Scoliosis and

Kyphosis

Definition



Scoliosis is a postural deformity of the

spine resulting in a lateral (coronal)

deviation, or curve.



Scoliosis is commonly associated with

rotation of the vertebral bodies located

within the curve.



It affects between 3% and 30% of the

population, with its incidence increasing with

age.



The scoliotic curve may be congenital, appearing

during infancy (infantile scoliosis), or develop in

childhood (juvenile scoliosis), adolescence

(adolescent scoliosis), or adulthood (degenerative

scoliosis).



When the diagnosis of scoliosis is made in an

adult patient, the curve should be defined as

adult onset (usually degenerative) or adult

presenting (most commonly an idiopathic

adolescent curve that was not previously

diagnosed).



Scoliosis can result from congenital,

degenerative, disease-related, or

idiopathic causes.



An idiopathic etiology of scoliosis is more

common than scoliosis due to other

causes, such as degenerative disc disease

and spondylosis, congenital malformation

of the vertebrae, tumor, neuromuscular

disease, or connective tissue disease.



Kyphosis is defined as a sagittal deviation in spinal

alignment, or backward curve exceeding normal

values.



Normal kyphosis in the thoracic spine varies between

20 and 40 degrees.



Pathologic kyphosis occurs in association with

structural changes in the spine due to pathology

such as osteoporotic compression fractures, tumor,

or Scheuermann's disease (juvenile kyphosis).



It is caused by the resulting wedge deformity of the

vertebral bodies.

Symptoms

Scoliosis



The symptoms produced by scoliosis relate to

the etiology, location, and severity of the

curve.



The curve itself often does not produce

symptoms or complaints, particularly a curve

that does not exceed 20 degrees.



When scoliosis is severe, pain and cosmetic

deformities occur.



Deformity, such as humping of the back,

asymmetric shoulder or hip height, or asymmetry

of breast size or waist contour may produce

psychosocial symptoms such as low self-esteem,

anxiety, and depression.



These may be the presenting complaints.



Curves that exceed 60 degrees begin to affect

other systems.



They can produce shortness of breath due to
restrictive lung disease; weakness, pain,
paresthesia; or hypesthesia due to compression
or impingement of nerve roots; and impaired
activity tolerance due to increased energy costs
for maintaining trunk stability.



Severe lumbar curves commonly produce low
back pain, whereas severe thoracic curvature
often results in psychosocial symptoms.

Kyphosis



Complaints relate to the degree and location of

the kyphos.



Intermittent aching back pain and stiffness are

the most usual presenting complaints and are

most prominent at the apex of the kyphos. Pain

and stiffness may be most severe when the

patient is leaning forward.



A compensatory increase in lumbar lordosis, with

or without spondylolysis, may be present and

associated with low back pain.



Cardiopulmonary compromise, though unusual,

can also develop in severe cases, causing

shortness of breath, fatigue, and poor activity

tolerance.

Physical Examination

Scoliosis:



Minor curves are difficult to detect on inspection of the

patient.



An easy way to detect a subtle thoracic or lumbar curve is to

drop a plumb line from the occiput, or C7 spinous process,

and inspect the spine for lateral deviations from this line.



Have the patient bend forward, because the rotation

associated with scoliosis is most easily seen in the forward

flexed position.



Asymmetry of the back contour in this position is due to

vertebral body or rib rotation and may be quantified.



A trunk rotation angle of 7 degrees roughly corresponds to

a coronal curve of 20 degrees.



Subtle indicators that can be sought on physical

examination include apparent (not actual) unequal breast

size, asymmetry of the waist fold contour, or unequal iliac

crest and shoulder height.



Scoliosis should be suspected when café au lait spots (often

associated with neurofibromatosis) or a leg-length

discrepancy exceeding 2.2 cm is present.



Thorough serial assessments are advisable every 6 to 12

months.



These assessments usually include x-rays and should

focus on the degree of curvature, location and extent

of the curve, degree of rotation, degree of skeletal

maturity, correctibility of the curve, height, vital

capacity, and expiratory pulmonary function tests.



Patients with degenerative scoliosis should be

examined for neurologic deficits.



Lower extremity strength, sensation, and reflexes

should also be checked when the curvature exceeds

40 degrees or when the patient complains of

weakness, paresthesias, or decreased sensation

regardless of the etiology of the scoliosis.



A full evaluation of a scoliotic curve necessitates

identification of the etiology of the curve for

optimal treatment and prognostication.



Curves may be idiopathic (juvenile, adolescent),

functional (muscle spasm, posture), congenital

(vertebral malformation), or degenerative or

paralytic (motor unit disease).



Scoliosis should be treated in the context of a

patient's global status, and identifying underlying

or idiopathic causes of the curve allows care to be

provided within the context of the patient's overall

health.

Kyphosis



Increased thoracic kyphos results in a forward

displacement of the head and neck and a

compensatory increase in lumbar lordosis.



These are apparent on inspection.



The rounding of the back will not fully correct with

trunk extension in a prone position, but the degree to

which the curve reverses should be noted.



