High Yield Overview
SCHEUERMANN KYPHOSIS
Juvenile Kyphosis | Thoracic Greater Than 45 Degrees | Vertebral Wedging | Bracing vs Surgery
1-8%Adolescent prevalence
greater than 45°Thoracic kyphosis threshold
3+Wedged vertebrae required
5°+Wedging per vertebra
TREATMENT THRESHOLDS
Less than 50°
PatternObservation, exercises
TreatmentPhysiotherapy, posture training
50-75°
PatternSkeletally immature
TreatmentMilwaukee brace, physiotherapy
Greater than 75°
PatternSevere or failed bracing
TreatmentSurgical correction and fusion
Critical Must-Knows
- Diagnostic criteria: Thoracic kyphosis greater than 45°, 3+ consecutive vertebrae with greater than 5° anterior wedging each
- Rigid kyphosis: Does NOT correct on hyperextension (unlike postural kyphosis which corrects)
- Peak incidence: 12-17 years during growth spurt, male predominance
- Bracing effective in immature patients: Greater than 1 year growth remaining, kyphosis 50-75°
- Surgical threshold: Greater than 75° kyphosis, progressive despite bracing, neurological symptoms
Examiner's Pearls
- "Adams forward bend test shows angular kyphosis (not smooth curve like postural)
- "Tight hamstrings and hip flexors common - always assess flexibility
- "Check for associated scoliosis (30% have combined deformity)
- "MRI if neurological symptoms - rare thoracic disc herniation can occur
Clinical Imaging
Imaging Gallery
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Critical Scheuermann Kyphosis Exam Points
Diagnostic Criteria (Sorensen)
Classic criteria: Thoracic kyphosis greater than 45° (Cobb angle), with 3 or more consecutive vertebrae each having greater than 5° anterior wedging. Additional findings include Schmorl nodes, endplate irregularities, and disc space narrowing. Apex typically T7-T9.
Scheuermann vs Postural
Key differentiation on exam: Have patient hyperextend spine. Postural kyphosis CORRECTS with hyperextension (flexible). Scheuermann kyphosis does NOT correct (rigid, structural). Also, postural kyphosis is a smooth, round curve; Scheuermann has angular apex.
Bracing Indications
Brace if: Kyphosis 50-75°, skeletally immature (Risser 0-3, greater than 1 year growth remaining), compliant patient. Milwaukee brace or TLSO worn 16-23 hours/day until skeletal maturity. Bracing can prevent progression but rarely corrects established deformity.
Surgical Threshold
Surgery if: Kyphosis greater than 75°, progressive despite bracing, intractable pain not responding to conservative treatment, neurological deficit (rare). Posterior-only fusion now most common. Anterior release rarely needed with modern posterior techniques.
Quick Decision Guide - Adolescent Kyphosis
| Feature | Scheuermann Kyphosis | Postural Kyphosis |
|---|---|---|
| Curve type | Rigid, angular apex | Flexible, smooth curve |
| Hyperextension test | Does NOT correct | Corrects fully |
| X-ray findings | Vertebral wedging, Schmorl nodes, endplate changes | Normal vertebrae, no structural changes |
| Pain | Often present, activity-related | Usually painless |
| Treatment | Bracing if immature, surgery if severe | Posture training, exercises only |
Mnemonic
SCHEUERMANNSCHEUERMANN - Diagnostic Features
S
Structural kyphosis
Rigid, does not correct with extension
C
Cobb greater than 45 degrees
Thoracic kyphosis measurement
H
Herniation of disc material
Schmorl nodes into vertebral bodies
E
Endplate irregularities
Characteristic radiographic finding
U
Usually 3+ vertebrae wedged
Consecutive vertebrae criteria
E
Each wedge greater than 5 degrees
Minimum wedging per vertebra
R
Rigid on hyperextension
Key clinical differentiation
M
Males more affected
Male to female ratio 2:1
A
Apex T7-T9 typically
Classic thoracic location
N
Negative Risser = brace candidate
Immature patients can brace
N
Neurological rare but check
MRI if symptoms present
Memory Hook:SCHEUERMANN criteria are specific - remember each letter corresponds to a diagnostic or management point.
