Osteochondrosis and other lesions in all intervertebral, articular process and rib joints from occiput to sacrum in pigs with poor back conformation, and relationship to juvenile kyphosis.

BACKGROUND: Computed tomography (CT) is used to evaluate body composition and limb osteochondrosis in selection of breeding boars. Pigs also develop heritably predisposed abnormal curvature of the spine including juvenile kyphosis. It has been suggested that osteochondrosis-like changes cause vertebral wedging and kyphosis, both of which are identifiable by CT. The aim of the current study was to examine the spine from occiput to sacrum to map changes and evaluate relationships, especially whether osteochondrosis caused juvenile kyphosis, in which case CT could be used in selection against it. Whole-body CT scans were collected retrospectively from 37 Landrace or Duroc boars with poor back conformation scores. Spine curvature and vertebral shape were evaluated, and all inter-vertebral, articular process and rib joints from the occiput to the sacrum were assessed for osteochondrosis and other lesions. RESULTS: Twenty-seven of the 37 (73%) pigs had normal spine curvature, whereas 10/37 (27%) pigs had abnormal curvature and all of them had wedge vertebrae. The 37 pigs had 875 focal lesions in articular process and rib joints, 98.5% of which represented stages of osteochondrosis. Five of the 37 pigs had focal lesions in other parts of vertebrae, mainly consisting of vertebral body osteochondrosis. The 10 pigs with abnormal curvature had 21 wedge vertebrae, comprising 10 vertebrae without focal lesions, six ventral wedge vertebrae with ventral osteochondrosis lesions and five dorsal wedge vertebrae with lesions in the neuro-central synchondrosis, articular process or rib joints. CONCLUSIONS: Computed tomography was suited for identification of wedge vertebrae, and kyphosis was due to ventral wedge vertebrae compatible with heritably predisposed vertebral body osteochondrosis. Articular process and rib joint osteochondrosis may represent incidental findings in wedge vertebrae. The role of the neuro-central synchondrosis in the pathogenesis of vertebral wedging warrants further investigation.

Analysis of cervical sagittal alignment change following correction of thoracic and thoracolumbar Scheuermann's kyphosis.

PURPOSE: To analyse pre-operative and post-operative changes of cervical sagittal alignment (CSA) in Scheuermann's kyphosis (SK) patients. METHODS: 64 SK and 33 control patients were retrospectively reviewed. Whole spine X-rays obtained at pre-op, 3 months post-op and at latest follow-up were reviewed and ten separate CSA radiological parameters were measured. Patients were divided in three groups: thoracic SK (TK group, apex T6-T9, n = 40), thoracolumbar SK (TLK group, apex T10-T12, n = 24), and controls. RESULTS: Pre-operative C2-C7 lordosis was 21.1° ± 8.1°(TK), 6.1° ± 5.0°(TLK), and 11.4° ± 8.3° in control group and correlated significantly with T1 slope in both SK groups (r = 0.640, r = 0.772). Pre-operative T1 slope was dependent on deformity type, thoracic kyphosis (TK, ß = 0.445), and lumbar lordosis (LL, ß = -0.354). At final follow-up C2-C7 lordosis decreased to 15.7° ± 5.5° in TK, and increased to 12.1° ± 4.1° in TLK group. C2-C7 lordosis changes linearly correlated with T1 slope changes post-operatively (r = 0.721). Post-operative T1 slope showed linear correlation with post-operative changes in TK (ß = 0.728) and pelvic tilt (PT, ß = 0.539) in TK, and LL (ß = -0.669), thoracolumbar kyphosis (TLK, ß = -0.434), and PT (ß = 0.760) in TLK group. CONCLUSIONS: Our study suggests that SK is not a homogenous group of patients. Two patterns of pre- and post-operative CSA are demonstrated in TK and TLK groups. T1 slope is the most important parameter in determining pre-operative CSA and correlates with other regional anatomical parameters (TK and LL). Post-operative CSA adaptations also correlate with T1 slope post-operative changes. However, post-surgical T1 slope correlates with different parameters in the two SK groups (TK and PT in TK group; TLK, LL, and PT in TLK group).

