Hypermobility Among Adolescents and the Association With Spinal Deformities: A Large Cross-Sectional Study.

INTRODUCTION: Adolescent idiopathic scoliosis and Scheuermann kyphosis are common spinal deformities (SD) among adolescents. The potential link between hypermobility and SD is a topic of debate. We aimed to investigate the prevalence of hypermobility and its association with SD. METHODS: A cross-sectional analysis of records of 17-year-old subjects who were recruited into mandatory military service was conducted. Study population comprised 1,220,073 subjects. Prevalence rates were calculated for hypermobility and different categories of SD by severity, studying the strength of the association between hypermobility and SD. RESULTS: Of 1,220,073 subjects, 0.0111% exhibited hypermobility. Spinal deformities were identified in 10.5% of subjects. Specifically, 7.9% had mild SD, 2.4% had moderate SD, and 0.1% had severe SD. The overall association between hypermobility and SD showed an odds ratio of 2.31 (P < 0.001). Subgroup analyses revealed ORs of 1.226 (P = 0.041) for mild deformities, 5.783 (P < 0.001) for moderate deformities, and 4.01 (P = 0.002) for severe deformities. The association was stronger for moderate and severe SD. CONCLUSIONS: This study establishes a notable association between hypermobility and SD among adolescents. The findings highlight the importance of understanding this relationship, which could contribute to advancements in comprehending SD development. Additional research is warranted to expand upon these findings.

In old men Scheuermann's disease is not associated with neck or back pain: a Swedish cohort study.

BACKGROUND AND PURPOSE: Scheuermann's disease is characterized by kyphosis and frequently mild back pain. As the level of kyphosis may progress over time, also the level of pain may increase. We evaluated the prevalence of Scheuermann's disease, and their pain, in Swedish elderly men. PATIENTS AND METHODS: The Osteoporotic Fractures in Men (MrOS) Study Sweden (n = 3,014) is a population-based prospective observational study of community-living men aged 69-81 years. At baseline, participants answered a questionnaire including history of neck/back pain during the preceding year and characteristics of any pain (severity, sciatica, and neurological deficits). Lateral thoracic/lumbar spine radiographs were taken of 1,453 men. We included the 1,417 men with readable radiographs. Scheuermann's disease was defined as 3 or more consecutive vertebrae with > 5° wedging with no other explanation for the deformity. RESULTS: 92 of the 1,417 men (6.5%, 95% confidence interval 5.3-7.9) had Scheuermann's disease. 31% of men with and 31% without Scheuermann's disease reported neck pain (P = 0.90) and 51% with and 55% without the disease reported back pain (P = 0.4). Among men with Scheuermann's disease and back pain, none reported severe pain, 57% moderate, and 43% mild, compared with 7%, 50%, and 44% in those without Scheuermann's disease (P = 0.2). In those with Scheuermann's disease 63% reported no sciatica, 15% sciatica without neurological deficits, and 22% sciatica with neurological deficits, compared with 56%, 16%, and 28% in those without the disease (P = 0.6). CONCLUSION: The prevalence of Scheuermann's disease in elderly Swedish men is between 5.3% and 7.9%. The condition seems at this age not to be associated with neck or back pain.

Enfermedad de Scheuermann lumbar atípica en rara asociación con artritis idiopática juvenil / Atypical lumbar Scheuermann disease and juvenile idiopathic arthritis: a rarely association

El dolor lumbar en los adolescentes es causa frecuente de motivo de consulta en reumatología y obedece a diferentes causas. Se presenta un caso clínico de un adolescente de 14 años de edad, de procedencia rural que acudió a consulta refiriendo dolor y aumento de volumen de ambas rodillas de 3 meses de evolución, acompañado de dolor lumbar desde hacía más de 2 años y que había requerido tratamiento con antinflamatorios no esteroideos y reposo, sin otros síntomas sistémicos acompañantes. Al examen físico se encontró artritis de rodillas, aumento de la cifosis fisiológica en la columna dorsal y puntos sacroilíacos positivos. En los exámenes complementarios fue significativa la presencia del HLA-B27, sinovitis en bolsa subcuadricipital bilateral detectada mediante ultrasonido de rodillas, así como hallazgos en las radiografías a nivel de los cuerpos de las vértebras lumbares característicos de la enfermedad de Scheuermann, y esclerosis de ambas sacroilíacas, características de artritis idiopática juvenil. Se concluyó que el paciente padecía de dos afecciones que por mecanismos diferentes causan dolor lumbar(AU)

