Sunday, December 16, 2018

Brain & Spine Disorders

Thoracic Kyphosis

What Is Kyphosis?
Kyphosis is a progressive spinal disorder that can affect children or adults. This disorder may cause a deformity described as humpback or hunchback. Kyphosis can be in the form of hyperkyphosis or sharp angular gibbus deformity (see 'Gibbus Deformity' below). Abnormal kyphotic curves are more commonly found in the thoracic or thoracolumbar spine, although they can be cervical.

Frequent Causes:
  • Postural round-back
  • Scheuermann's Disease
  • Congenital Kyphosis
  • Kyphosis associated with neuromuscular disorders
  • Kyphosis secondary to trauma, tumors, infection, and arthritis
Kyphosis in the thoracic spine means exaggerated kyphotic angle from the spine's normal kyphotic curve. Normal lordotic curves in the cervical and lumbar regions may also be diminished to contribute to the overall pitched-forward posture. The spine's natural curves position the head over the pelvis and work as shock absorbers to distribute mechanical stress during movement.

Postural and Structural Kyphosis
Kyphosis is classified as either postural or structural. Postural means the kyphosis is attributed to poor posture, usually presenting a smooth curve, which can be corrected by the patient. Structural kyphosis is caused by an abnormality affecting the bones, intervertebral discs, nerves, ligaments, or muscles. Kyphosis with a structural pathology may require medical intervention because the patient alone cannot control curve progression.

Gibbus Deformity
A Gibbus Deformity is a form of structural kyphosis. The posterior (from behind) curve presents sharply angled; the curvature is not smooth. This deformity may result in a humpback found to be more prominent when bending forward.

This term is used to describe 'excessive' (hyper) curvature exceeding the normal range. Hyperkyphosis occurs in the thoracic spine. In adults, osteoporosis is a common cause often involving several vertebrae.

Congenital Kyphosis
Congenital means the disorder is found at birth. Congenital kyphosis is a structural abnormality.

Scheuermann's Disease
Scheuermann's Disease is juvenile (adolescent) thoracic kyphosis. Although the cause is unknown, it may be familial. This disease can cause decreased intervertebral disc space and vertebral wedging resulting in an excessive curve described as stiff or rigid. The classic definition of Scheuermann's is anterior (front) vertebral wedging of at least 5 degrees involving three consecutive vertebrae. The neck and head may present in an abnormal forward position. The onset usually begins (or is noticed) between the ages of 12 and 15 years affecting females more often than males. For many patients (up to 50%), pain is a common complaint.

Deformity and pain often motivates the patient to visit their physician. Early treatment is important to control curve progression especially in adolescents.

Physical Examination
A thorough physical examination reveals a lot about the health and general fitness of the patient. The exam provides a baseline from which the physician can measure the patient's progress during treatment. The physical exam will include:

  • Observation of the posture may reveal round-back or gibbus deformity. The sagittal balance or balance of the head and trunk over the pelvis viewing from the side can be assessed. Any associated scoliosis will be observed.
  • Adam's Forward Bending Test requires the patient to bend forward at the waist. This may reveal a thoracolumbar kyphosis.
  • Palpation determines spinal abnormalities by feel. Often the paraspinal musculature is tender. When Scheuermann's Disease is present, the hamstring muscles may be tight.
  • Range of Motion measures the degree to which a patient can perform movements of flexion, extension, lateral bending, and spinal rotation. Asymmetry is also noted. The deformity is palpated during range of motion to assess flexibility or rigidity of the curve.
Neurologic Evaluation
A neurological evaluation includes an assessment of the following symptoms: pain, numbness, paresthesias (e.g. tingling), extremity sensation and motor function, muscle spasm, weakness, and bowel/bladder changes.

Full-length AP (anterior/posterior, front/back) x-rays are taken of the spinal column. The patient stands with arms extended forward while keeping the head erect. To determine curve flexibility, x-rays may be taken with the patient supine. These x-rays are used to evaluate vertebral wedging and end plate irregularities, characteristic of Scheuermann's Disease.

An MRI may be ordered if the spinal cord has been compromised (or suspected). The Cobb Angle Method measures the kyphotic curve in degrees using a standard full-length AP x-ray.

Early treatment is especially important to the adolescent patient. Left untreated, the curve progression can lead to significant problems later during adulthood. Routine follow-up is essential to properly monitor curve progression.

Treating Postural Kyphosis
Certain exercises may be recommended (e.g. physical therapy) to strengthen the patient's paravertebral muscles. Further, the patient must make a conscious effort to work toward correcting and maintaining proper posture.

Treating Structural Kyphosis
Analgesics and anti-inflammatory medication may be used to provide relief. Padded orthoses can be used to control pain, but these do not control curve progression. The patient's age, remaining growth potential, degree of kyphosis, curve progression, and the amount of vertebral wedging determine treatment of Scheuermann's Disease.

Bracing is the standard treatment to control curve progression in adolescents. For curve correction, a Cervical Thoraco Lumbar Sacral Orthotic (CTLSO) may be worn for 24 hours per day for a period of one year.* After the initial bracing period, the patient is weaned out of the brace. Bracing does not provide permanent benefit to patients 16 years or older. Adolescents may find bracing difficult because the brace can be uncomfortable, hot, rigid, unattractive and may make the patient self-conscious. Surgery is a consideration when kyphosis is severe (e.g. >70 degree curve) and symptoms (e.g. pain) are unrelieved by conservative treatment.

Surgery is indicated when: (1) The deformity is progressive beyond severe angle (e.g. 70 degrees for Scheuermann's kyphosis) or sagittal balance is significantly abnormal, (2) Neurologic symptoms exist, and/or (3) When persistent pain cannot be alleviated using conservative treatment. In addition, adolescents with significant deformity, who may not respond to conservative therapy (e.g. bracing) and adults with curve progression and/or chronic back pain, may be accorded surgery.

Spinal Instrumentation and Fusion are surgical procedures that may be used to correct spinal deformity and to provide permanent stability to the spinal column. These procedures join and solidify the level where a spinal element has been damaged or removed (e.g. intervertebral disc). Instrumentation uses medically designed hardware such as rods, bars, wires, and screws. These devices hold the spine straight during fusion.

Fusion is the adhesive process joining bony spinal elements. In severe cases, spinal fusion is performed both anteriorly (from the front) through thoracotomy (entering chest cavity) and posteriorly (from behind) using instrumentation.

Recovery and Conservative Treatment
Closely follow the physician and/or physical therapist's instructions including regular follow-up visits to monitor curve progression.

Physical therapy may be incorporated into the treatment plan to build strength, flexibility, and increase range of motion. The therapist may provide the patient a customized home exercise program.

Recovery from Surgery
Post-operative pain and/or discomfort should be expected. Patient Controlled Analgesia (PCA) enables the patient to control their pain without hospital staff assistance.


PCA is eventually replaced by oral medication.

The patient may be encouraged to get up and walk the following day. Activity enhances circulation and healing.

Physical therapy is added post-operatively enabling the patient to build strength, flexibility, and increase range of motion. The patient continues physical therapy on an outpatient basis for a period of time. Additionally, the therapist provides the patient with a customized home exercise program.

Prior to release from the hospital, the patient is given written instructions and prescriptions for necessary medication. The patient's care continues during follow-up visits with their spinal surgeon.

Mid Back Pain & Disorders (Thoracic Spine)

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