Comparison of radiographic sagittal spinopelvic alignment between skeletally immature and skeletally mature individuals with Scheuermann's disease.

PURPOSE: The aim of this study was to compare radiographic sagittal spinopelvic parameters between skeletally immature and skeletally mature patients with Scheuermann's disease (SD). METHODS: Cross-sectional analysis of standing postero-anterior and lateral radiographs of the spine of patients with SD was performed. Sagittal vertical axis (SVA), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were measured on the lateral radiographs. Risser's sign was assessed on the postero-anterior radiographs. All of the parameters measured were compared between skeletally immature (Risser's sign 0-3) versus mature patients (Risser's sign 5). PI, PT, and SS in both groups were compared to PI, PT, and SS reported for normal children, adolescents, and adults. RESULTS: Sixty-six patients with SD (33 immature and 33 mature) were retrospectively reviewed and included in the study. There was no significant difference between the two groups of SD patients in: SVA (-16.6 vs. -22.9 mm, p = 0.74), TK (57.8° vs. 56°, p = 0.66), TLK (7.8° vs. 11.7º, p = 0.14), LL (63.2° vs. 62.2°, p = 0.74), PI (36.7° vs. 39.4°, p = 0.20), PT (3.8° vs. 7.3°, p = 0.10), and SS (32.8° vs. 32.1°, p = 0.75). Both, the immature and mature group of SD patients presented significantly lower PI and SS than normal children, adolescents, and adults, and significantly lower PT than normal adults. CONCLUSIONS: There is no significant difference in sagittal spinopelvic parameters between skeletally immature and mature subjects with SD. Pelvic incidence in both groups of SD patients was significantly lower than PI in normal children, adolescents, and adults. This challenges the role of PI in predicting desired LL in patients with SD.

Proximal Junctional Kyphosis Following Spinal Deformity Surgery in the Pediatric Patient.

Proper understanding and restoration of sagittal balance is critical in spinal deformity surgery, including conditions such as adolescent idiopathic scoliosis and Scheuermann kyphosis. One potential complication following spinal reconstruction is proximal junctional kyphosis. The prevalence of proximal junctional kyphosis varies in the literature, and several patient- and surgery-related risk factors have been identified. To date, the development of proximal junctional kyphosis has not been shown to lead to a negative clinical outcome following spinal fusion for adolescent idiopathic scoliosis or Scheuermann kyphosis. Treatment options range from simple observation in asymptomatic cases to revision surgery with extension of the fusion proximally. Several techniques and technologies are emerging that seek to address and prevent proximal junctional kyphosis.

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.

Cardiorespiratory function of patients undergoing surgical correction of Scheuermann's hyperkyphosis.

The aim of this study was to analyze the impact of surgical correction of the thoracic deformity on the cardiorespiratory function of patients with moderate-severe Scheuermann's hyperkyphosis (SK). A series of 23 adolescents with SK who underwent surgery through an only posterior approach using all pedicle screw constructs were included in the study. Cardiorespiratory parameters were measured during a maximal exercise tolerance test before and 2 years after surgery. Heart rate, oxygen saturation (SatO2), maximum oxygen uptake (VO2 max), ventilatory capacity at maximal exercise (VEmax), and energy costs were recorded. There were statistically significant differences in the forced vital capacity (FVC) (P < 0.05), total VO2max (ml/min) (P < 0.01), maximum expired volume (VEmax) per minute (P < 0.01) and cardiovascular efficiency (HR/VO2 ratio) (P < 0.05). None of these changes were clinically relevant. There were no changes in the VO2max per kg of body mass. The magnitude of the kyphosis correction did not correlate with the change in normalized VO2max or VEmax. In conclusion, patients with moderate-severe SK improve their baseline respiratory limitations and the tolerance to maximum exercise 2 years after surgery. However, the slight cardiorespiratory functional improvements should not necessarily be attributed to the surgery, and could also be caused solely by the residual growth of the lungs and thorax. Furthermore, respiratory functional changes are under thresholds considered as clinically relevant.