Mnemonic
BRACEBRACE - Bracing Criteria
B
Below 75 degrees kyphosis
Greater than 75 usually needs surgery
R
Risser 0-3 (immature)
Need growth remaining
A
Above 50 degrees threshold
Less than 50 observe only
C
Compliant patient/family
16-23 hours/day wear required
E
Expected 1+ year growth
Minimum growth remaining for effect
Memory Hook:To BRACE, patient must meet all criteria - immature, kyphosis 50-75°, compliant.
Mnemonic
SURGERYSURGERY - Surgical Indications
S
Severe kyphosis greater than 75 degrees
Main indication
U
Unresponsive to bracing
Failed conservative treatment
R
Refractory pain
Intractable despite conservative care
G
Growing rapidly despite brace
Progression during treatment
E
Elderly adolescent (mature)
Bracing ineffective after maturity
R
Rare neurological symptoms
Thoracic disc herniation, cord compression
Y
Young adult cosmetic concern
Significant deformity impact
Memory Hook:SURGERY threshold is greater than 75° or failed conservative treatment.
Overview and Epidemiology
Scheuermann Disease (Scheuermann Kyphosis) is the most common cause of structural kyphosis in adolescents. It is characterized by vertebral wedging leading to an exaggerated thoracic kyphosis that is rigid and does not correct with hyperextension.
Epidemiology:
- Prevalence 1-8% of adolescents (varies by diagnostic criteria used)
- Male predominance 2:1 (historical), may be equalizing
- Peak presentation during adolescent growth spurt (12-17 years)
- Often diagnosed when parents notice "round back" or stooped posture
- Associated with heavy manual labor historically (juvenile disc disorder)
Thoracic vs Lumbar Scheuermann
Classic (thoracic): Apex T7-T9, more common, better tolerated. Atypical (thoracolumbar/lumbar): Apex T10-L2, more painful, higher risk of degenerative changes. Lumbar Scheuermann may present primarily as low back pain rather than visible kyphosis.
Etiology (Multifactorial):
- Genetic component (autosomal dominant with variable penetrance)
- Mechanical overload during growth (anterior vertebral compression)
- Possible cartilage endplate abnormality
- Associated with growth plate disorders
Pathophysiology and Mechanisms
Normal vs Scheuermann Kyphosis
Spinal Curvature Norms
| Region | Normal Range | Scheuermann Threshold | Surgical Threshold |
|---|---|---|---|
| Thoracic kyphosis | 20-45° | Greater than 45° (with vertebral wedging) | Greater than 75° |
| Lumbar lordosis | 40-60° | May be increased (compensatory) | Consider in surgical planning |
| Cervical lordosis | 20-40° | May be increased (compensatory) | Assess for chin-on-chest risk |
Vertebral Wedging Mechanism
Pathophysiology
- Anterior growth plate injury: Repetitive loading damages vertebral endplates
- Asymmetric growth: Posterior vertebral body grows faster than anterior
- Vertebral wedging: Each affected vertebra contributes greater than 5° wedging
- Schmorl nodes: Disc material herniates into weakened endplates
- Disc space narrowing: Secondary degenerative changes
Biomechanical Consequences
- Increased thoracic kyphosis: Cumulative effect of wedged vertebrae
- Compensatory hyperlordosis: Lumbar and cervical regions compensate
- Tight posterior chain: Hamstrings, hip flexors tighten
- Anterior chest wall tightness: Pectorals shortened
- Altered center of gravity: Forward shift
Associated Scoliosis
30% of Scheuermann patients have associated scoliosis. Always check for coronal plane deformity as well. Combined kyphoscoliosis may affect surgical planning.
Classification Systems
Classic Diagnostic Criteria (Sorensen 1964)
All criteria must be met:
- Thoracic kyphosis greater than 45° (Cobb angle on standing lateral X-ray)
- Three or more consecutive vertebrae with greater than 5° anterior wedging each
- Vertebral endplate irregularities
Supportive findings (not required for diagnosis):
- Schmorl nodes (disc herniation into vertebral body)
- Disc space narrowing
- Increased AP diameter of apical vertebrae
- Apex typically T7-T9
Standard criteria for diagnosis. Some authors use greater than 40° as threshold.
