A Patient's Guide to Adult Kyphosis
The word "kyphosis" describes a type of curve in the spine. A kyphotic curve is normally present in the thoracic spine (the part of the spine in the chest area). A kyphotic curve looks like the letter "C" with the opening of the C pointing towards the front. Though the thoracic spine is supposed to be curved, if the curve in a person's thoracic spine is more than 40 to 45 degrees, it is considered abnormal - or a spinal deformity.
Adult kyphosis can have varying symptoms and degrees of severity, from minor changes in the shape of your back, to severe deformity, nerve problems, and chronic pain. Kyphosis is most common in the thoracic spine, though it can also affect the cervical and lumbar spine.
There are several causes of kyphosis in adults. The first is congenital, which means it is a condition present from birth. A congenital spine problem affects the development of the spine. The second cause is traumatic, which means it is caused by a trauma or injury to the spine. Third are "iatrogenic factors"; these are from the effects of medical treatment or surgery. Finally, osteoporosis can cause kyphosis in adults. Osteoporosis is a condition that leads to major losses of bone mass, leaving the bones brittle and prone to fractures. Osteoporosis is the most common cause of kyphosis in adults. It is much more common in women than men, due to losses of estrogen in menopausal and postmenopausal women.
Kyphosis can be effectively treated. Methods of treatment have evolved over time. Originally, body casts were used to treat kyphosis. Later, treatment turned to surgery. Today there are numerous effective treatment options for correcting a severe kyphotic deformity.
This website will provide information about:
- The normal anatomy of the spine
- Different types of adult kyphosis
- Treatment of adult kyphosis
As mentioned above, the thoracic spine naturally has some kyphosis. A kyphotic spinal deformity really means there is too much kyphotic curve in the spine.
The thoracic spine is made up of the middle 12 vertebrae of your spine. The normal amount of curve in the thoracic spine is considered to be from 20 to 40 degrees within the entire thoracic spine. There is a range because the amount of "normal" curve varies from person to person.
In order to understand your symptoms and treatment choices, you should start with some basic understanding of the general anatomy of your spine. This includes becoming familiar with the various parts that make up the spine and how they work together.
Please review the document, entitled:
Different types of Kyphosis
There are many types of adult kyphosis. This section will discuss the major types and causes of kyphosis.
Postural kyphosis, or "round back", is the result of poor posture. This condition is most common in adolescents and young adults, as they often slouch when standing and sitting, causing the spine to curve forward.
Postural kyphosis is often accompanied by "hyperlordosis" of the lumbar (lower) spine. The lumbar spine naturally has a "lordosis", a backward "C"-shape. Hyperlordosis means the lumbar spine compensates for the excessive thoracic kyphosis by curving more in the opposite direction.
A postural kyphosis corrects itself when lying down on a flat surface, or when the spine is hyper-extended. On X-rays, there will not be any vertebral abnormalities, because structural damage or deformity does not cause this kyphosis. In fact, postural kyphosis is rather easily corrected with education about proper posture and some retraining on how to sit and stand correctly. Treatment does not need to include casting, bracing, or exercise. However, strengthening the back muscles can help with proper posture.
With Scheuermann's kyphosis, the thoracic curve is usually 45 and 75 degrees. There will also be vertebral wedging of greater than five degrees of three or more vertebrae that are next to each other. The vertebrae in these cases have a triangular appearance, so they wedge together and cut down the normal space between vertebrae.
With Scheuermann's disease, there is also the presence of Schmorl's nodes at the ends of the affected (wedged) vertebrae. These nodes are small herniations of intervertebral disc (the cushion between each vertebra) in the vertebra's endplates. A herniated disc is when a disc's outer fibers (the annulus) are damaged and the soft inner material of the nucleus pulposus ruptures out of its normal space. With Scheuermann's, there are also thickened anterior longitudinal ligaments, and the tightness of these ligaments may contribute to the spinal deformity. Ligaments connect bones together, including spinal vertebrae.