Validity of a one-item drawing-based instrument to assess trunk deformity perception in kyphotic deformities.

INTRODUCTION: Body image and trunk appearance perception are two crucial attributes in determining the quality of life of individuals with spinal deformities. The Trunk Appearance Perception Scale (TAPS) is a drawing-based instrument used to evaluate this feature. The TAPS does not include a sagittal view of the trunk so it is never been used to assess trunk deformity perception in hyperkyphotic patients. This study aims to analyze the effect of introducing a new drawing on the TAPS scale representing the trunk view in the sagittal plane. PATIENTS: 170 non-surgical patients were included (mean age 16.9 years and 77.4% women) distributed in three groups. CONTROL group (no deformity): 22 cases; KYPHOSIS group (sagittal deformity): 49 cases and SCOLIOSIS group (coronal deformity): 99 cases (mean Cobb 42.4º). METHOD: Cross-sectional study. A new drawing (TAPS4) was designed to represent the deformity in the sagittal plane with five response options. Clinical (SRS-22 and TAPS 4-items) and radiological (kyphosis T4-T12) data were collected in all patients. The statistical analysis consisted in determining for each group the internal consistency of the 3-items TAPS vs 4-items TAPS, as well as the discriminant validity (correlation with kyphosis magnitude) and convergent validity (correlation with the SRS-22 image subscale). In addition, test-retest reliability of new item 4 was determined in a subgroup of 30 kyphotic patients. During control visit, the patients received a complete physical examination and a full-spine AP and lateral X-ray in standing position using a low-radiation technique and fulfilled instruments TAPS 4 items and SRS-22r. RESULTS: The three groups were found to have statistically significant differences in the magnitude of kyphosis, quality of life, body image perception, the 3-items TAPS, 4-items TAPS and new item 4 score. The addition of the item 4 to TAPS 3 items did not cause a significant change in the internal consistency of the scales (Cronbach's alpha) (TAPS 3-items 0.8 vs. TAPS 4-items 0.8). Kyphosis magnitude was not correlated with the 3-items TAPS and 4-items TAPS scores; however, in the KYPHOSIS group, a significant negative correlation was observed between kyphosis and item 4 (Rho = - 0.4, p = 0.0001). A significant correlation was found in all groups between TAPS 3-items and TAPS 4-items and SRS-22 image domain; the correlation between item 4 and SRS-22 body image domain was 0.3 in the Scoliosis group and 0.7 in the Kyphosis group. CONCLUSIONS: The 4-items TAPS scale does not provide advantages in the assessment of trunk deformity over the 3-items scale. However, in patients with kyphosis, the item 4 (Kypho-TAPS) alone is a valid and reliable instrument to monitor the perception of the trunk deformity.

Surgical strategy for correction of severe, rigid, post-tubercular cervical kyphosis: an experience of two cases.

