 59.89 ± 11.34), OPLL group (12 patients; 8 women; mean age ± Sd = 56.08 ± 14.74), and OLF group (36 patients; 20 women; mean age ± Sd = 58.69 ± 9.77). A total of 41 age-matched healthy individuals (19 women; mean age ± Sd = 54.88 ± 13.63) were designated as the control group. In each group, both typical and atypical SD criteria were radiologically examined. The demographic data and presence of SD between the control group and 3 subgroups of TSS pathomechanisms were evaluated. RESULTS: SD characteristics were identified in 83.33% (15/18) of patients in the TDH group, 44.44% (16/36) in the OLF group, 25% (3/12) in the OPLL group, and 17.07% (7/41) of the control individuals. When analyzed by the chi-squared test and logistic regression analysis, the presence of SD was significantly associated with TDH (P < 0.01) and OLF (P < 0.05) but not OPLL (P > 0.05). Patients with TDH and OLF showed peak involvement of T10/11, and patients with OPLL did not. Furthermore, we determined that age, sex, body-mass index, and smoking status were not the risk factors for TDH, OPLL, and OLF (P > 0.05). SD was found to be a risk factor for TDH (P < 0.01) and OLF (P < 0.05) but not for OPLL (P > 0.05). CONCLUSION: Evidence from this study indicated that SD might be a risk factor for OLF and TDH but not for OPLL.

Treatment approaches for Scheuermann kyphosis: a systematic review of historic and current management.

OBJECTIVE: Scheuermann kyphosis (SK) is an idiopathic kyphosis characterized by anterior wedging of ≥ 5° at 3 contiguous vertebrae managed with either nonoperative or operative treatment. Nonoperative treatment typically employs bracing, while operative treatment is performed with either a combined anterior-posterior fusion or posterior-only approach. Current evidence for these approaches has largely been derived from retrospective case series or focused reviews. Consequently, no consensus exists regarding optimal management strategies for patients afflicted with this condition. In this study, the authors systematically review the literature on SK with respect to indications for treatment, complications of treatment, differences in correction and loss of correction, and changes in treatment over time. METHODS: Using PubMed, Embase, CINAHL, Web of Science, and the Cochrane Library, all full-text publications on the operative and nonoperative treatment for SK in the peer-reviewed English-language literature between 1950 and 2017 were screened. Inclusion criteria involved fully published, peer-reviewed, retrospective or prospective studies of the primary medical literature. Studies were excluded if they did not provide clinical outcomes and statistics specific to SK, described fewer than 2 patients, or discussed results in nonhuman models. Variables extracted included treatment indications and methodology, maximum pretreatment kyphosis, immediate posttreatment kyphosis, kyphosis at last follow-up, year of treatment, and complications of treatment. RESULTS: Of 659 unique studies, 45 met our inclusion criteria, covering 1829 unique patients. Indications for intervention were pain, deformity, failure of nonoperative treatment, and neural impairment. Among operatively treated patients, the most common complications were hardware failure and proximal or distal junctional kyphosis. Combined anterior-posterior procedures were additionally associated with neural, pulmonary, and cardiovascular complications. Posterior-only approaches offered superior correction compared to combined anterior-posterior fusion; both groups provided greater correction than bracing. Loss of correction was similar across operative approaches, and all were superior to bracing. Cross-sectional analysis suggested that surgeons have shifted from anterior-posterior to posterior-only approaches over the past two decades. CONCLUSIONS: The data indicate that for patients with SK, surgery affords superior correction and maintenance of correction relative to bracing. Posterior-only fusion may provide greater correction and similar loss of correction compared to anterior-posterior approaches along with a smaller complication profile. This posterior-only approach has concomitantly gained popularity over the combined anterior-posterior approach in recent years.

What Are the Indications for Spinal Fusion Surgery in Scheuermann Kyphosis?