Low back pain in adolescents is a frequent reason for consultation in rheumatology and is due to different causes. A clinical case of a 14-year-old adolescent from rural origin who comes to the clinic reporting pain and volume increase in both knees of three months of evolution accompanied by low back pain of more than two years of evolution that had required treatment is presented. with non-steroidal anti-inflammatory drugs and rest, without other accompanying systemic symptoms, physical examination revealed knee arthritis, increased physiological kyphosis in the thoracic spine and positive sacroiliac points. In the complementary tests, the presence of HLA-B27, synovitis in the bilateral sub quadriceps bursa on ultrasound of the knees, findings in the radiographs at the level of the bodies of the lumbar vertebrae characteristic of Scheuermann's disease, and sclerosis of both sacroiliacs' characteristic of juvenile idiopathic arthritis, it is concluded that the patient suffers from two conditions, which by different mechanisms cause low back pain(AU)

Scheuermann's Disease as a Risk Factor for Lumbar Disc Herniation Recurrence.

OBJECTIVE: To verify whether Scheuermann's disease (SD) is a risk factor for patients with recurrent lumbar disc herniation (rLDH) than in patients without recurrence. STUDY DESIGN: Case-control study. PLACE AND DURATION OF STUDY: Department of Orthopaedics, Yantaishan Hospital, China, from December 2016 to September 2019. METHODOLOGY: The demographics (age, gender, body mass index [BMI], alcohol abuse, and current smoking), diabetes mellitus, and radiological data (affected levels, herniated side, herniation type, Pfirrmann grade, and the presence of SD) of 602 patients were retrospectively analysed, who underwent surgery for symptomatic LDH from December 2016 to August 2018. They were underwent one-year follow-up and were divided into LDH and rLDH groups. Both typical and atypical SD criteria were used to diagnose SD. Independent-sample t-test was used to analyse the role of age and BMI in both groups, and the Chi-square test was conducted to analyse other parameters. Logistic regression analysis was performed to evaluate various factors. RESULTS: There was a significant difference in age (p=0.026), BMI (p=0.007), current smoking (p=0.001), and SD (p<0.001) between the groups. When these parameters were included in the logistic regression analysis, age, current smoking status, and SD were found to be risk factors for rLDH. CONCLUSION: Age, current smoking, and SD are risk factors for rLDH. Older patients with radiological characteristics of SD should quit smoking to prevent rLDH. Key Words: Scheuermann's disease, Kyphosis, Disc herniation, Recurrence, Age, Smoking, Risk factor.

Scheuermann's disease in patients 15-40 years old: A study to determine its prevalence and its relationship with age and sex using chest radiographs as screening tool.

BACKGROUND: There is insufficient knowledge of the epidemiology of Scheuermann's disease. The data available comes from estimations from young adults with obvious deformity, from studies evaluating children who may not have developed the deformity yet, or from older populations who can develop vertebral wedging secondary to other causes. We aimed to determine the prevalence of Scheuermann's disease in patients 15-40 years old using plain chest radiographs as a screening tool. METHODS: We evaluated 454 patients aged 15-40 years old studied using standing plain chest radiographs. We measured thoracic kyphosis from T5 to T12; using the intraclass correlation coefficient (ICC), we determined inter- and intra-observer agreement. To determine the prevalence of Scheuermann's disease we used the Sorensen criteria. We performed a correlation analysis of thoracic kyphosis and age, and a linear regression to determine the impact of age and sex on the kyphosis angle. RESULTS: The prevalence of Scheuermann's disease was 2.2% (0.9-3.5%). The prevalence was not different in females (1.4%) and males (2.8%), p = 0.36. Inter-and intra-observer agreements were excellent: ICC = 0.93 (0.84-0.97) and 0.97 (0.95-0.98). There was a small positive correlation of kyphosis angle with age (r = 0.110; p = 0.019). Linear regression revealed that age (ß = 0.138; p = 0.019) was an independent predictor of kyphosis angle, but sex was not (ß-coefficient = 0.007; p = 0.994). CONCLUSION: We found a prevalence of Scheuermann's disease of 2.2%, without significant differences between males and females. Age independently influenced the kyphosis angle; sex did not. This study allows a better understanding of the epidemiology of Scheuermann's disease.

