What is the initial approach to managing kyphosis?

Initial Management of Kyphosis

Conservative management is the initial approach for most patients with kyphosis, including observation, anti-inflammatory medications, and physical therapy, with surgical intervention reserved for specific indications such as severe curves, intractable pain, neurologic deficits, or cardiopulmonary compromise.

Types and Assessment of Kyphosis

Kyphosis refers to an abnormally rounded back due to excessive curvature of the thoracic spine. The management approach depends on the underlying cause:

• Scheuermann's kyphosis: Defined radiographically as three or more contiguous vertebrae with at least 5° of anterior wedging 1
• Osteoporotic kyphosis: Often associated with vertebral compression fractures (VCFs)
• Ankylosing spondylitis-related kyphosis: Inflammatory condition leading to progressive spinal fusion and deformity
• Degenerative, traumatic, or iatrogenic kyphosis

Conservative Management Algorithm

For mild to moderate kyphosis (primary approach):

1. Physical therapy and exercise

   • Core strengthening
   • Postural training
   • Flexibility exercises

2. Pain management

   • Anti-inflammatory medications
   • Activity modification

3. Bracing

   • Though widely prescribed, scientific validation is limited 2
   • Most beneficial during growth periods in adolescents

Surgical Management Indications

Surgical intervention should be considered when:

• Thoracic curves exceed 70-75° 1
• Thoracolumbar curves exceed 25-30° 1
• Patient experiences intractable pain unresponsive to conservative measures
• Neurologic deficits are present
• Cardiopulmonary compromise occurs
• Poor cosmesis significantly impacts quality of life

Special Considerations for Different Types of Kyphosis

Osteoporotic Vertebral Compression Fractures

For VCFs causing kyphotic deformity:

1. Initial conservative management

   • Most VCFs show gradual improvement in pain over 2-12 weeks 3
   • Medical management with or without immobilization

2. Consider vertebral augmentation (VA)

   • If medical management fails with worsening symptoms
   • If spinal deformity or pulmonary dysfunction develops
   • VA has shown immediate improvement in pain and mobility 3
   • The timing remains debated, but can be considered after 3 months of failed conservative treatment 3

Ankylosing Spondylitis-Related Severe Kyphosis

For patients with ankylosing spondylitis and severe kyphosis:

• Elective spinal osteotomy is generally not recommended
  • High procedure-associated risks including 4% perioperative mortality and 5% permanent neurologic sequelae 3
  • Only consider in highly selected patients who lack horizontal vision causing major physical and psychological impairments 3
  • If performed, should be done at specialized centers by surgeons with extensive experience 3

Pitfalls and Caveats

• Avoid spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis due to risk of severe complications 3

• Surgical correction should not exceed 50% of the original deformity to minimize risk of neurological complications 4

• Appropriate selection of upper and lower instrumented vertebrae is critical when planning surgery to achieve a well-balanced spine, preserve motion segments, and reduce risk of junctional kyphosis 1

• Correction should include the entire length of the kyphosis to avoid partial correction and subsequent complications 4

• Modern surgical techniques allow better correction through posterior-only approaches with lower complication rates compared to combined anterior-posterior approaches 2

By following this structured approach to kyphosis management, clinicians can optimize outcomes while minimizing risks associated with both conservative and surgical interventions.