BACKGROUND: Surgical indications for Scheuermann kyphosis are variable. We sought to evaluate the characteristics of patients undergoing operative versus nonoperative treatment of Scheuermann kyphosis to better understand current practices and the factors which contribute to the decision for surgical management. METHODS: Multicenter prospective cohort study. We evaluated consecutive patients presenting with Scheuermann kyphosis. Patients underwent either surgical or nonoperative management according to surgeon and patient discretion. Preoperative patient-reported outcome measures (Scoliosis Research Society and Spinal Appearance Questionnaire scores), demographics, and radiographic characteristics were assessed. RESULTS: Overall, 150 patients with Scheuermann kyphosis were enrolled, with 77 choosing nonoperative treatment and 73 treated operatively. Compared with the nonoperative cohort, patients treated operatively were older (16.3±2.0 vs. 15.1±2.2, P=0.0004), and had higher body mass index (26.3±7.2 vs. 22.7±6.5, P=0.003), had greater T2-T12 kyphosis (71±14 degrees vs. 61±12 degrees, P<0.001), increased pelvic incidence (46 vs. 41 degrees, P=0.03) and pelvic tilt (10 vs. 3 degrees, P=0.03). There was no detected difference in maximal sagittal Cobb angle in the operative versus nonoperative patients (73±11 vs. 70±12 degrees, P=0.11). Functionally, the operative patients had worse Scoliosis Research Society pain scores (3.7±0.9 vs. 4.1±0.7, P=0.0027) and appearance scores (2.9±0.7 vs. 3.4±0.8, P <0.0001). CONCLUSIONS: Patients undergoing surgical management of Scheuermann disease were more likely to have large body mass index and worse pain scores. Other factors beyond radiographic measurement likely contribute to the decision for surgical management of Scheuermann kyphosis. LEVEL OF EVIDENCE: Level II.

Single-stage deformity correction in children with neurogenic kyphoscoliosis: nuances and a proposal for risk stratification.

OBJECTIVE Neurogenic kyphoscoliosis in pediatric patients has varied causes and diverse management options. The most common management strategy is to stage the orthopedic and neurosurgical aspects of the correction at an interval of 3-6 months from each other. The aim of this study was to report the authors' experience with correction of deformity in children with associated neurological abnormalities requiring intervention as a single-stage surgical treatment. METHODS Of 591 pediatric patients with scoliosis treated at the Amrita Institute of Medical Sciences and Research Centre between January 2001 and January 2011, the authors identified all patients with neurogenic kyphoscoliosis who underwent deformity correction and a neurosurgical procedure in the same surgical session when they were younger than 15 years. Data regarding the demographic details, preoperative Cobb angle/kyphotic angle, surgical details, postoperative complications, cost of the procedure, and long-term neurological outcome were collected for each case and analyzed. Based on the results of this analysis, the authors propose a 2-category risk stratification system for the timing of deformity correction depending on the primary neurogenic etiology. RESULTS Ten cases involving patients with neurogenic kyphoscoliosis requiring both deformity correction and neurosurgical procedure met the criteria and were included in the analysis. All 10 patients were younger than 15 years; their mean age was 10.8 years. The average Cobb angle was 59.5°. Five patients underwent foramen magnum decompression, 5 patients underwent spinal cord detethering, and 1 patient had intraspinal intradural tumor excision. The mean estimated blood loss was 1177 ml (range 700-1550 ml), and the mean operative time was 4.4 hours (range 3-5.5 hours). There were no intraoperative complications. None of the patients had any new postoperative neurological deficits. The mean postoperative Cobb angle of the main thoracic curve was 12.6°. CONCLUSIONS Simultaneous deformity correction along with a definitive neurosurgical procedure in patients with neurogenic kyphoscoliosis can be performed without added morbidity and avoids both the added costs and the risk of complications associated with a second surgery. The risk stratification system proposed in this paper may serve as a guideline for case selection and help to optimize outcome.

Familial lumbar Scheuermann disease with idiopathic scoliosis in China: First case report.