Cervical Sagittal Alignment in Scheuermann Disease.

STUDY DESIGN: Retrospective evaluation of radiographs. OBJECTIVE: The aim of this study was to assess sagittal cervical balance in patients with the two types Scheuermann disease (SD). SUMMARY OF BACKGROUND DATA: The structural hyperkyphosis characterizing SD may be localized in the thoracic (SDT) or thoraco-lumbar (SDTL) spine segments. This may affect sagittal cervical balance. METHODS: Seventy-one patients (41 males and 30 females), aged 16.3 ±â€Š3.8 years with SD, were enrolled into the study. On standing lateral long-cassette radiographs, the following measurements were made: C0-2 angle, C2-7 angle (CL), C1-C2 angle, relative rotation angle (RRA)-measured at levels from C2 to C7, cervical tilt (CT), thoracic inlet angle (TIA), T1 slope, neck tilt (NT), C0-angle, cranial offset (CO), and cranial tilt (CRT). Comparison with t test was performed with significance level P < 0.05. RESULTS: There were 38 SDT and 33 SDTL patients. In SDT, the T1 slope was significantly greater than that in SDTL (38.1° vs. 28.9°; P = 0.0002), and consequently CL (-19.8° vs. -8.9°; P = 0.0160), CT (29.8° vs. 24.3°; P = 0.0190), and TIA (81.9° vs. 71.1°; P = 0.0022) in SDT were significantly greater as well. The difference in CL was expressed mainly in C6-C5 (-4.8° vs. -1.4°; P = 0.0146) and C5-C4 (-4.4°; vs. -1.5° P = 0.0464) segments. There were no significant differences in proximal cervical lordosis: C0-2 angle (-21.6° vs. -20.8°; P = 0.7597), C1-C2 angle (-30.8°vs. -27.5°; P = 0.1746), C3-C2 (-5.4° vs. -5.1°; P = 0.7976), and C4-C3 (3.5° vs. -1.5°; P = 0.1464) segments. There was no significant difference in cranial parameters C0-angle, CRT, and CO. CONCLUSION: Scheuermann disease type has an influence on cervical sagittal balance. Localization of structural kyphosis affects the T1 slope as well as C2-C7 lordosis, cervical tilt, and thoracic inlet angle. Significant difference in C2-C7 lordosis in comparison to similar C0-2 lordosis demonstrates that compensation is present in subaxial cervical spine. Position of the head center of gravity is not dependent on the SD type. LEVEL OF EVIDENCE: 4.

Vertebral Scheuermann's disease in Europe: prevalence, geographic variation and radiological correlates in men and women aged 50 and over.