Thoracolumbar and lumbar kyphoses are less readily

appreciated on inspection.



The clinician should note any prominence of the

spinous processes, which indicates lower spine

kyphosis.



Associated scoliosis should be sought and will be

present in about one third of patients.



Restricted trunk extension results from either

deformity or pain.



Tenderness to palpation may be elicited over the

spinous processes.



Tightness of the hamstring and pectoralis

muscles is common.



A neurologic examination should be performed

when the patient complains of weakness, sensory

changes, or gait abnormalities.



Vital capacity, peak flow, and other expiratory

respiratory parameters should be performed

when the kyphosis exceeds 40 to 50 degrees.

Functional Limitations



The functional limitations related to scoliosis and

kyphosis result from the loss of spinal motion.



A kyphosis related restriction in upward gaze may

affect driving and cause difficulty with lying prone or

swimming in a prone position.



Loss of shoulder range of motion, particularly forward

flexion and abduction, may result from restricted

scapular excursion over the thorax.



This can interfere with overhead activities of daily

living.



Pain can result in limited sitting, standing,

or walking tolerance.



The disruption of spinal balance that

occurs will displace the center of gravity,

particularly with severe kyphosis.



This increases the energy costs for

standing and ambulation.



It can also impair balance.



With severe deformity, cardiopulmonary
compromise may decrease endurance.



If the patient perceives cosmetic
deformities as severe, social isolation can
result.

Diagnostic Studies



Standing anteroposterior (AP) and lateral x-rays are

useful in the evaluation of scoliosis and kyphosis.



Bending or supine radiographs are not usually done

but can help to determine the flexibility or

correctability of the curve.



X-rays can reveal congenital abnormalities of the

vertebral body that cause spinal imbalance (block,

bar, butterfly vertebrae), evidence of Scheuermann's

disease (endplate fluting), or the lateral vertebral

body wedging that is characteristic of idiopathic

scoliosis.



Measurement of the scoliotic curve on plain films is done by

either the Cobb or Risser method.



The most common measurement, the Cobb angle, is determined

by the intersection of two lines drawn perpendicular to the

vertebral endplates that represent the maximal deviation of the

spine.



Plain films also allow assessment of vertebral body rotation and

the growth centers in the ilium, vertebrae, and humerus.



The degree of vertebral body rotation is gauged by the deviation

from the midline of either the spinous process or pedicles.



Rotation is graded 0 (no rotation) to 4 (rotation of 90 degrees or

more).



Epiphyseal closure can sometimes be assessed by

plain films.



Closure of the growth plates proceeds in a

cephalad manner.



Since vertebral growth plates are not consistently

demonstrated on plain films, the iliac crest is a

useful site for assessing spine growth status.



This is Risser's sign, which is graded 0 (no

mineralization) to 5 (fusion of the growth plate).



Magnetic resonance imaging (MRI), computerized

tomography (CT), and nuclear medicine scans are

indicated for specific purposes, such as identifying a

neurofibroma or diastomatomyelia.



If a neurologic deficit is present, MRI or CT should be

performed to delineate the lesion.



Electrodiagnostic studies are a useful adjunct to

these tests for grading the severity of the lesion and

prognostication.



If surgery is being considered, preoperative MRI or

CT myelogram is indicated.



Bone scans are helpful to exclude discitis or
tumor as the cause of pain or spinal deformity.



Pulmonary function testing, particularly volume
and expiratory studies, should be performed
when curves exceed 60 degrees.

Treatment



In all patients, regardless of age, it is important to

identify curves that are likely to be progressive.



Curves that are large (degree of curvature), closely

packed (spanning a relatively small spinal segment),

related to congenital vertebral body malformation, and

very rotated or occur in the immature spine require

more aggressive intervention.



In general, scoliotic curves less than 20 degrees and

kyphotic curves less than 40 degrees are observed

through serial assessment.



NSAIDs/COX-2 inhibitors or analgesics may be used for

pain management.



Transcutaneous electrical nerve stimulation

(TENS) may also be used to manage pain.



If the scoliosis exceeds 20 degrees or the

kyphosis exceeds 40 degrees, assess for bracing

or surgery.



The treatment goal for idiopathic curves is to limit

progression of the scoliosis or kyphosis and

maintain full activity, independence, and comfort.



This is best done with patient education, exercise,

and bracing.

Rehabilitation



Exercise is beneficial for general well-being, flexibility, and

to improve posture.



There is no clear evidence that exercise is a disease-

modifying intervention for
idiopathic scoliosis.



Kyphosis may improve with cervicothoracic extension

exercise; pelvic tilt to reduce lumbar lordosis; and

stretching/strengthening exercise of the hamstring, hip

flexor, and pectoralis muscles.



Exercise, particularly spinal extension, abdominal

strengthening, and hamstring stretch, is also helpful to

reduce back pain.



Bracing is an important part of the rehabilitation

intervention.



There is no consensus regarding recommended brace wear-

time per day; recommendations range between 8 and 23

hours of daily wear.