RATIONALE: Given that Scheuermann disease rarely occurs in the lumbar region and that the co-occurrence of Scheuermann disease and idiopathic scoliosis (IS) has not been reported-the etiology of Scheuermann disease and IS is not clear. In this case report, we present familaiar lumbar Scheuermann disease with IS, in a Chinese proband, who was successfully treated with surgery. PATIENT CONCERNS: A 16-year-old boy presented at the Second XiangYa Hospital of Central South University with a chief complaint of kyphotic deformity in the lower back for 4 years and obvious lower back pain. In addition, he complained of limited lumbar activity. And The proband's family history was obtained by routine inquiring. In this Chinese family with 17 members over 3 generations. The 3 patients (proband, proband's sister and father) shared the characteristics of vertebral wedging from L1 to L3 and a kyphosis Cobb angle of 37°, 70°, or 73°, respectively. The main deformity of the proband's mother was at T7-L1 with a Cobb angle of 102° in the coronal plane at T7-L1, thoracic kyphosis of 73°, and lumbar lordosis of 62°. DIAGNOSES: Scheuermann's disease. INTERVENTIONS: Clinical history, physical examination, laboratory tests, and radiographs of those in the pedigree were recorded, and the related literature was reviewed. The proband accepted osteotomy and orthopedic surgery for treatment. OUTCOMES: After 3 months of treatment, postoperative lateral radiographs showed a significantly improved sagittal vertical axis (SVA). The other patients were continued to be seen in follow-up visits. LESSONS: This series of lumbar Scheuermann patients with IS in a pedigree support the genetic contribution to Scheuermann disease. Therefore, this study provides some insight into the genetic etiology of Scheuermann disease with IS.

Spinal epidural lipomatosis - an easily ignored secondary intraspinal disorder in spinal kyphotic deformities.

BACKGROUND: A previous study reported a high prevalence of spinal epidural lipomatosis (SEL) in patients with Scheuermann kyphosis (SK) and suggested that it may play a role in the pathogenesis of this disease. According to our observation, however, SEL occurs in other spinal kyphotic deformities as well. The aim of this study was to test the hypothesis that SEL commonly occurs in patients with different types of kyphotic deformities as a secondary intraspinal disorder. METHODS: MR images of 16 patients with congenital kyphosis (CK), 40 patients with SK, 13 patients with tuberculotic kyphosis (TK), and 69 age- and sex-matched controls were retrospectively evaluated. The body mass index (BMI), kyphosis Cobb angle, and sagittal diameters of spinal epidural fat (EF) and the dural sac (DS) in the apical region (EFA, DSA) and non-kyphotic region (EFN, DSN) were measured. The EF ratios at the apical vertebral level (EFRA) and in the non-kyphotic region (EFRN) were calculated as EF / (EF + DS). RESULTS: EFA and EFRA were significantly higher among patients with CK, SK, and TK than among controls (P < 0.05). Seven CK patients (43.8%), 8 SK patients (20.0%), and 11 TK patients (84.6%) fulfilled the diagnostic criteria for SEL, while only 6.3, 2.5, and 0% of patients in the control groups did (P = 0.019, 0.014, and < 0.001, respectively). Spearman's correlation analysis showed statistically significant correlations between the kyphosis Cobb angle and the amount of EF in all three patient groups. CONCLUSIONS: SEL is a common secondary intraspinal disorder in different types of kyphotic deformities, and surgeons should pay increased attention to this intraspinal anomaly because excessive EF may compress the spinal cord and cause neurological deficits.

MRI Screening in Operative Scheuermann Kyphosis: Is it Necessary?