UNLABELLED: In 27 centres across Europe, the prevalence of deforming spinal Scheuermann's disease in age-stratified population-based samples of over 10,000 men and women aged 50+ averaged 8% in each sex, but was highly variable between centres. Low DXA BMD was un-associated with Scheuermann's, helping the differential diagnosis from osteoporosis. INTRODUCTION: This study aims to assess the prevalence of Scheuermann's disease of the spine across Europe in men and women over 50 years of age, to quantitate its association with bone mineral density (BMD) and to assess its role as a confounder for the radiographic diagnosis of osteoporotic fracture. METHODS: In 27 centres participating in the population-based European Vertebral Osteoporosis Study (EVOS), standardised lateral radiographs of the lumbar and of the thoracic spine from T4 to L4 were assessed in all those of adequate quality. The presence of Scheuermann's disease, a confounder for prevalent fracture in later life, was defined by the presence of at least one Schmorl's node or irregular endplate together with kyphosis (sagittal Cobb angle >40° between T4 and T12) or a wedged-shaped vertebral body. Alternatively, the (rare) Edgren-Vaino sign was taken as diagnostic. The 6-point-per-vertebral-body (13 vertebrae) method was used to assess osteoporotic vertebral shape and fracture caseness. DXA BMD of the L2-L4 and femoral neck regions was measured in subsets. We also assessed the presence of Scheuermann's by alternative published algorithms when these used the radiographic signs we assessed. RESULTS: Vertebral radiographic images from 4486 men and 5655 women passed all quality checks. Prevalence of Scheuermann's varied considerably between centres, and based on random effect modelling, the overall European prevalence using our method was 8% with no significant difference between sexes. The highest prevalences were seen in Germany, Sweden, the UK and France and low prevalences were seen in Hungary, Poland and Slovakia. Centre-level prevalences in men and women were highly correlated. Scheuermann's was not associated with BMD of the spine or hip. CONCLUSIONS: Since most of the variation in population impact of Scheuermann's was unaccounted for by the radiological and anthropometric data, the search for new genetic and environmental determinants of this disease is encouraged.

The prevalence of abnormal preoperative neurological examination in Scheuermann kyphosis: correlation with X-ray, magnetic resonance imaging, and surgical outcome.

STUDY DESIGN: Retrospective. OBJECTIVE: The purpose of this study was to report the prevalence of abnormal neurological findings detected by physical examination in Scheuermann kyphosis and to correlate it to radiographs, magnetic resonance imaging (MRI) findings, and results of operative treatment. SUMMARY OF BACKGROUND DATA: There have been sporadic reports about abnormal neurological findings in patients with Scheuermann kyphosis. METHODS: Among 82 patients with Scheuermann kyphosis who underwent corrective surgery, 69 primary cases were selected. Patients' charts were reviewed retrospectively in terms of pre and postoperative neurological examinations. Sensory or motor change was defined as an abnormal neurological examination. Their duration, associated problems, and various parameters on preoperative radiographs and MRI examinations were also measured to search for any atypical findings associated with an abnormal neurological examination. RESULTS: There were 6 cases (9%) (group AbN), with an abnormal neurological examination ranging from severe myelopathy to a subtle change (e.g., sensory paresthesias on trunk). Five patients recovered to a normal neurological examination after corrective surgery. The remaining 1 patient with severe myelopathy also showed marked improvement and was ambulatory unassisted by 2-year follow-up. In patients with a normal neurological examination (group N, n = 63), only 1 patient had neurological sequelae because of anterior spinal artery syndrome after combined anterior-posterior correction. No preoperative radiographical parameters were significantly different between groups. Average age was 21.3 (AbN) and 18.6 (N) years (P = 0.55). Average preoperative T5-12 kyphosis was 69.0° (AbN) and 72.5° (N) (P = 0.61). Forty-two magnetic resonance images were obtained and all showed typical findings of Scheuermann kyphosis. Five patients in the AbN group (1 patient underwent computed tomography/myelography) and 37 patients in the N group underwent an MRI. CONCLUSION: The prevalence of abnormal neurological findings in Scheuermann kyphosis was 9%, emphasizing the importance of performing a detailed preoperative neurological examination. If congenital stenosis or a herniated thoracic disc is present, myelopathy can occur. No radiographical findings correlated with the abnormal preoperative neurological examinations. A normal MRI can exist in the face of an abnormal neurological examination, and conversely, a normal neurological examination can be seen with an abnormal MRI. Surgery was successful in alleviating abnormal neurological issues. LEVEL OF EVIDENCE: 4.

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.