Clinical Assessment
Systematic Examination
Step 1History
- Onset: Gradual, noticed during growth spurt
- Pain: Present in 50%, usually activity-related, localized to apex
- Cosmesis: Parents/patient notice "round back" or stooped posture
- Activity level: Impact on sports, sitting tolerance
- Family history: May be positive
- Neurological symptoms: RARE - but ask about weakness, numbness
Step 2Inspection
- Standing: Exaggerated thoracic kyphosis, forward head posture
- Adams forward bend: Angular apex (not smooth curve)
- Compensatory lordosis: Increased lumbar curve, extended cervical spine
- Shoulder position: Often protracted
- Associated scoliosis: Check for rib hump, asymmetry
Step 3Flexibility Testing
- Hyperextension test: Scheuermann does NOT correct (rigid)
- Postural kyphosis DOES correct - key differentiation
- Hamstring tightness: Very common, assess straight leg raise
- Hip flexor tightness: Thomas test often positive
- Pectoralis tightness: Assess shoulder flexibility
Step 4Neurological Exam
- Full neurological examination if any symptoms
- Cord compression rare but possible with severe kyphosis
- Thoracic disc herniation can occur into spinal canal
- Check reflexes, strength, sensation in lower limbs
Hyperextension Test is Key
Have patient lie prone and hyperextend the spine (or extend over examiner's arm). Scheuermann kyphosis remains fixed (rigid, structural). Postural kyphosis corrects completely (flexible, non-structural). This single test distinguishes the two conditions.
Investigations
Standing Lateral X-ray
Standing lateral spine X-ray with arms forward (on a support) is the standard view for measuring kyphosis. Cobb angle measured from superior endplate of first tilted vertebra to inferior endplate of last tilted vertebra (usually T4-T12). Also obtain AP view to assess scoliosis.
Radiographic Findings
| Finding | Description | Clinical Significance |
|---|---|---|
| Thoracic kyphosis greater than 45° | Cobb angle T4-T12 or affected levels | Diagnostic criterion |
| Vertebral wedging greater than 5° | Anterior height loss, 3+ consecutive vertebrae | Diagnostic criterion |
| Schmorl nodes | Disc herniation into vertebral endplates | Supportive finding |
| Endplate irregularities | Wavy, irregular vertebral endplates | Supportive finding |
| Disc space narrowing | Secondary degenerative change | Supportive finding |
Other Imaging:
- MRI: Only if neurological symptoms, to assess cord/disc
- CT: Rarely needed, for surgical planning in complex cases
- Bone scan: Not routinely indicated
Advanced Imaging Examples
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Skeletal Maturity Assessment:
- Risser sign on iliac crest
- Hand X-ray for bone age if needed
- Critical for determining bracing candidacy
Management Algorithm
Non-Operative Management
| Kyphosis | Skeletal Maturity | Treatment | Expected Outcome |
|---|---|---|---|
| Less than 50° | Any | Observation, physiotherapy, posture training | Stable, rarely progresses |
| 50-75° | Immature (Risser 0-3) | Milwaukee brace or TLSO 16-23 hrs/day | Prevents progression, some correction |
| 50-75° | Mature (Risser 4-5) | Physiotherapy, activity modification | Bracing ineffective after maturity |
| Greater than 75° | Any | Surgical consultation | Likely needs operative treatment |
Physiotherapy Program:
- Core strengthening (especially extensors)
- Hamstring and hip flexor stretching
- Pectoralis stretching
- Postural awareness training
- Activity modification (avoid heavy lifting)
Bracing Protocol:
- Milwaukee brace (extends to chin) or TLSO
- Wear 16-23 hours/day until skeletal maturity
- Weaning protocol over 6-12 months after maturity
- Exercises continued during bracing
Compliance is the key determinant of bracing success.
Surgical Technique
Posterior Spinal Fusion with Instrumentation
Standard approach for Scheuermann kyphosis.