STUDY DESIGN: Patients with preoperative spine magnetic resonance imaging (MRI) studies from a prospective multicenter study of operative adolescent Scheuermann kyphosis (SK). OBJECTIVES: To investigate the usefulness of MRI screening in operative planning for SK surgeries. SUMMARY OF BACKGROUND DATA: Neural axis abnormalities in operative SK have not been previously studied with MRI screening, despite its use. METHODS: One orthopedic surgeon and two radiologists evaluated all images retrospectively. Radiographs were evaluated for kyphosis apex and magnitude. MRIs were evaluated for spinal cord abnormalities, epidural lipomatosis, location and number of vertebral wedging, Schmorl nodes and posterior disc herniations, frequency of spondylolysis, etc. The relationship of these pathologies to the kyphosis apex was explored. This group was compared to a surgical SK group without preoperative MRIs. RESULTS: Eighty-six patients with MRIs, mean age 16.3 years, 64% male, and a mean preoperative kyphosis of 75.9° were evaluated. There were 17 spinal cord abnormalities. Low-lying conus was found in 2 patients, and syrinx in 15 (no Chiari malformations). Epidural lipomatosis was found in 49 patients, average of 5.7 levels. Anterior vertebral wedging occurred in all (mean 4.7 levels). Posterior disc herniations averaged 5.2 levels/patient and 1.8 levels caudad to the apex. Spondylolysis was reported in 8.1%. Four cases (4.7%) had the operative plan changed as a result of the preoperative MRI: two due to neural compression, one due to disc herniation and one due to a spinal cord draped over the apex. Thirty-one patients did not receive an MRI; there were no significant differences between the two groups. The rate of postoperative neurologic change was 3.5% in the MRI group and 3.2% in the no-MRI group. CONCLUSIONS: Based on 4.7% of cases requiring a change in the operative plan as a result of preoperative MRI, the authors recommend considering performing screening MRI in operative SK patients.

Prevention of proximal junctional kyphosis after posterior surgery of Scheuermann kyphosis: an operative technique.

STUDY DESIGN: A prospective randomized study. OBJECTIVE: To introduce an operative technique that prevents proximal junctional kyphosis (PJK) in Scheuermann disease after a segmental posterior spinal instrumentation and fusion. SUMMARY OF BACKGROUND DATA: PJK is the progression of kyphotic deformity at the proximal end of a construct >10 degrees, and it can be seen up to 30% after posterior Scheuermann kyphosis surgery. After posterior fusion the biomechanics of the spine changes and the loss of motion at the fused levels is compensated by increased motion at other unfused segments. As a result significant amount of additional force is placed on the proximal junction. With our operative technique, we aimed to have a smooth passage from rigid to mobile segments and to decrease the stress on proximal junction during cantilever reduction to prevent PJK. METHODS: A total of 60 consecutive patients (mean age: 18.27±3.19, male/female: 28/32) who were surgically treated for Scheuermann kyphosis in our institution were recruited into this study and were prospectively evaluated. Patients were divided into 2 groups according to upper-most screw fixation technique. In group 1, a standard screw insertion technique was used (ST group). The technique was modified in group 2 (MT group), leaving 2 threads out of the posterior cortex. There were 29 patients in group 1 (ST) and 31 patients in group 2 (MT). Patients had an average follow-up time of 24.2 months (range, 19-48 mo). Evaluated radiographic parameters were preoperative and postoperative kyphosis angle, and proximal junctional angle (PJA) at last visit. PJA was defined as the angle between the caudal endplate of the upper instrumented vertebra and the cephalad endplate of 2 suprajacent vertebrae above the upper instrumented vertebra. PJA exceeding 10 degrees was accepted as PJK. Quality of life measurement was assessed preoperatively and postoperatively with SF-36 questionnaire. RESULTS: Correction amounts in ST group and MT group were 46.8% and 43.7%, respectively, which was statistically insignificant. The mean PJA was 8.08±2.96 degrees and 4.44±1.55 degrees in ST and MT groups, respectively, which demonstrated a statistically significant difference (P=0.001). Five patients in ST group had a PJA exceeding 10 degrees (PJK), whereas PJK was not seen in MT group (P=0.022). The improvement in physical component summary of SF-36 was significantly better in MT group; however, mental component summary was similar in both groups. CONCLUSIONS: This study introduces a new technique that may have an effect in preventing PJK. Our results seem to be satisfactory, but additional studies with more patients and longer follow-up times are needed to further delineate the feasibility of this technique.