Scheuermann disease: evaluation of radiological criteria and population prevalence.

STUDY DESIGN: Observational population-based study. OBJECTIVE: To determine the prevalence of radiographical Scheuermann disease in a Dutch population and evaluate the consistency of diagnostic criteria. SUMMARY OF BACKGROUND DATA: Scheuermann disease is a form of osteochondrosis characterized by increased posterior rounding of the thoracic spine with structural vertebral deformity. Different expert opinion-based radiological criteria exist, yet these have not been validated. The prevalence in the general population reported ranged from 1% to 10%. METHODS: Lateral spine radiographs of 2753 Rotterdam Study participants (aged 45-89 yr) were assessed for Scheuermann disease using Sørensen and Sachs' radiographical criteria in 2 phases. Cohen κ statistics were calculated for interrater agreement. Prevalence estimates were calculated and sex differences were tested with Pearson χ test. We evaluated whether varying the kyphosis angle criterion would change the prevalence estimate. RESULTS: A total of 677 (24.6%) individuals had endplate irregularities and 140 (5.1%) individuals had vertebral wedging. Abnormalities were significantly more prevalent among males (P < 0.05). The interrater agreement κ statistics were 78.8% for vertebral wedging and 79.4% for endplate irregularity. A total of 127 individuals had both criteria, of which 111 had a kyphosis angle greater than 45°, resulting in a prevalence of 4.0% (95% confidence interval [CI]: 3.3%-4.7%). The disease prevalence was 4.5% in males versus 3.6% in females, yet this difference was not statistically significant (P = 0.23). Adjustment of the kyphosis angle criterion from 45° to 40° or 35° increased the number of cases marginally, corresponding to prevalence estimates not significantly different from the estimates using original criteria (4.2% [95% CI: 3.3%-4.7%] and 4.4% [95% CI: 3.6%-5.2%]). CONCLUSION: Our results revealed a prevalence of 4.0% of radiographical Scheuermann disease in Dutch individuals aged 45 years and older. Although there is no current "gold standard" for the radiographical definition, standardized scoring of independent features resulted in substantial interobserver agreement, and different applications of diagnostic criteria did not significantly alter the classification.

Spinal deformity in young athletes.

Young athletes may have a spinal deformity incidentally or potentially related to their sport. These athletes should be encouraged to continue sports participation in many instances. Brace wear is commonly used for kyphotic and scoliosis deformities. Many sports can be played in the brace. Even with sports that cannot practically be played in the brace, most bracing protocols have enough time out of brace during the day for the athlete to continue participation. However, good physical therapy for flexibility and strengthening of the spine should be continued. Even sports that potentially aggravate the deformity may be continued in these circumstances.

Orofacial characteristics of adolescents with diagnosed spinal disorders.

The objective of the current epidemiological study is to show the correlation of various postural abnormalities and spinal deformities and the clinically identifiable dentofacial anomalies by orthodontic examination. Twenty-three children with Scheuermann's disease [mean age: 14 years 8 months; standard deviation (SD): 1 year 8 months] and 28 with scoliosis (mean age: 14 years 7 months; SD: 2 years 3 months) participated in the study. Standardized orthodontic screening protocols were used to map the occlusal relations in the sagittal, vertical, and horizontal dimensions; the space relations of the maxillary and mandibular frontal segment; the temporomandibular joint (TMJ) status; and the facial asymmetries. Statistically significant differences (p<0.05) were found between the values of the examined groups of patients for the following measurements: incisal overjet and overbite, upper and lower midline deviation, mandibular frontal spacing, TMJ pathological symptoms and functional characteristics, and frequency of facial asymmetries. A large percentage of patients with pre-pubertal developments of spinal deformities have various dentofacial anomalies. The majority of these anomalies are present in patients with Scheuermann's disease. Early treatment of the malocclusions closely correlated to postural disorders should minimize the progression of the dentofacial anomalies, making necessary performing orthodontic screening of these patients as early as possible.