Surgical Steps
Step 1Positioning
- Prone position on appropriate frame
- Arms forward, knees slightly flexed
- Neuromonitoring (SSEPs, MEPs) throughout
Step 2Exposure
- Midline incision over affected levels
- Subperiosteal exposure of posterior elements
- Usually T2/T3 to L1/L2 depending on curve
Step 3Osteotomies
- Ponte osteotomies at multiple levels to increase flexibility
- Remove ligamentum flavum and facet joints
- Allows posterior column shortening and correction
Step 4Instrumentation
- Pedicle screws at all levels (or hybrid with hooks)
- Dual rods (usually cobalt chrome or titanium)
- Sequential compression to correct kyphosis
- Use of set screws to lock correction
Step 5Fusion
- Decorticate transverse processes and facets
- Apply bone graft (local autograft ± allograft)
- Close in layers over drain
Key Principles:
- Preserve lower lumbar lordosis (avoid flat-back)
- Stop fusion at stable vertebra
- Achieve correction with compression, not distraction
These principles are essential for durable correction and avoiding junctional complications.
Complications
Complications of Treatment
| Complication | Incidence | Prevention/Management |
|---|---|---|
| Junctional kyphosis (PJK) | 10-20% | Appropriate fusion levels, avoid flat-back |
| Neurological injury | Less than 1% | Neuromonitoring, careful correction |
| Pseudarthrosis | 5-10% | Adequate bone graft, avoid smoking |
| Infection | 1-3% | Prophylactic antibiotics, meticulous technique |
| Hardware failure | Variable | Adequate fixation, patient compliance |
| Bracing skin issues | Common | Padding, skin checks, brace adjustments |
Proximal Junctional Kyphosis (PJK)
PJK is the most common complication after kyphosis surgery. Occurs at the level above the instrumentation. Risk factors: osteoporosis, stopping fusion at kyphotic segment, excessive correction. Prevention includes ending fusion at lordotic vertebra, avoiding overcorrection, and hooks/wires at proximal level.
Postoperative Care and Rehabilitation
Post-Surgery Protocol
ImmediateHospital (Days 1-5)
- Mobilize day 1-2 with physiotherapy
- Wean pain control, oral medications
- Drain removal when output minimal
- Wound check before discharge
EarlyWeeks 1-6
- Limited activity, no bending/twisting/lifting
- Walking encouraged, increase distances
- Wound care, monitor for infection
- May use brace if surgeon preference
IntermediateWeeks 6-12
- Gradual increase in activity
- May return to school/desk work
- No sports or heavy activity
- X-rays to assess alignment
RecoveryMonths 3-12
- Progressive return to activities
- Sports typically 6-12 months
- Physical therapy for core strength
- Final X-rays at 1-2 years
Conservative Treatment Rehabilitation:
- Physiotherapy ongoing during bracing
- Exercises continued after brace weaning
- Postural awareness lifelong
- Activity modification if symptomatic
Outcomes
Conservative Treatment Outcomes:
- Bracing effective in preventing progression if criteria met
- Rarely achieves significant correction of established deformity
- Good long-term function for curves less than 75°
- Back pain may persist, usually manageable
Surgical Outcomes:
- High satisfaction rates (greater than 90%)
- Correction from average 75° to 45-50°
- Pain improvement in most patients
- Return to full activities 6-12 months
- Long-term fusion outcomes generally good
Evidence Base
Natural History of Scheuermann Kyphosis
Murray PM et al • J Bone Joint Surg Am (1993)
Key Findings:
- Long-term follow-up of untreated Scheuermann patients
- Back pain more common than controls but rarely disabling
- Most patients function well without treatment
- Severe curves (greater than 75°) more likely to be symptomatic
Clinical Implication: Many patients with mild-moderate Scheuermann have acceptable outcomes without aggressive treatment. Severity guides intervention.
Limitation: Retrospective study, historical cohort.
Bracing for Scheuermann Kyphosis
Sachs B et al • Spine (1987)
Key Findings:
- Milwaukee brace effective in skeletally immature patients
- Average 5-10° correction during bracing
- Maintenance of correction after weaning in compliant patients
- Compliance is the major determinant of outcome
Clinical Implication: Bracing is effective but requires strict compliance. Best results in immature patients with curves 50-75°.
Limitation: Variable compliance reporting, no control group.
Posterior-Only vs Combined Approach
Lim M et al • Spine (2012)
Key Findings:
- Comparison of posterior-only with posterior osteotomies vs combined anterior-posterior
- Similar correction achieved with both approaches
- Lower morbidity with posterior-only approach
- Anterior approach reserved for very rigid curves
Clinical Implication: Posterior-only with osteotomies is the preferred approach for most patients. Combined approach rarely needed with modern techniques.