STUDY DESIGN: Case series. OBJECTIVES: To describe a novel surgical strategy for severe, rigid post-tubercular cervical kyphosis with treatment outcomes in two patients. BACKGROUND DATA: Spinal tuberculosis is a common cause of kyphotic deformity in the developing world with 3-5% of non-operatively managed patients ending up with kyphosis exceeding 60°. Ventral, dorsal and combined approaches have been described for cervical kyphosis, but there is no established surgical strategy for severe, rigid post-tubercular cervical kyphosis. METHODS: We operated on two girls with severe, rigid cervical kyphosis with preoperative kyphosis measuring 98° and 62°. Our surgical strategy included a three-step approach in the same sitting-(1) An anterior approach to osteotomize the fused vertebral body mass, decompress the spinal cord ventrally and place a temporary cage to stabilize the spine, (2) A posterior approach to osteotomize the fused facets and decompress the cord dorsally. With the completion of the osteotomy, a combination of pedicle screws and lateral mass screws was used to correct the deformity via an anterior opening, posterior closing type of osteotomy. This was followed by, (3) An anterior approach to replace the corpectomy cage with a larger one supplemented with an anterior cervical plate. RESULTS: Our 540° approach achieved a substantial improvement in each of the clinical and radiological parameters we measured, viz. C2-C7 lordosis angle, C2-C7 sagittal vertical axis, neck tilt and Neck Disability Index. CONCLUSION: For severe, rigid post-tubercular cervical spine kyphosis, a three-step, anterior-posterior-anterior procedure can be used for achieving acceptable correction, improving symptoms and avoiding further progression. LEVEL OF EVIDENCE: IV.

Scheuermann's Kyphosis: Diagnosis, Management, and Selecting Fusion Levels.

Scheuermann's kyphosis (SK) is a rigid structural deformity of the thoracic spine defined radiographically as three or more contiguous vertebrae with at least 5° of wedging anteriorly. Prevalence of the disease is thought to be between 0.4% and 10%. The true cause of SK remains unclear; however, various theories include growth irregularities, mechanical factors, genetic factors, and/or poor bone quality as the causes. Patients with mild disease (less than 70°) generally have a favorable prognosis with good clinical outcomes. Most patients with SK are successfully treated nonsurgically with observation, anti-inflammatory medications, and physical therapy. Surgical intervention is indicated in patients with greater than 70° to 75° thoracic curves, greater than 25° to 30° thoracolumbar curves, intractable pain, neurologic deficit, cardiopulmonary compromise, or poor cosmesis. Because of advances in posterior spinal instrumentation, surgery can typically be performed through a posterior-only approach. When surgical treatment is planned, appropriate selection of the upper- and lower-instrumented vertebrae is important to achieve a well-balanced spine, preserve motion segments, and reduce the risk of junctional kyphosis.

Scheuermann's disease: focus on weight and height role.

The aim of this cross-sectional case-control study is the comparison of the weight and height between a group of children with Scheuermann's disease (SD) and a comparable group of healthy ones and also the correlation of them with the degree and the morphology of the kyphotic curve. Following a school-screening program of 10,057 school students, aged between 11 and 17 years old, 175 adolescents with Scheuermann's disease were diagnosed. The mean height and weight of 175 adolescents diagnosed to have SD compared with this of a group of normal children taken randomly from the group of 9,882 healthy children screened. The control group was comparable with the study group concerning age (p = 0.605) and sex. The weight, height and body mass index (BMI) were significantly lower in the healthy (control) group (p < 0.001). However, there was no correlation between weight (r = -0.019, p = 0.804), height (r = 0.053, p = 0.484) and BMI (r = -0.177, p = 0.019) with the magnitude of kyphotic curve. There was also no correlation between weight (r = -0.27, p = 0.722), height (r = -0.025, p = 0.744) and BMI (r = -0.038, p = 0.619) with Voutsinas index as well. Scheuermann's disease is probably a multifactorial skeletal deformity. Weight and height do not seem to affect the magnitude and morphology of the main kyphotic curve in SD. It seems probably that this observation is not part of the pathogenetic mechanism of SD but a result of its cascade. The increased weight and height of these patients may be the secondary result of other disturbances (i.e. hormonal), which may play more crucial role in Scheuermann's disease pathogenesis.

Transient kyphotic deformity of the thoracolumbar junction resulting from a large abdominal cyst: a case report.