Some correction of the curvature may take place with

conscientious use of the orthosis, although the goal of

orthotic treatment is to reduce pain and limit progression of

the curve.



The most common brace selection is a body jacket

thoracolumbosacral orthosis (TLSO) such as the Boston or

Denver brace.



High thoracic and cervical curves and kyphotic curves may

require a Milwaukee cervicothoracolumbosacral orthosis

(CTLSO).



Bracing for idiopathic curves in a growing child or

adolescent is maintained until spinal growth centers fuse.



When a TLSO body jacket or corset is used to decrease pain

and improve posture for patients with degenerative

scoliosis, wear time depends on symptoms.



For scoliosis associated with neuromuscular diseases,

bracing is often withheld if the patient is ambulatory.



When a body jacket is provided, an abdominal

window is needed to allow respiratory excursion.



Contoured or custom molded seating systems

that align and support the trunk are useful.



These allow the child, adolescent, or adult to

maintain an upright posture while seated,

improving head control and hand function.

Procedures

There are no invasive procedures indicated for
the treatment of scoliosis or kyphosis.

Surgery



Surgical procedures attempt to restore spinal balance.



The goal of surgery is to stabilize the spine through

correction or control of the deformity. Improved

cosmesis is a secondary goal.



Restoring lumbar lordosis is important.



Indications for surgical correction of scoliosis or

kyphosis include progressive deformity, instability,

progressive or new neurologic deficit, and

cardiopulmonary compromise.



Surgical stabilization of the spine for scoliosis

associated with neuromuscular disease is

performed earlier than for curves due to other

causes.



Pain, even when refractory to conservative

management, is a controversial indication for

surgery.



Inability to use a brace, and severe cosmetic

deformity may be relative indications for surgery

in specific instances.

Scoliosis



Surgery addresses the coronal and rotational

deformities by derotation and, less commonly,

distraction.



Any spinal instability is eliminated through

compression or bony fusion.



Spine surgery may be complemented by rib resection

in an attempt to improve appearance.



The postoperative management of surgical patients

varies according to the etiology of the curve, age of

the patient, and specifics of the surgery.



Some patients may be placed in a cast or body

jacket to immobilize the operated segment until

bony fusion occurs.



Cotrel-Dubbousset instrumentation and its

various modifications that derotate the spine

commonly do not require fusion, immobilization,

or rib resection.



Other surgical procedures such as osteotomy or

laminectomy are done as appropriate.

Kyphosis

Various surgical approaches have been
used, but anterior plus posterior
instrumentation with fusion currently
provides the highest success rate for
lasting correction and pain relief.

Potential Disease

Complications



Complications of scoliosis or kyphosis result from

the structural and degenerative changes that

occur in the spine, along with secondary tightness

or restriction due to soft tissue shortening.



An increased incidence of spondylosis, facet

arthropathy, spondylolisthesis, and spondylolysis

is associated with large curves and correlates

with the angle and rotation at the curve apex.



Such degenerative changes related to the curve

are the most common causes of pain, but

scoliosis can also produce discogenic pain.



Foraminal, recess, or canal stenosis can occur with

resulting neurologic compromise.



Root entrapment usually occurs on the concave side

of the curve (rarely both convex and concave sides).



Cauda equina compression has also been reported.



Lumbar spinal stenosis due to scoliosis can

sometimes be differentiated from other types of

stenosis because the disease and symptoms are

more structural than positional.



Patients often will not report relief of symptoms

when sitting.



Restrictive lung disease may occur as a

complication of scoliotic curves exceeding 40

degrees or kyphosis in excess of 50 degrees, and

cor pulmonale can complicate severe kyphosis or

scoliotic curves in excess of 110 degrees.

Potential Treatment

Complications



Most treatment complications relate to surgery or bracing.



Reported complications of bracing include skin breakdown;

dermatitis due to an allergy to the orthotic material; hyperhidrosis;

cutaneous infection; gastroesophageal reflux disease (GERD);

esophagitis; altered gastrointestinal motility; and psychosocial

complications including low self-esteem, altered body image, and

depression.



Surgery may cause vascular or neurologic injury, pseudarthrosis,

infection, graft donor site pain, progressive pelvic obliquity, painful

degenerative changes in the segment adjacent to the level of

fusion, instability, hardware prominence or failure, and

thromboembolism.



Hardware complications include slippage of anchoring hooks,

bending or fracture of a rod, wire pull-out, and migration of the

hardware.



Progression of the curve is possible despite surgical fixation.



In the growing adolescent the crankshaft phenomenon—

progressive deformity resulting from continued growth of the

anterior spine after posterior arthrodesis—may occur.



This results in further loss of spinal balance, but is usually not

problematic.



The patient with degenerative scoliosis who has undergone

otherwise successful surgery may continue to experience pain

or restricted mobility.



Exercise related complications are less common but include

overuse conditions of the soft tissues (tendinitis, bursitis,

sprain, strain). Complications following NSAID therapy are

possible, particularly in the gastric, renal, and hepatic systems.