Limitation: Retrospective comparison, selection bias.
Proximal Junctional Kyphosis Prevention
Yagi M et al • Spine (2011)
Key Findings:
- PJK incidence 10-20% after kyphosis surgery
- Risk factors: older age, larger correction, termination at kyphotic level
- Hooks or wires at proximal level may reduce risk
- Patient factors (bone quality) also important
Clinical Implication: End fusion at lordotic vertebra, use transitional fixation proximally, avoid overcorrection to minimize PJK risk.
Limitation: Retrospective analysis, multiple confounding factors.
Long-Term Surgical Outcomes
Lonner BS et al • Spine (2007)
Key Findings:
- Minimum 5-year follow-up of surgical patients
- Maintained correction, high satisfaction
- Adjacent segment degeneration minimal
- Return to full activities including sports
Clinical Implication: Surgical correction for Scheuermann kyphosis provides durable correction with good long-term patient satisfaction.
Limitation: Single-center experience, selected patient population.
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
VIVA SCENARIOStandard
Scenario 1: Adolescent with Round Back
EXAMINER
"A 14-year-old boy presents with progressive round back posture noticed by his parents over the past year. He complains of mild mid-back pain after prolonged sitting. How would you differentiate Scheuermann kyphosis from postural kyphosis?"
EXCEPTIONAL ANSWER
The key is the **hyperextension test**. I would have the patient lie prone and hyperextend the spine, or extend over my arm while standing. In **postural kyphosis**, the curve corrects completely - it is flexible and non-structural. In **Scheuermann kyphosis**, the curve remains fixed - it is rigid and structural.
Additionally, on **forward bend testing**, Scheuermann has an angular apex at the thoracic region, while postural kyphosis shows a smooth, rounded curve.
**X-rays would confirm Scheuermann** if there is kyphosis greater than 45° with 3+ consecutive vertebrae each wedged greater than 5°, plus endplate irregularities and Schmorl nodes.
**Follow-up: His X-ray shows 60° thoracic kyphosis with vertebral wedging. Risser sign is 1. What is your management plan?**
This patient meets criteria for **bracing**. He has Scheuermann kyphosis with 60° curve (between 50-75° treatment range), and is skeletally immature with Risser 1 (significant growth remaining).
My management would include:
1. **Milwaukee brace or TLSO** worn 16-23 hours/day until skeletal maturity
2. Concurrent **physiotherapy program** focusing on core strengthening, hamstring and hip flexor stretching, and postural training
3. Regular follow-up every 4-6 months with standing X-rays to monitor curve
4. Activities modification - avoid heavy lifting
Goal is to **prevent progression** during remaining growth, not necessarily to correct the deformity significantly.
**Follow-up: What would make you consider surgery instead?**
I would consider surgery if:
1. **Kyphosis exceeds 75°** - this is the primary surgical threshold
2. Curve **progresses despite compliant bracing**
3. **Intractable pain** not responding to conservative treatment
4. **Neurological symptoms** develop - rare but thoracic disc herniation or cord compression can occur
5. Significant **cosmetic concern** in a skeletally mature patient
The surgery would typically be **posterior spinal fusion** with pedicle screw instrumentation, using **Ponte osteotomies** to improve correction. The goal is to reduce kyphosis to around 45-50° and achieve solid fusion.
KEY POINTS TO SCORE
Hyperextension test differentiates Scheuermann (rigid) from postural (flexible)
Bracing for 50-75° in immature patients (Risser 0-3)
Surgery threshold is greater than 75° or failed conservative treatment
Posterior-only fusion with osteotomies is standard surgical approach
COMMON TRAPS
✗Bracing a skeletally mature patient (ineffective)
✗Missing associated scoliosis (30% have both)
✗Not checking for neurological symptoms
LIKELY FOLLOW-UPS
"What is proximal junctional kyphosis?"
"How long does bracing continue?"
VIVA SCENARIOChallenging
Scenario 2: Failed Bracing Treatment
EXAMINER
"A 16-year-old girl with known Scheuermann kyphosis returns after completing 2 years of bracing. Her curve has progressed from 55° to 70° despite reported compliant brace wear. She now has daily back pain. Why might the kyphosis have progressed despite bracing?"