BACKGROUND CONTEXT: Pronounced kyphosis of the thoracolumbar junction is a common orthopedic problem in adolescents and may require prolonged bracing therapy or correction spondylodesis. PURPOSE: To describe a case where a kyphotic deformity was related to gynecological instead of spine pathology. STUDY DESIGN: Case report. METHODS: A 17-year-old girl presented with a structural hyperkyphosis of the thoracolumbar spine and radiographic changes of the involved vertebral end plates. RESULTS: The thoracolumbar hyperkyphosis appeared to have evolved from a massive intra-abdominal ovarian cyst. Endoscopic paracentesis of the cyst resulted in a complete regression of the hyperkyphosis. CONCLUSIONS: A hyperkyphosis is not always related to spine pathology, and other potential causes must be excluded before bracing therapy is initiated.

Pathogenesis of osteochondrosis juvenilis Scheuermann.

In osteochondrosis juvenilis Scheuermann, foci of various sizes in the cartilaginous end plates of the vertebral bodies display a loosening or complete interruption of the collagen fibers. These findings, together with an alteration and occasional absence of the growth zone, may result in the typical deformation of the vertebral bodies. Electron micrographs of the areas with optically absent collagen fibers reveal collagen fibrils. They are arranged in an irregular pattern. We conclude that a disturbance of collagen or ground substance biosynthesis is of importance in the pathogenesis of juvenile osteochondrosis.

Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individuals.

We reviewed magnetic resonance imaging studies of the thoracic spines of ninety asymptomatic individuals to determine the prevalence of abnormal anatomical findings. This group included sixty individuals who had no history of any thoracic or lumbar pain and thirty individuals who had a history of low-back pain only. In addition, we reviewed imaging studies of eighteen patients who had an operatively proved herniation of a thoracic disc and studies of thirty-one patients who had been seen with thoracic pain. Sagittal T1-weighted spin-echo and axial multiplanar gradient refocused images at each disc level were interpreted by us (two neuroradiologists and two orthopaedic spine surgeons); we had no clinical information about the patients. Sixty-six (73 percent) of the ninety asymptomatic individuals had positive anatomical findings at one level or more. These findings included herniation of a disc in thirty-three subjects (37 percent), bulging of a disc in forty-eight (53 percent), an annular tear in fifty-two (58 percent), deformation of the spinal cord in twenty-six (29 percent), and Scheuermann end-plate irregularities or kyphosis in thirty-four (38 percent). This study documents the high prevalence of anatomical irregularities, including herniation of a disc and deformation of the spinal cord, on the magnetic resonance images of the thoracic spine in asymptomatic individuals. We emphasize that these findings represent roentgenographic abnormalities only, and any clinical decisions concerning the treatment of pain in the thoracic spine usually require additional studies.

Collagen stability and cross-linking in normal and kyphoscoliotic mouse intervertebral discs.

Intervertebral discs of the cervical-thoracic region of the spine of BDL mice which are homozygous for the ky gene mutation undergo degeneration. Discs from these mice have a normal collagen content and undergo normal collagen cross linking prior to the appearance of degenerative changes. The major reducible collagen cross-link formed in discs of these mice and in normal CBA strain mice is hydroxylysino-5-ketonorleucine. These results and other previous results indicate that the discs in the ky mouse develop degenerative disease due to an extrinsic factor rather than to an intrinsic abnormality of their extracellular matrix. The extrinsic factor has been identified as spinal muscle atrophy.

Vertebral alterations in Scheuermann's kyphosis.

In a cadaver-derived skeletal collection of 1,384 thoracolumbar spinal columns, 103 (7.4%) individuals with vertebral changes of Scheuermann's kyphosis were identified. Anterior extension of the vertebral specimens was noted in 94% of affected specimens. No evidence of osteoporosis was noted by single-photon absorptiometric analysis in the affected sample compared with a normal control group. Biopsy specimens from two immature patients obtained at surgery suggested disorganized endochondral ossification similar to that noted in Blount's disease. It was concluded that increased pressure on the anterior margin of the centrum is responsible for histologic and morphologic changes of Scheurermann's kyphosis.