The relationship of symptomatic thoracolumbar disc herniation and Scheuermann's disease.

PURPOSE: Symptomatic disc herniations in the thoracolumbar spine between T10/11 and L1/2 can be collectively called thoracolumbar disc herniation (TLDH). The etiology of this disorder is unclear. However, it is interesting that we have noted numerous TLDH patients have radiographic features of another spinal disorder which is Scheuermann's disease (SD). The purpose of this study is to investigate the relationship between symptomatic TLDH and SD in a symptomatic TLDH cohort. METHODS: A cohort of 63 patients with symptomatic TLDH, who had surgery was investigated. Incidences of associated SD and four radiographic signs of SD that were Schmorl's node, irregular vertebral end plate, posterior bony avulsion of the vertebra and wedge-shaped vertebra, average thoracolumbar kyphotic angle and incidences of disc herniation at segments with and without radiographic signs of SD were examined. Data from the TLDH group were compared with 57 patients undergoing surgery for lower lumbar disc herniation (LDH, L3/4-L5/S1) in the same period. RESULTS: The incidences of the four radiographic signs of SD and the incidence of associated SD were all significantly higher in the TLDH group than in the LDH group. 95.2 % of the patients in the TLDH group were diagnosed with SD (either classical SD or its atypical form). The average thoracolumbar kyphotic angle of the TLDH group was 16.9°, while that of the LDH group was 7.6° (P = 0.000). In the TLDH group, the incidences of disc herniation at segments with radiographic signs of SD were all significantly higher than at segments where no sign of SD was found. CONCLUSIONS: The high proportion of associated SD and the tendency of SD's signs to promote disc herniation in symptomatic TLDH patients suggest a close relationship between these two disorders. Symptomatic TLDH should be seen as a truly different surgical entity, that is, a special form of SD rather than just an indicator of a failing back.

Spinal epidural lipomatosis: a common imaging feature in Scheuermann disease.

STUDY DESIGN: Retrospective study. OBJECTIVES: To find out if spinal epidural lipomatosis (SEL) occurs more commonly among patients with Scheuermann disease than in the general population. SUMMARY AND BACKGROUND: On the basis of our own radiologic and operative observation, SEL seems to occur frequently in patients with Scheuermann disease. METHODS: Magnetic resonance imaging of 87 individuals (72% male, average age 19±6 y) from 2 centers (29 consecutive patients with Scheuermann disease and 58 controls) were retrospectively evaluated by 2 neuroradiologists. Spinal epidural fat (EF) at seventh thoracic vertebra (EF7), maximum EF (EFmax), dural sac diameter at T7 and at the level of maximum EF (DS7 and DSmax) were measured. EF ratios at T7 (EFR7) and at maximum EF (EFRmax) were calculated as EF/DS. Body mass index (BMI) for study population and kyphosis severity for the patients were recorded. Mann-Whitney, Spearman correlation, and χ tests were performed dependent on the variable in question. RESULTS: EF7, DS7, EFmax, EFR7, and EFRmax was significantly higher among patients with Scheuermann disease (EFmax 5.7±2.4 mm) than among controls (EFmax 3.8±1.1 mm), P<0.001. Twelve patients with Scheuermann disease (41%) fulfilled our proposed criteria for the diagnosis of SEL (EFmax>6 mm+EFRmax>0.51) compared with 2 (3%) among controls (P<0.001). Patients with Scheuermann disease exhibited higher BMI than controls (24.9±5 kg/m vs. 22.9±4 kg/m, P=0.138). Logistic regression showed that the occurrence of SEL among patients with Scheuermann disease was independent of BMI (P=0.880). The degree of kyphosis in patients with Scheuermann's disease (62±20°) was correlated to the amount of the EF. CONCLUSIONS: As SEL occurs more frequently among patients with Scheuermann disease, spine magnetic resonance imaging should be routinely performed to screen each of these patients to avoid impending neurological injury during surgery, especially in those exhibiting SEL.

