Diagnosis and treatment of Scheuermann’s disease

The normal curvature of the thoracic spine is between 20 and 50 degrees. A curvature of more than 50 degrees, where the spine has three contiguous vertebral bodies that have wedging of 5 degrees or more, constitutes Scheuermann’s disease.

Postural roundback in adolescents is most often caused by posture and not by structural changes to the spine. Postural roundback can be easily distinguished from Scheuermann’s kyphosis by the fact that the deformity goes away when the patient lies down. Typically, patients with true Scheuermann’s kyphosis need to sleep on two or three pillows at night to stay comfortable because there deformity remains when they lie down.

Most patients with Scheuermann’s also have a mild scoliosis (when the spine curves to the side). These mild scoliosis curves rarely require treatment. As with scoliosis, an X-ray is used to confirm a diagnosis of Scheuermann’s disease.

Treatment options for Scheuermann's disease
Treatment of Scheuermann’s disease is indicated to relieve pain, to correct an unacceptable cosmetic deformity, and to prevent potential progression or worsening of the curve. Treatment will vary depending on the size of the curve, the flexibility of the curve, the patient’s age and the patient’s preferences.

Conservative treatments for Scheuermann's disease
For patients with more than one year of growth left, the kyphosis can be partially reversed by wearing a brace (e.g. a Milwaukee brace). The brace can improve the curve during the growing years by restoring height to the front of the vertebral body and sometimes can reduce pain if present. Depending on the severity and progression of the curve, patients may be prescribed a brace for one to two years.

For patients who are already skeletally mature, bracing is not an effective treatment.

An exercise program, including specific strengthening and hamstring stretching exercises, may be recommended in conjunction with bracing. While exercise won’t correct the deformity, it can be helpful in alleviating back pain and fatigue.

Surgery for Scheuermann's disease
Surgery is rarely needed for Scheuermann’s disease. It may be considered for patients with severe deformities (e.g. more than 70 degrees for thoracic kyphosis), if neurological deficits are present, and occasionally if pain is present with the deformity. The goal of the surgery is mostly to reduce the deformity, although some feel it can lessen pain if present (See Figure 2).

Surgery will typically include:

• A front thoracotomy (approach through the chest) to release the tissues, remove the discs, and place bone graft in the spaces to fuse the thoracic spine;

• During the same surgery, the spine is then approached from the back and instrumentation (such as rods, bars, wires, or screws, which hold the spine straight during the fusion process) is put in place.

After surgery, provided the fusion is successful, all of the affected segments will be fused into one continuous bone that will not progress into kyphosis.

Because Scheuermann’s disease usually occurs in the thoracic spine, which has almost no motion, a fusion in this area does not affect the normal motion of the spine and typically does not lead to pain later in life. Most of the motion in the spine is in the lumbar spine, and it is usually not necessary to fuse this area. This is important to avoid overstressing the other lumbar spinal segments and causing early breakdown at adjacent levels.

In general, in a skeletally mature patient, Scheuermann’s kyphosis is not progressive. This is different from adolescent scoliosis, which can continue to progress (if the deformity is more than 50 degrees) going into adulthood.

For adults with Scheuermann’s kyphosis, the treatment is usually observation, anti-inflammatory drugs or reconstructive surgery, depending on the severity of the symptoms.