Combined idiopathic kyphosis and scoliosis. An analysis of the lateral spinal curvatures associated with Scheuermann's disease.

A radiological study of 50 patients with thoracic Scheuermann's disease revealed two types of lateral spinal curvature. A total of 43 lateral curves was present in 35 of the patients. Thirteen were apical at the same level as the Scheuermann's kyphosis and were due to vertebral-body wedging in the coronal plane; these curves had a mean Cobb angle of 15 degrees, occurred with equal prevalence in boys and girls and were directed equally to right and left. Thirty curves occurred in regions of compensatory lordosis (mean 5.6 degrees) situated above or, more commonly, below the Scheuermann's kyphosis. These scolioses had a mean Cobb angle of 16 degrees, were more often convex to the right than to the left and were significantly more prevalent in girls than in boys. The presence of these kyphoses and scolioses in the same spine, separated by only a few vertebrae, emphasises the importance of the sagittal plane in idiopathic spinal deformities and strongly suggests that idiopathic scoliosis and Scheuermann's disease share a common pathological process.

Outcome of in-patient rehabilitation in patients with M. Scheuermann evaluated by surface topography.

For the follow-up of patients with sagittal spinal deformities and postural disorders, we do not have well validated measuring systems at our disposal. All clinical measuring parameters are liable to a high margin of error. With a growing number of patients suffering from postural disorders and kyphoses, we have to look for other possibilities to monitor changes of the back, as well as in the short term, without the support of X-rays. As the measuring of the surface with the Formetric system showed a high measurement reliability in previous studies, we used this system to demonstrate the rehabilitation results of our patients with Scheuermann's disease. An intervention study (pre-/post-design) was undertaken including the following material.: 62 female patients with Scheuermann's disease and an average age of 19 years old and 74 male patients with Scheuermann's disease and an average age of 20 years old were measured with the Formetric system before an in-patient rehabilitation of four to six weeks. For this study, we evaluated the maximal kyphotic angle as shown by the system. In the case of female patients, the maximal kyphotic angle decreased highly significantly from sixty two to nearly fifty four degrees. In the case of the male patients, it decreased from sixty to nearly fifty five degrees at the end. It showed that the surface measuring system with the Formetric System is a reliable instrument for the follow-up of sagittal postural disorders and kyphoses for the present study, especially in the case of Scheuermann's disease. In praxis, the use of this measurement is very easy, we obtain the measurement results very quickly, so that the evaluation of data is not very time consuming. After the in patient treatment, the kyphotic angle decreased highly significantly. The changes range far above the margin of error, thus the following conclusions are justified. Firstly, the Formetric System is the appropriated instrument for the follow-up of postural disorder and kyphoses. Secondly, the in-patient rehabilitation with an intensive treatment program may result in a correction of also structural kyphoses with sure signs of Scheuermann's disease. Thus we recommend an in-patient rehabilitation in adolescent age in case of Scheuermann kyphoses with large curvatures and in case of Scheuermann kyphoses in adults suffering from pain.

[Suggestions for criteria for uniform evaluation of changes in the spine in vertebral dysostosis of the Scheuermann type]. / Návrh na kritéria jednotného hodnocení zmen na páteri u vertebrální dysostózy Scheuermannova typu.

The author recommends in his proposal of uniform criteria to evaluate pathological changes of the spine according to a pattern where the first place is held by morphological changes (unevenness of the covering plates, changes in the shape of bodies of the vertebrae, changes in the height of disc and changes in the curvature of the spine). The second place in held by functional changes and the third one by the general extent and quality of pathological changes. In the latter group the author draws attention to the appearance of a stigmatized spine. It is essentially an abortive form of vertebral dysostosis with frust not very marked morphological symptoms. He draws attention to the importance of this form for explanation of an obscure vertebral algic syndrome, in particular in children. The unform evaluation of these pathological changes should help to establish order in the hitherto controversial problem of evaluation of vertebral dysostosis.