Acutely progressing paraplegia caused by traumatic disc herniation through posterior Schmorl's node opening into the spinal canal in lumbar Scheuermann's disease.

STUDY DESIGN: A case report. OBJECTIVE: To report an unusual neurologic complication caused by traumatic disc herniation through atypical posterior Schmorl's node (SN) opening into the spinal canal in lumbar Scheuermann's disease. SUMMARY OF BACKGROUND DATA: Neurologic complications in Scheuermann's disease are rare and disc hernia has been reported as one of the causes of neural compression. However, there has been no report on acutely progressing paraplegia caused by traumatic disc herniation through an atypical posterior SN opening into the spinal canal in lumbar Scheuermann's disease. METHODS: A clinical and radiologic review of such a case of traumatic disc herniation through an atypical posterior SN that resulted in acutely progressing paraplegia in Scheuermann's disease was performed. RESULTS: The patient presented with severe back pain after a fall, without any neurologic abnormalities. Computed tomographic scan revealed lumbar Scheuermann's disease, acute compression fracture of T12, and a large posterior SN with "trough-like" indentation of the lower endplate of T12 opening into the spinal canal. Abruptly progressing paraplegia occurred in less than 24 hours after the first visit and the magnetic resonance imaging revealed severe spinal cord compression by large disc extrusion with superior migration at T12-L1 through the atypical posterior SN at the lower endplate of T12. The patient underwent posterior decompression and discectomy at T12-L1 through transfacet pedicle-sparing approach. Postoperatively, the patient showed immediate improvement in the sensory deficit on L1 dermatome and the perianal area and motor function of the hip flexors to grade 2 without further neurologic improvement, at 2-year follow-up. CONCLUSION: The case report highlights the clinical significance of the atypical posterior SN that could be a channel for large disc extrusion after a traumatic event in Scheuermann's disease and the clinical importance of surgeon's close attention to the possibility of abruptly progressing neurologic compromise in this situation.

Septic shock after posterior spinal arthrodesis on a patient with Scheuermann kyphosis and multiple body piercings.

STUDY DESIGN: A case report. OBJECTIVE: We report septic shock as postoperative complication following an instrumented posterior spinal arthrodesis on a patient with multiple body piercings. The management of this potentially catastrophic complication and outcome of treatment is been discussed. SUMMARY OF BACKGROUND DATA: Body piercing has become increasingly more common because of change in culture or as a fashion statement. This has been associated with local or generalized ill effects including tissue injury, skin and systemic infections, and septic shock. There is no clear guideline pathway regarding removal and reinsertion of body piercings in patients who undergo major surgery. Complications following orthopedic or spinal procedures associated with body piercing have not been reported. METHODS: We reviewed the medical notes and radiographs of an adolescent patient with Scheuermann kyphosis and multiple body piercings who underwent a posterior spinal arthrodesis and developed septic shock. RESULTS: Septic shock developed on postoperative day 2 after reinsertion of all piercings following the patient's request. The patient became systemically very unwell and required intensive medical management, as well as a total course of antibiotics of 3 months. The piercings remained in situ. She did not develop a wound infection despite the presence of bacteremia and spinal instrumentation. The patient had no new piercings subsequent to her deformity procedure. Two and a half years after spinal surgery she reported no medical problems, had a balanced spine with no loss of kyphosis correction and no evidence of nonunion or recurrence of deformity. CONCLUSION: The development of septic shock as a result of piercing reinsertion in the postoperative period has not been previously reported. This is an important consideration to prevent potentially life-threatening complications following major spinal surgery.