- Discussion: 
      - most common cause of structural kyphosis of thoracic & thoracolumbar spine;
      - most commonly seen in skeletally immature adolescents; 
      - there is usually a strong hereditary tendency (may be autosomal dominant); 
      - etiology is not known; 
      - criteria for diagnosis: 
             - thoracic kyphosis > 45 deg (25 to 40 deg being normal);  
             - wedging > 5 deg of three adjacent vertebrae 
             - thoracolumbar kyphosis > 30 deg (thoracolumbar spine is normally straight); 
       - associated conditions: 
             - spondylolysis:
                      - scheurermanns' disease causes increased lumbar lordosis which strains L5 pars interarticularis; 
             - scoliosis: occurs in 25%; 

- Clinical Findings: 
        - hyperkyphosis that doesn't reverse w/ hyperextension; 
        - tight hamstrings; 
        - poor posture; 
        - back pain located over apex of kyphosis; 
        - back pain involving lower lumbar spine when excessive lordosis is present; 
        - associated neurological deficits are uncommon; 
        - where as thoracic Scheurman's is not usually associated w/ pain, lumbar Scheurman's is often symptomatic; 

- Diff Dx: 
        - postural roundback: 
        - these patients will have a flexible roundback and no wedging on x-rays; 
        - rickets 
        - juvenile osteoporosis 
        - neurofibromatosis 
        - Morquio's  
        - spondyloepiphyseal dysplasia tarda 

- Radiographs: 
       - required views:  
             - lateral x-ray, made w/ pt lying supine over bolster; 
             - this will hyperextend spine, & will show if deformity is correctable; 
             - lateral standing view: required for diagnosis; 
- criteria for diagnosis: (lateral standing x-ray); 
       - thoracic kyphosis > 45 deg (25 to 40 deg being normal); 
       - thoracolumbar kyphosis > 30 deg (thoracolumbar spine is normally straight); 
       - wedging > 5 deg of three adjacent vertebrae 
       - kyphotic angle > than 45 degrees is considered to be abnormal; 
       - misc: - apex of the deformity is usually located at the level of T7 & T8; 
                - Schmorl nodes (end plate erosion) is a common finding; 
                - irregularity & flattening of vertebral end-plates; 
                - narrowing of vertebral disc spaces; 
                - varying degrees of Scoliosis in approx one-third of patients; 

- Non Operative Treatment: 
        - natural history: pain usually subsides at end of growth unless deformity is severe; 
        - curve < 50 deg: 
        - young adolescents w/ kyphotic deformity of < 50 deg & no evidence of progression may be observed; 
        - exercise & stretching of hamstrings & back may prevent excessive lordosis and hamstring contractures; 
        - bracing to correct thoracic kyphosis may be useful in pts w/ pain; 
        - curve of 50 to 70 deg: 
        - braces are worn for 1 year around the clock & then at night for 2 years; 
        - unlike scoliosis, bracing after skeletal maturity may be effective, and permanent correction can be obtained; 
        - Milwaukee brace is required for thoracic curves; 
        - TLSO is required for curves below T-8; - progressive curve > 60 - 65 deg 
        - Milwaukee brace is required even if patient has no pain;
        - better prognosis for correction in skeletally immature patients; 
        - w/ good compliance in brace, expect correction of deformity at 1-2 years; 
        - misc: - hamstring stretching is useful in the presence of contracture; 

- Operative Treatment: 
        - indications: - thoracic kyphosis > 75 deg 
        - persistent back pain that is unresponsive to non operative treatment; 
        - rigid kyphosis > 55 deg; 
                 - requires anterior release w/ interbody fusion followed by posterior fusion w/ compression instrumentation 

The natural history and long-term follow-up of Scheuermann kyphosis. 

The surgical management of patients with Scheuermann's disease: a review of twenty-four cases managed by combined anterior and posterior spine fusion.

Vertebral osteochondrosis (Scheuermann's kyphosis).