Comparison of sagittal spinopelvic alignment in Chinese adolescents with and without idiopathic thoracic scoliosis.

STUDY DESIGN: A retrospective radiographical study investigated the sagittal alignment in healthy Chinese girls and Chinese girls with idiopathic thoracic scoliosis (T-AIS). OBJECTIVE: To evaluate the sagittal alignment of the pelvis and spine in Chinese girls with idiopathic scoliosis and healthy girls and to assess whether the pelvic morphology differed between white and Chinese girls with AIS. SUMMARY OF BACKGROUND DATA: It has been shown that patients with AIS have an abnormal spinopelvic balance and pelvic morphology. Race is a determinant factor of sagittal spinal alignment and serves as a reminder when planning surgical reconstruction for spinal deformity. Until now, there have been no studies documenting the sagittal lumbosacral spine morphology in Chinese girls with T-AIS. METHODS: In this study, 95 patients with T-AIS and 33 healthy age-matched adolescents were recruited consecutively. Sagittal spinal and pelvic parameters were measured from the standing lateral radiograph, including thoracic kyphosis (TK), lumbar lordosis (LL), upper arc of LL, lower arc of LL, pelvic incidence (PI), sacrum slope (SS), and pelvic tilt (PT). Analysis of variance was used in the comparison of each dependent variable between patients with AIS and healthy adolescents. The relations between all parameters were determined via Pearson correlation coefficient (r). RESULTS: For all the sagittal parameters, only the TK and the upper arc of the LL showed significant differences between girls with AIS and healthy girls. The LL, lower arc of the LL, and 3 pelvic parameters were similar for both groups. The TK was found to be strongly correlated with LL and the upper arc of the LL in both groups. However, the TK was not related to the lower arc of the LL, nor were the 3 pelvic parameters in either group. In addition, LL was found to be associated with PI and SS in both groups. The lower arc of the LL was also correlated with PI for both groups. The PI was related to PT and SS in both groups; however, no correlation was found between PT and SS. In this study, the TK (15.7°), SS (35.1°), and PI (44.2°) were found to be significantly lower in Chinese patients with T-AIS than the values reported in the AIS cohort. CONCLUSION: In our study, the Chinese girls with T-AIS had similar PI, PT, and SS values when compared with the age-matched healthy girls. There were significant differences in pelvic morphology between Chinese and white girls with AIS. These results suggest that race may influence an individual's spinopelvic morphology. Although we have shown that the TK could affect LL through the upper arc of the LL directly, the evaluation of the thoracolumbar morphology of T-AIS before surgery is important for surgical planning.

Genetic epidemiology of Scheuermann's disease.

BACKGROUND AND PURPOSE: The genetic/environmental etiology of Scheuermann's disease is unclear. We estimated the heritability of the disease using an etiological model adjusted for sex and time of diagnosis, and examined whether the prevalence of Scheuermann's disease was constant over time. METHODS: 46,418 twins were sent a questionnaire about health and disease. Of these, 75% returned the questionnaire and 97% answered the question "Have you been diagnosed as having Scheuermann's disease by a doctor?" RESULTS: Responders included 11,436 complete pairs of twins. Data were analysed using classical twin modeling methods. Tetrachoric correlations were used to decide which etiological model to fit. The best-fitting model was the AE model. Heritability was 0.74 (95% CI: 0.65-0.81), while variance explained by environmental factors was 0.26 (95% CI: 0.19-0.35). A threshold of 2.1 (95% CI: 1.9-2.2) was calculated, corresponding to a prevalence of 1.9% (95% CI: 1.3-2.8) for women. Regression coefficients for age and sex were 0.000 (95% CI: -0.003 to 0.002) and -0.32 (95% CI: -0.42 to -0.23). INTERPRETATION: We found a heritability of 0.74 in Scheuermann's disease. The threshold in men was lower than in women, corresponding to a male prevalence that was almost twice that of females. We found no change in the prevalence of Scheuermann's disease throughout the 50-year age span that we examined.

Two brothers with a symptomatic thoracic disc herniation at T11-T12: clinical report.