The cause of Scheuermann's kyphosis has not been discovered, but there are many possible theories about its development. Scheuermann, the Danish radiologist for whom the disease is named, was the first to notice the problem. He proposed that the problem was a result of a process of "avascular necrosis" of the cartilage ring of the vertebral body. This means the cartilage of the spinal bone's ring died because it lacked the necessary blood supply. Scheuermann believed that this interrupted bone growth during development, leading to wedge-shaped vertebrae.
Most researchers think that some sort of damage to the growth area of the vertebrae starts the process. The abnormal growth that follows is what causes the excessive kyphosis. For instance, there may be a vertebral disorder during the rapid growth spurts of adolescence, which then leads to abnormal bone growth. Many spine specialists also suspect that problems with the mechanics of the spine (the way it is put together and functions) play a part in Scheuermann's kyphosis. Others suggest mild osteoporosis could contribute to the deformity. Muscle abnormalities have been considered as a possible cause. There also seems to be a high genetic predisposition to this disease, which means that it runs in families.
To learn more about Scheuermann's kyphosis, you may wish to review the document, entitled:
Congenital kyphosis refers to abnormal development of the spine that is inherited. This means a person is born with some sort of defect, such as incomplete formation of the spine, which can lead to a severe abnormal kyphosis. This kyphosis is also the most common non-traumatic, non-infectious cause of paraplegia (paralysis of the lower part of the body).
With congenital kyphosis, there is a strong (20-30%) association of congenital abnormalities with the body's urinary collecting system. If this type of kyphosis is suspected, your doctor may suggest that you have an IVP (a type of X-ray that looks at the kidneys), a myelogram, or an MRI done. The myelogram and the MRI scan are done to make sure that the parts of the spine have developed normally.
Treatment for severe congenital kyphosis deformities is usually surgery. If necessary, early surgical intervention generally produces the best results and can prevent progression of the curve. The type of surgical procedure will depend on the nature of the abnormality.
Conservative (non-surgical) treatment plans are less successful at correcting this type of kyphosis. If non-surgical treatment is chosen, there is a critical need for observation and close medical follow-up to prevent serious problems later.
Conditions that cause paralysis can lead to kyphosis. The kyphosis that results is a secondary result of the paralysis. The causes of the paralysis can include disorders such as Polio, spinal muscle atrophy (a deterioration that leads to paralysis), and Cerebral Palsy (paralysis caused by trauma at birth or developmental defects in the brain). The development of kyphosis in these cases is gradual rather than sudden.
Injury to the spine can lead to both progressive kyphosis and nerve problems in the spine. When the trauma is a vertebral fracture in the thoracic or lumbar spine, 90% of the time some degree of kyphosis will result. Treatment for post-traumatic kyphosis can include either bracing or surgery. The choice will depend upon the severity of the condition.
Kyphosis can develop after surgery of the spine to correct other problems. This usually occurs when the surgery performed does not heal as intended. For example, a spine fusion may not heal. The unstable fusion may cause the spine to collapse into a kyphosis. The ligaments of the spine may not heal strong enough to support the vertebrae and allow the spine to form a kyphotic curve. These conditions may require a second operation to try to correct the problem.
There are also cases of kyphosis that are caused by degeneration, or wear and tear of the lumbar (lower) spine. Over time, the degenerative process can result in: collapse of the intervertebral disc, changes in the shape of the vertebrae, and weakening of the ligaments that support the spine. This can result in the gradual development of a kyphosis over many years. Once the kyphosis begins to form, it gets worse because the imbalance of the forces continually increase the wear and tear.
Other Causes of Kyphosis
Different types of systemic diseases can cause a kyphosis to develop over time. These conditions include: infection in the spine, cancer or tumors that involve the spine, and different types of systemic arthritis. This type of kyphosis is caused by changes in the spine brought on by inflammation of the tissue in the area surrounding the thoracic spine. Kyphosis can also develop in people who were treated for a malignant (cancerous) childhood disease by radiation to the axial skeleton.
The symptoms of kyphosis can range from causing pain to severely affecting the function of the lungs and heart. Kyphosis can be painful and cause pain primarily in the area of the kyphosis. If the curve is severe it can begin to put pressure on the spinal cord and cause problems due to the compression of the nerves of the spinal cord. This can cause weakness in the lower extremities. Finally if the kyphosis is in the thoracic spine the curve can make it difficult to breath and affect the function of the heart as well.
