Most common causes of Kyphosis in children include Scheuremann’s disease, Congenital malformation and neuromuscular disease. Typical characteristic findings in Scheuremann Kyphosis include irregular endplates, vertebral wedging and Schmorl’s nodes. Congenital Kyphosis usually result from defects of formation with resultant posterior hemivertebra and segmentation defects with anterior bar. Neuromuscular Kyphosis in children result from muscular imbalance due to a myopathic condition or neurologic dysfunction with asymmetric paralysis or weakness
Scheuremann’s Kyphosis (Adolescent Roundback)
- Prevalence: 0.4- 8.0% of general population
- Its more common in males than females
- Etiology: No definite conclusion but implicated are the following
- Hormonal abnormalities
- Histologic Changes
- Avascular necrosis
Surgical indications in Scheuremann’s Kyphosis include kyphosis greater than 75° in adolescents and adults, pain, deformity unresponsive to brace and Cosmesis. Most cases can be adequately treated with current posterior segmental instrumentation such as pedicle screws and obviate the need for anterior releases in order to reduce postoperative morbidity. A recent study comparing Kyphosis correction by anterior versus posterior only pedicle screw approach showed that, posterior only conserved and maintained better kyphosis correction than with combined fusion; with less complications.
This is highly progressive and surgery is mainstay of treatment. Operative choices available are:
- Posterior Spine Fusion
- Ant/-post Spine Fusion
- Posterior Pedicle Subtraction
- Posterior Vertebral Column Resection
Posterior only procedures are adequate for formation defects with deformity less than 50° and an age below 5 years. Consider augmentation of fusion if no implant is used. Combined procedures are considered for older child or adult Complex rigid deformities. Consider kyphectomy/resection and anterior strut graft with posterior stabilization for sharp angular deformities and segmentation defects.
Recent surgical advances have included the technique of Posterior Vertebral Column Resection.
- Curves exceeding 180 degrees have been classified at our center as (Gamma Deformity) which can be effectively unwound with long term Halo gravity traction prior to definitive surgery.
- High IOM alerts are common with high neurologic complication.
- The procedure is technically challenging and has a high complication rate.
A FOCOS Review of 14 patients with Gamma Deformity results showed:
- Pre operation Coronal vertebral translation average was 75% (27% – 100%) was corrected in all cases post operation.
- Sagittal deformity average was 211deg (184-241deg). After using the HGT, the deformity improved by 36%. and averaged Post Operation Sagittal deformity of 53deg (74% correction).
- Pre operation Thoracic kyphosis averaged -42deg (-7 to -107) and was corrected to post operation average of 53deg (27-100deg).
- Intra-op spinal cord monitoring alerts in 8 patients (57%) and post op neuro deficits occurred 5 patients (36%). One patients remained paraplegic. (7%)
- There was one pop mortality. (7%)
- There were no deep infections.
- 1 Broken Rod at 2 yrs. post op who was revised and went on to heal
Surgical indications for neuromuscular Kyphosis include progressive postural deformity, pain and loss of function. Most patients can be treated with posterior only procedures to reduce morbidity. Primary goal is curve stabilization
In general surgery for Kyphosis has a higher complication than Idiopathic scoliosis surgery and ranges from 0.6 to 15percent.
CEO, FOCOS Orthopedic Hospital
Orthopedic Surgeon, FOCOS Orthopedic Hospital