BACKGROUND: In contrast to what is commonly believed, thoracic disc herniations are not rare lesions. Their etiopathogenesis is largely unknown, but may be linked to trauma, Scheuermann's disease or a degenerative back. OBJECTIVE: We report two brothers with a symptomatic thoracic disc herniation at T11-T12 and address the possibility of a genetic factor as well as other factors in the etiopathogenesis of (symptomatic) thoracic disc herniations. CLINICAL FEATURES: Both brothers were in their early thirties and had a physically demanding job, however, only the first one was a smoker and was diagnosed with Scheuermann's disease. CONCLUSION: The etiology of thoracic disc herniations is likely multifactorial. Their occurrence in siblings may reflect some genetic predisposition or may be merely coincidental, given the high prevalence of thoracic disc herniations in asymptomatic individuals. Further research, including genetic studies, is warranted.

The role of sternum in the etiopathogenesis of Scheuermann disease of the thoracic spine.

STUDY DESIGN: A clinical cohort study of sternum clinical measurements was performed in 10,057 students, during a school screening program for Scheuermann disease. OBJECTIVE: To determine whether the length of sternum is correlated with Scheuermann disease pathogenesis. SUMMARY OF BACKGROUND DATA: Many theories have been proposed for the etiology of Scheuermann disease, but the true cause remains unclear. Probably mechanical factors play a role in the development of the deformity. The reported success of brace treatment leads to the support to this theory. METHODS: There were 5048 boys and 5009 girls. The mean age of children was 13,07 years (SD = +/-0.82). Scheuermann disease was detected clinically and was documented with lateral radiograph of spinal column. All children were measured for their sternum's length from the jugular notch until the top of xiphoid process. This measure was repeated 3 times for each child. The height of all students and the arm span were measured, as well. RESULTS: In total 10,057 students screened, children with Scheuermann disease (study group) were 175 (147 men and 28 women). The length of sternum was greater in the healthy (control) group. There was a statistically significant difference between the 2 groups with regard to the sternum's length (Mann-Whitney U test, P = 0000). This is of particular importance, because in 2 groups that were comparable according to age (Mann-Whitney U test, P = 0605), the children with Scheuermann disease were taller in relation with the control group (Mann-Whitney U test, P = 0000). CONCLUSION: The smaller length of sternum than the normal has a possible correlation with the appearance of Scheuermann disease. Probably the smaller length of sternum increases the compressive forces on the vertebral endplates anteriorly, allowing uneven growth of the vertebral bodies with wedging. More studies are required for the documentation of this theory of pathogenesis.

Evidence based medicine: analysis of Scheuermann kyphosis.

STUDY DESIGN: : A review of the current literature using evidence-based medicine (EBM) regarding etiology, natural history, and treatment of Scheuermann kyphosis. OBJECTIVE: : To provide current concepts for the rational evaluation and treatment of Scheuermann kyphosis supported by EBM. SUMMARY OF BACKGROUND DATA: : The literature concerning etiology, natural history, and treatment of Scheuermann disease has mixed views and recommendations, most of which are not strongly supported with levels of evidence. METHODS: : A thorough database search was performed in order to obtain the best current information and levels of evidence on etiology, natural history, and treatment options for Scheuermann kyphosis based on EBM criteria. RESULTS AND CONCLUSION: : Scheuermann kyphosis is the most common cause of hyperkyphosis in adolescence. Its true etiology remains unknown, but there appears to be a strong genetic as well as an environmental contribution. The kyphotic deformity is frequently attributed to "poor posture" resulting in delayed diagnosis, and treatment indications remain debated because the natural history has not been clearly defined. When recognized early in adolescence with progressive kyphosis, bracing treatment will usually result in modest correction of the deformity. Symptomatic adolescents with severe deformity have demonstrated significant deformity correction following surgical intervention; however, clinical outcomes data are not yet available, and the studies available do not have strong levels of evidence.

Prevalence, concordance, and heritability of Scheuermann kyphosis based on a study of twins.