If kyphosis is suspected in an adult, a diagnosis must be made before an appropriate treatment plan can be developed.
In order to make a proper diagnosis and rule out other possible conditions, the first step is to take a history. The provider may ask about the following:
- Family History - Some types of kyphosis tend to run in families, so it may
have a genetic cause. Your provider will want to know if anyone else in your
family has the problem.
- Date of Onset - When did you first notice the appearance of your spinal
- Measured Curve Progression - If X-rays have been taken of your spine in
the past, the doctor will want to see if the curve is getting worse. This
can be measured comparing new x-rays with old ones, measuring the size of
the curve, or measuring changes in your height.
- The Presence or Absence of Pain - Not all cases of kyphosis produce pain.
However, if there is pain, your doctor needs to know where it is, what brings
on or intensifies the pain, and if there is any radicular pain - pain that
radiates away from the spine itself. This usually comes from irritation of
the nerves as they leave the spine.
- Bowel or Bladder Dysfunction - Are you having problems knowing when you
have to urinate or have a bowel movement? This is extremely important because
it could signal the presence of serious nerve damage.
- Motor function - Has there been a change in how your muscles work? This
may be the result of pressure on the nerves or spinal cord itself.
- Previous surgery - If you have had any surgery on your spine, it may have caused the kyphosis due to weakened muscles or other problems. In order to evaluate your condition properly, it is important that your physician knows about any spinal surgery you have had in the past.
The spine specialist will then perform a physical examination. During the exam, the provider will try get an understanding of the curve in your back and how it is affecting you. This mean first trying to get a "mental picture" of how the spine is curved from examining your back and watching you move about. Your doctor will look at the flexibility you have bending in certain directions. Finally, your nerves will be tested by checking: your sensation, your reflexes, and the strength of your muscles.
Usually, after the examination, X-rays will be ordered that allow the provider to see the structure of the spine and measure the curve. During the X-rays, you will be asked to hold certain positions while standing or lying on a table. You will need to hold very still while pictures are taken of your spine. With kyphosis the following images may be taken:
- Front view - These are X-rays of the entire spine taken from the front.
- Lateral view - These are X-rays of the entire spine taken from the side.
- Lateral bend - These are X-rays taken while you are bending sideways.
- Traction films - Traction is when your spine is pulled and held in a particular position to take X-rays. These films are only taken occasionally.
Depending on the outcome of your history, physical examination, and initial X-rays, other tests may be ordered to look at specific aspects of the spine. The most common tests that are ordered are: the MRI scan - to look at the nerves and spinal cord; the CAT scan - to get a better picture of the vertebral bones; and special nerve tests - to determine if any nerves are being irritated or pinched.
To learn more about these tests, you may wish to review the document, entitled:
Treatment for Adult Kyphosis
Adult kyphosis has a variety of treatment options. Whenever possible, the first choice of treatment for adult kyphosis is always going to be conservative. Spinal surgery will always be the last choice of treatment due to the risks involved. Conservative treatment that is commonly recommended includes: medications, exercise, and certain types of braces to support the spine.
If osteoporosis is present, then treatment of the osteoporosis may slow the progression of the degenerative kyphosis as well. This can be accomplished in several ways. The current recommendations include: increasing your calcium and vitamin D intake, hormone replacement therapy, and weight-bearing exercises.
For more information on osteoporosis, you may wish to review the document, entitled:
The use of a spinal brace may provide some pain relief. However, in adults, it will not cause the spine to straighten. Once you have reached skeletal maturity, bracing is used for pain relief rather than prevention. If there is a difference in the length of your legs (or if the scoliosis causes you to walk somewhat crooked), special shoe inserts, called orthotics, or a simple shoe lift may reduce your back pain.
To learn more about the different types of braces available for the spine, you may wish to review the document, entitled:
Physical therapy and exercise is an important part of treating adult kyphosis. A well-designed exercise program can also provide pain relief in many patients. A physical therapist will develop an appropriate exercise routine for your case. It is essential that you stick to the plan.