EXCEPTIONAL ANSWER
Several factors could explain progression despite reported compliance:
1. **Actual non-compliance** - patients may report wearing brace but actual wear time is less. In-brace monitoring sensors show many patients wear braces less than prescribed.
2. **Insufficient brace correction** - brace may not have been adequately correcting the curve in position.
3. **Rapid growth spurt** - deforming forces may have exceeded brace effect during peak growth.
4. **Curve too stiff initially** - some curves are not amenable to bracing correction.
5. **Incorrectly fitted brace** - may not have been applying appropriate corrective forces.
I would review in-brace X-rays from during treatment and honestly reassess compliance history.
**Follow-up: She is now Risser 4. What are your options?**
At Risser 4, she is near skeletal maturity so **bracing is no longer effective**. With a 70° curve and daily pain, my options are:
1. **Conservative management** with physiotherapy, activity modification, and pain management - reasonable if pain is tolerable and curve is not progressing.
2. **Surgical intervention** - becoming more indicated given the 70° curve with progression and pain. This is approaching the 75° surgical threshold.
I would discuss with her and family that surgery would aim to correct the kyphosis, relieve pain, and prevent further progression. Given her age and the trend, continued observation alone is less attractive. Surgery would be **posterior spinal fusion with osteotomies**.
**Follow-up: She opts for surgery. Discuss the surgical planning.**
Surgical planning for this case:
1. **Fusion levels** - typically T2 or T3 proximally to the upper end vertebra, and distally to the first lordotic vertebra to avoid junctional issues (likely L1 or L2).
2. **Approach** - posterior-only with **Ponte osteotomies** at multiple levels to improve flexibility for correction. At 70° the curve should be correctable posteriorly.
3. **Instrumentation** - pedicle screws at all levels (possibly hooks at proximal end), dual rods.
4. **Correction** - sequential compression across the apex. Goal is 45-50° final kyphosis.
5. **Neuromonitoring** throughout.
6. **Bone graft** - local autograft with allograft supplement.
I would counsel about **PJK risk (10-20%)**, neurological risk (less than 1%), infection, and pseudarthrosis. Recovery is 6-12 months to full activity.
KEY POINTS TO SCORE
Compliance is the major determinant of bracing success
Bracing is ineffective after skeletal maturity
70° with progression and pain is indication for surgical discussion
Posterior fusion with osteotomies is standard approach
COMMON TRAPS
✗Continuing bracing in mature patient
✗Not addressing compliance honestly
✗Not discussing PJK risk with patient
LIKELY FOLLOW-UPS
"What is a Ponte osteotomy?"
"How would you minimize PJK risk?"
VIVA SCENARIOCritical
Scenario 3: Neurological Emergency
EXAMINER
"A 15-year-old with severe Scheuermann kyphosis (85°) presents with new onset lower limb weakness over 2 weeks. He has difficulty walking and describes numbness in both legs. What is your immediate concern and management?"
EXCEPTIONAL ANSWER
This is a **neurological emergency**. My immediate concern is **thoracic spinal cord compression**, which can occur in severe Scheuermann kyphosis from thoracic disc herniation or direct cord compression from the deformity.
**Immediate management:**
1. Full neurological examination documenting motor and sensory levels
2. **Urgent MRI spine** to assess cord compression and identify cause
3. Neurosurgery/spinal surgery consultation **immediately**
4. High-dose corticosteroids may be considered if cord compression confirmed
5. Admission for close monitoring
If MRI shows significant cord compression, **urgent surgical decompression** may be required. This takes precedence over elective kyphosis correction.
**Follow-up: MRI shows T6-T7 disc herniation causing cord compression. How does this change your surgical approach?**
The thoracic disc herniation with cord compression changes the surgical approach significantly:
1. **Priority is cord decompression** which is urgent.
2. **Anterior approach may be needed** for safe thoracic disc excision - a posterior approach risks pushing disc further into the cord. Thoracotomy or thoracoscopic discectomy at T6-T7 would allow safe disc removal under direct vision.
3. After decompression, I would address the kyphosis - this may be **staged** (anterior decompression first, then posterior fusion later) or combined depending on the clinical situation.
4. **Posterior fusion alone** without addressing the disc would not decompress the cord and could worsen compression with correction maneuvers.
Close collaboration between spine surgeons experienced in both deformity and thoracic disc surgery is essential.