BACKGROUND: The purpose of this study was to establish a cohort of symptomatic twins with Scheuermann kyphosis to provide estimates of prevalence, concordance, odds ratio, and heritability. These estimates indicate to what extent genetic factors contribute to the etiology of this disease. METHODS: The Odense-based Danish Twin Registry is unique in that it contains data on all 73,000 twin pairs born in Denmark over the last 130 years. For the present study, all 46,418 twins born from 1931 through 1982 received a seventeen-page questionnaire, in which one question was "Have you been diagnosed with Scheuermann disease by a doctor"? The prevalence of self-reported Scheuermann disease was calculated, with the total number of answers used as the general population. Pairwise and probandwise concordance, odds ratio, tetrachoric correlations, and heritability were calculated. RESULTS: We found that the overall prevalence of Scheuermann disease was 2.8%, with a prevalence of 2.1% among women and 3.6% among men (p < 0.0001). The pairwise concordance for monozygotic twins was 0.19 compared with 0.07 for dizygotic twins. The probandwise concordance was 0.31 for monozygotic twins and 0.13 for dizygotic twins. The odds ratios were 32.92 and 6.25 in the monozygotic and dizygotic twins, respectively. These differences were significant (p < 0.01). Heritability was 74%. CONCLUSIONS: In a large cohort of twins that included almost 35,000 individuals, the self-reported overall prevalence of Scheuermann disease was 2.8% and the male-to-female ratio was close to 2:1. Because the pairwise and probandwise concordance and the odds ratio were two to three times higher in monozygotic than in dizygotic twins and the heritability was high, we concluded that there is a major genetic contribution to the etiology of Scheuermann disease.

Measurement of spinal kyphosis: implications for the management of Scheuermann's kyphosis.

STUDY DESIGN: Repeat clinical radiograph measurement of kyphosis was performed. OBJECTIVES: To evaluate precision in kyphosis measurement, the presence of intra- and interobserver error, and the effect of endplate selection and curve magnitude on error. SUMMARY OF BACKGROUND DATA: One study thus far has shown no interobserver difference in readings and an error interval of +/-11 degrees. METHODS: Four experienced examiners measured 30 radiographs of varying angles of kyphosis without preselected end vertebrae twice using the Cobb method. RESULTS: The mean intraobserver variance was 4.3 degrees (95% confidence interval, +/-9.6 degrees). One examiner had significantly better precision (P= 0.02) than the other examiners, who had no significant difference among them (P = 0.41). This examiner's mean intraobserver difference was 2.3 degrees (95% confidence limit, +/-6.2 degrees ). The 95% confidence limit for the interobserver difference was +/-8.7 degrees. The vertebral error index did not have a rank correlation with precision between readings. Magnitude of curve did not correlate with variance in measurement. CONCLUSIONS: The broad range in intra- and interobserver differences in the measurement of kyphosis should be taken into account in making management decisions or evaluating the success or failure of a treatment program. Careful technique in measurement may allow for improvement in individual precision.

Radiographic abnormalities in the thoracolumbar spine of young elite skiers.

An increased frequency of radiologic abnormalities in the thoracolumbar spine has been reported among young athletes in various sports, but there are no data concerning ski sports. To evaluate the incidence of these abnormalities in young elite skiers, we compared 120 skiers younger than 17 years old (alpine skiers, ski jumpers, and Nordic cross-country skiers) with a random sample of 39 control subjects of the same age who had no history of high-performance sports participation. Standardized anteroposterior and lateral radiographs of the entire lumbar spine, the lower thoracic spine, and the upper part of the sacrum were obtained from each athlete and each control subject. Radiographs were evaluated by two independent observers for the presence and size of anterior and posterior endplate lesions and Schmorl's nodes. The elite alpine skiers and ski jumpers demonstrated a significantly higher rate of anterior endplate lesions than did the control subjects. This finding might be attributable to excessive loading and repetitive trauma of the immature spine under high velocity, especially in the forward bent posture.