Typical advice includes:
- Learning correct body mechanics to maintain erect posture that counteracts the effects of the kyphosis
- Doing regular non-jarring exercises, such as swimming
- Maintaining high levels of activity
- Doing your daily stretching exercises
Surgery for adult kyphosis carries with it some risks. For this reason, surgery is only recommended when the risks are far outweighed by the expected benefits. Surgery will not be recommended for most cases of kyphosis. Surgery may be recommended in the following situations:
- Pain - The most common reason for surgery is pain relief for increasing,
chronic discomfort. Most cases of adult kyphosis surgeries are done to relieve
severe pain. However, if the pain is manageable through any conservative way,
surgery will not usually be recommended.
- Progression of Curve - Progression of the kyphosis deformity is another
reason for considering surgery. If the curvature continues to worsen, surgery
may be suggested. Surgery is recommended in this situation to prevent the
problems that come from severe kyphosis.
- Cosmetics - In most cases of kyphosis, surgery will not be recommended simply for the sake of appearances. However, in some cases, the kyphosis causes physical deformity that is unbearable to the patient. In these cases, surgery is the only option for correcting the condition. Most cases of cosmetic kyphosis surgery are in young adults that have very noticeable curves.
When adult kyphosis requires surgery, many different procedures may be suggested. Each case of kyphosis is somewhat different and each may require a very specialized approach for optimal results. Surgery is suggested to solve the problems brought on by the kyphosis - not just to straighten the spine. The goals of most surgical procedures for adult kyphosis are to:
- Reduce the deformity (straighten the spine as much as possible)
- Stop the progression of the deformity
- Remove any pressure from the nerves and spinal cord
- Protect the nerves and spinal cord from further damage
To succeed at doing these things, the spine surgeon may suggest an operation on the back of the spine, the front of the spine - or both. The goal is to first straighten the spine and then fuse the vertebrae together into one larger bone.
Nearly all surgeries will use some type of metal screws, plates, or rods, in order to help straighten the spine and hold the vertebrae in place while the fusion heals and becomes solid. The screws are placed into the vertebra. The rods or plates then attach to the screws to connect everything together. When everything is tightened together, the "construct" forms a sort of internal brace to hold the vertebrae in alignment while the fusion heals.
To better understand the types of procedures that are used to treat adult kyphosis, please review the document, entitled:
Possible Complications/Problems with Surgery
With any surgery, there is a risk of complications. When surgery is done near the spine and spinal cord these complications (if they occur) can be very serious. Complications could involve subsequent pain and impairment and the need for additional surgery. You should discuss the complications associated with surgery with your doctor before surgery. The list of complications provided here is not intended to be a complete list of complications and is not a substitute for discussing the risks of surgery with your doctor. Only your doctor can evaluate your condition and inform you of the risks of any medical treatment he or she may recommend.
Please review the document entitled:
In addition, the surgical treatment of adult kyphosis may result in two special complications.
The lumbar (lower) spine naturally has a "C"-shaped curve called lordosis. When the vertebrae in the lumbar spine are fused together, this lordosis curve may be lost, leaving the patient with a "flat-back" deformity. However, the loss of curve may not appear right after surgery. In fact, if the surgery it is done in a young person, the loss of lordosis may not appear until sometime between the ages of 30 to 50.
The term "pseudo" means false and "arthrosis" refers to joint. The term "pseudoarthrosis" then means false joint. A surgeon uses this term to describe either a fractured bone that has not healed or an attempted fusion that has not been successful. A pseudoarthrosis usually means that there is motion between the two bones that should be healed, or fused, together. When the vertebrae involved in a surgical fusion do not heal and fuse together, there is usually continued pain. The pain may actually increase over time. The spinal motion can also stress the metal hardware used to hold the fusion. The screws and rods may break, leading to an increase in pain. A pseudoarthrosis may require more surgery to try to get the bones to heal. Your surgeon may add more bone graft, replace the metal hardware, or add an electrical stimulator to try to get the fusion to heal.
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