Sheuermann disease

1. SHEUERMANN DISEASE
Dr. sajil krishna k

2. • Structural kyphosis of thoracic or thoracolumbar spine
• Unknown etiology
• Incidence: 0.4-10% of adolescent ( 10- 14 years of age)
• Onset: during prepubertal growth spurt, apparent at around 10-12
years of age
• Sex: M>/=F

3. Definition
• Normal kyphosis of thoracic spine(scoliosis research society)
– 20-45 degree( T1- T12)
• Angulation >45 degree – hyperkyphosis
• Normal lumbar lordosis :- 50-70 degree ( L1-S1)
• Normal thoraco lumbar junction : 0-10 degree
• Sagittal gravity line passes through spinous process of T1, T 12 and
sacral promontory.

4. • Characterised by
vertebral wedging
thoracic kyphosis of >40 degree
>5 degree anterior wedging of 3 consecutive adjacent vertebral
bodied at apex of kyphosis
Schmorl’s nodes
Irregualr end plate
Narrowing of vertebral disc space
Increased vertebral AP diameter at apex

6. History
• Initially known as “Apprentice or muscular kyphosis”
• Holger Werfel Scheuermann (1921) described as “ Kyphosis dorsalis
juvenilis”

7. Aetiopathogeneis ( theories)
• Scheuermann vertebral epiphyseal disturbance theory
• Schorml et al – vertebral wedging caused by herniation of disc
material into vertebral body
• Ferguson et al – anterior vascular groove in v. body- structural
weakness- wedging- kyphosis
• Bradford et al – secondary to vertebral osteoporosis during juvenile
period
• Ippolito and ponseti et al :- biomechanical abnormality of collegen
and matrix od v. body end plate cartilage

8. • Frank Damborg et al : genetic theory
• Mechanical factors:
supported by bracing therapy as treatment, commonly seen in heavy
weight lifting or manual labour

9. Anatomic and histological changes
• Gross:
* thickened ALL
* narrowed vertebral disks
* wedging of vertebral bodies

10. • Histology
* abnormality of cartilaginous endplate include disorganized
endochondral ossification
• Collagen
* proteoglycan ratio in endplate matrix is low
* results in alteration in ossification of endplate causing altered
vertical growth

11. Types
1. Typical scheuermann disease
2. Atypical scheuermann disease

12. Typical scheurmann disease
• Most common
• Usually involve thoracic spine
• Involve >/= 3 consecutive vertebrae each wedged >/= 5 degree
• Producing structural kyphosis

13. Atypical scheuermann disease
• Usually located in the thoracolumbar junction or lumbar spine
• Vertebral end plate changes, disc space narrowing, anterior schmorl
nodes
• Doesnot necessarily have 3 consecutively wedged vertebrae of 5
degree

14. Clinical features
• PAIN
• DEFORMITY and its progression
• NEUROLOGIC COMPROMISE
• CARDIOPULMONARY COMPROMISE
• COSMETIC and POSTURAL PROBLEM

15. Pain
• MC complaints in adult
• Located just distal to the apex of the deformity in the paraspinal
location
• Commonly activity related pain
• Relieved immediately with rest and usually are not activity limiting
• Hyperlordosis distal to thoracic deformity and degenerative disc and
facet arthropathy predispose low back apin.

16. • Adolescent present with progressive low back pain and may interfere
with activities of daily living, pain radiating to buttocks and lower
extremities, and may awaken from sleep

17. Deformity
• Progressive deformity cause patient to seek tx

18. Neurologic compromise
• Cord compression secondary to scheuermann disease is rare, may
need sx.
• Variable onset
• Ranging from acute onset of unilateral radiculopathy to insidious
onset of spastic paraplegia
• Cause is that spinal cord is draped over apex of deformity
• Can also due to extradural cysts, acute thoracic disk herniations( 4-
7%)

19. Cardiopulmonary complaints
• Extremely rare on initial presentation
• Restrictive pulmonary disease in kyphosis > 100 degree, with apex in
upper thoracic region

20. Physical examination
• Erect patient demonstrate increased thoracic kyphosis with sloping
shoulders
• Forward posturing of head and neck ( due to increased cervical
lordosis)
• increased lumbar lordosis with weakened abdominal muscles causing
mildly protuberant abdomen
• Adam’s forward bend test :-slight truncal asymmetry associated with
mild scoliosis,, side view gives “ A” frame deformity due to abrupt
angulation

21. • Deformity is not easily corrected with postural changes or passive
manipulation
• Lumbar lordosis is usually reversible, flexible and corrects with
forward bending. But cervical lordosis may become fixed.
• Neurological exam may normal
• Tight or contracted hamstring and pectoral muscles
• Arms and legs appear relatively long compared to trunk

22. Radiologic evaluation

23. 1. Standing PA view
• May show mild scoliosis that rarely > 25 degree and show minimal
vertebral rotation
• Allows assessment of skeletal maturity (RISSER SIGN- BY DEGREE OF
OSSIFICATION OF ILIAC APOPHYSIS)