**Follow-up: What is the prognosis for neurological recovery?**
Prognosis depends on several factors:
1. **Duration of symptoms** - 2 weeks of progressive symptoms is subacute; early decompression gives better outcomes.
2. **Severity of deficit** - incomplete deficits have better recovery potential than complete cord syndromes.
3. **Imaging findings** - cord edema vs myelomalacia affects prognosis.
4. **Speed of decompression** - urgent surgery improves outcomes.
In general, if decompression is performed promptly for incomplete thoracic cord compression, **significant recovery is possible**, though some residual deficit may persist. Complete cord injuries have poor recovery. I would counsel the family that recovery may take months, may not be complete, and intensive rehabilitation will be required post-operatively.
KEY POINTS TO SCORE
Neurological deficit in Scheuermann is a surgical emergency
Thoracic disc herniation can cause cord compression
Anterior approach may be needed for safe disc decompression
Early decompression improves neurological outcomes
COMMON TRAPS
✗Delaying imaging in patient with neurological symptoms
✗Attempting posterior-only approach when disc needs excision
✗Forgetting that kyphosis correction can worsen cord compression
LIKELY FOLLOW-UPS
"What steroid protocol would you use?"
"How would you approach a central thoracic disc?"
MCQ Practice Points
Diagnostic Criteria
Q: What are the Sorensen criteria for Scheuermann kyphosis? A: Thoracic kyphosis greater than 45° with 3 or more consecutive vertebrae each having greater than 5° anterior wedging. Supportive findings include Schmorl nodes, endplate irregularities, and disc space narrowing.
Hyperextension Test
Q: How do you differentiate Scheuermann from postural kyphosis clinically? A: Hyperextension test - Scheuermann does NOT correct (rigid, structural). Postural kyphosis corrects fully (flexible, non-structural).
Bracing Criteria
Q: When is bracing indicated for Scheuermann kyphosis? A: Kyphosis 50-75° in skeletally immature patients (Risser 0-3) with greater than 1 year growth remaining. Bracing is ineffective after skeletal maturity.
Surgical Threshold
Q: What is the surgical threshold for Scheuermann kyphosis? A: Greater than 75° kyphosis, or progressive curve despite bracing, or intractable pain, or neurological symptoms.
Medicolegal Considerations
Documentation Points:
- Document hyperextension test result (rigid vs flexible)
- Record Cobb angle and vertebral wedging measurements
- Document skeletal maturity assessment (Risser sign)
- Record neurological examination findings
- Document bracing compliance discussions
Consent for Surgery:
- Proximal junctional kyphosis risk (10-20%)
- Neurological injury risk (less than 1%)
- Pseudarthrosis, infection, hardware failure
- Blood loss and transfusion possibility
- Long fusion and loss of motion
Missing Neurological Symptoms
Although rare, thoracic cord compression can occur with severe Scheuermann kyphosis. Document neurological examination at each visit. Missing progressive weakness could lead to delayed treatment and worse outcomes.
Australian Context
Epidemiology:
- Similar prevalence to international data
- Managed at pediatric spine centers and adult spine services
Access to Care:
- Specialized spine surgery available at major centers
- Bracing services through orthotists
- Interstate referral may be needed for complex cases
Bracing:
- Milwaukee brace and TLSO available through orthotics services
- Some private health insurance coverage
- Compliance remains the major challenge
High-Yield Exam Summary
Diagnosis
- •Kyphosis greater than 45° (Cobb angle)
- •3+ consecutive vertebrae with greater than 5° wedging each
- •Schmorl nodes, endplate irregularities
- •Hyperextension test: does NOT correct (rigid)
Bracing
- •Kyphosis 50-75°
- •Risser 0-3 (immature)
- •Greater than 1 year growth remaining
- •16-23 hours/day until maturity
Surgery
- •Kyphosis greater than 75°
- •Progressive despite bracing
- •Intractable pain
- •Neurological symptoms
Surgical Approach
- •Posterior fusion with pedicle screws
- •Ponte osteotomies for correction
- •Anterior release rarely needed
- •Goal: 45-50° final kyphosis
Complications
- •PJK 10-20% (most common)
- •Neurological less than 1%
- •Pseudarthrosis 5-10%
- •End fusion at lordotic vertebra