24. 2. Lateral 36 inch (90cm) spine erect
• with hips and knee extended, arms resting at shoulder height on a
crossbar infront.
• Reveals thoracic kyphosis over 40 degree ( Cobb technique)
• To r/o associated conditions
• Radiographic criteria by Sorenson
1) >5o of anterior wedging of 3 consecutive vertebral bodies at apex
2) irregular vertebral apophyseal lines with flattening and wedging
3) narrowing of intervertebral spaces and variable presence of
schmorl’s nodes

25. Hyperextension lateral image of thoracic
spine
• To assess flexibility of kyphosis

26. Lumbar scheuermann’s disease
• Lateral view show decreased lumbar lordosis and possible kyphotic
deformity at thoraco lumbar junction
• Lumbar vertebrae is scalloped with lucent defects at anterosuperior
corners
• Schmorl nodes and endplate irregularity

27. MRI
• For atypical or rapidly progressive kyphosis or any neurological signs
or symptoms
• Mainly for preoperative evaluation

28. Natural history
• Untreated kyphosis may progress if deformity is severe
• Adults with mild residual kyphosis will have little, if any are not likely
to seek treatment
• Pain in adults due to degenerative spondylosis often sequel of
untreated scheuermann disease, usually resistant to non operative
treatment and not usually seen kyphosis<60o
• Pulmonary compromise if curve >100o
• Type II scheuermann almost never require sx

29. classification
• 1) thoracic type
• 2) lumbar type

30. Thoracic type
• Pure thoracic:- apex at mid thoracic spine
• When kyphosis <750 , chance of progression is less without significant
pain
• When >800 continues to progress with increased pain
• Common in adolescent as well as adult
• Thoracolumbar pattern with its apex at thoracolumbar Jn has high
propensity to progress and can be significantly painful.

31. Lumbar type
• Generally males with back apin
• Benign prognosis

32. Differential diagnosis
• postural kyphosis

33. Treatment

34. Non operative treatment
Indications
• Relative skeletal immaturity ( </= rise grade II) and a progressive
deformity that cosmetically or functionally unacceptable ( usually
>600)
Goals
• To control the deformity
• To reconstitute the anterior vertebral height by applying hyper
extension forces

35. Modalities
• Anti-inflammatory medications
• Exercises
• Bracing

36. • Apical vertebra at or above T7 : Milwaukee brace
• Apical vertebra below T7 : thorocolumbar sacral orthosis (TLSO),
usually supplemented with anterior sternal or infraclavicular
outtriggers
• With a decrease in lumbar lordosis, patient encouraged to actively
hyperextend the spine to maintain the head in a more upright
position
• Initially bracing is recommended for 18 hours a day, radiographs every
6 months.
• Brace treatment continue until skeletal maturity.

37. TLSO
MILWAUKEE BRACE

38. Cast treatment
• When passive correction on lateral bolster radiograph is <40%, brace
TX is not likely to be effective
• Need total compliance and desire of the adolescent to achieve
correction
• Risser casts applied in a serial fashion to produce more correction
• Following 6-9 month period of casting , then treated with Milwaukee
brace or other brace to maintain the correction upto skeletal maturity

39. Surgical management
Indications
• Kyphosis: >80o in T spine, >650 in T-L spine
• Symptomatic ( pain, neurologic deficit, cosmetic) of T spine > 750 or T-
L spine >600 not controlled by non operative methods
• Significant sagittal imbalance

40. Determining level of fusion
• From standing lateral radiograph
• Upper limit must include most proximal vertebra that is tilted into the
kyphosis, generally upto T2
• Caudal should include first lordotic disk space, commonly includes
one level distal to thee measured end vertebra of kyphosis

41. Surgical technique options

42. Anterior release and fusion
• Indication : when kyphosis is rigid on hyperextension films
• Level of anterior release:include the rigid apical based on
hyperextension films
• Technique: right sided thoracotomy / thoracoscopic
• Procedure: disc spaces exposed and curetted preserving the bony
endplate, bone graft placed at each disc space

43. Posterior instrumented correction
• Done as standalone / combined with anterior procedure
• Either single /staged procedure

44. posterior instrumentation alone
• skeletally immature ( risser grade III) and has some anterior growth
potential remaining and if the kyphosis is corrected to <500 on
hyperextension lateral film
• chances of loss of correction is high

45. Principle of posterior instrumentation
• Correcting maneuver used is cantilevering the rod on to spine and
segmental compression from apex to ends
• Include minimum of 8 anchors above and below the apex
• 3-5 pairs of pedicle hook- transverse process claws cephalad and
similar number of pedicle screws caudal to apex

46. Surgical technique
• LUQUE instrumentation: degmental sublaminar wiring
• Multisegmnet hook rod system
• Pedicle screw system
• Harrington rod system
• amount of correction achieved increased by osteotomizing the
facets, excising the ligamnetum flavum( PONTE OSTEOTOMY)

47. • THANK YOU