What is the best management approach for Scheuermann’s disease?

Management of Scheuermann's Disease

The best management approach for Scheuermann's disease involves a stepwise treatment algorithm based on curve severity, skeletal maturity, and symptoms, with conservative measures as first-line treatment for most patients and surgery reserved for severe cases. 1, 2

Diagnosis and Assessment

• Radiographs are the standard imaging modality to confirm diagnosis, looking for:

  • Vertebral end plate irregularity
  • Anterior wedging of ≥5° in three or more adjacent vertebrae
  • Disc space narrowing
  • Schmorl's nodes
  • Irregular endplates 3, 4

• Clinical assessment should evaluate:

  • Curve severity (measured in degrees)
  • Skeletal maturity (growth remaining)
  • Pain level and location
  • Neurological symptoms
  • Cosmetic concerns
  • Functional limitations 2, 5

Treatment Algorithm

Mild Kyphosis (<50°)

• First-line treatment:
  • Observation with regular monitoring
  • Physical therapy focusing on:
    • Postural education
    • Core strengthening
    • Hamstring stretching
    • Extension exercises for thoracic spine 6
  • Anti-inflammatory medications for pain control 5

Moderate Kyphosis (50-75°) in Skeletally Immature Patients

• First-line treatment:
  • Bracing (Milwaukee brace or custom thoracolumbosacral orthosis)
    • Full-time wear (16-23 hours/day)
    • Continue until skeletal maturity
  • Combined with physical therapy
  • Regular radiographic monitoring (every 4-6 months) 2, 6

Moderate Kyphosis (50-75°) in Skeletally Mature Patients

• First-line treatment:
  • Physical therapy
  • Anti-inflammatory medications
  • Activity modification
  • Ergonomic adjustments 5

Severe Kyphosis (>75°)

• Consider surgical intervention when:

  • Curve exceeds 75° in thoracic spine or 30° in thoracolumbar spine
  • Progressive deformity despite conservative treatment
  • Refractory pain unresponsive to conservative measures
  • Neurological deficit present
  • Significant cosmetic concerns affecting quality of life 4

• Surgical approach:

  • Posterior spinal fusion with instrumentation is the standard approach
  • Correction should not exceed 50% of initial deformity
  • Instrumentation should extend beyond the end vertebral body to the first lordotic disc 5, 4

Special Considerations

• Early intervention is key: Bracing appears more effective when initiated before curves exceed 50° in growing patients 2

• Pain management: Most adolescents with pain respond well to physical therapy and short courses of anti-inflammatory medications 5

• Adult patients: Adults more commonly present with pain rather than cosmetic concerns and may initially respond to conservative measures 5

• Monitoring: Regular radiographic follow-up is essential, especially in skeletally immature patients, to detect progression 1, 3

Common Pitfalls

• Misdiagnosis as poor posture: Parents and clinicians may mistake Scheuermann's kyphosis for postural roundback, delaying appropriate treatment 3

• Inadequate bracing: Insufficient brace wear time or improper fit can lead to treatment failure 6

• Excessive surgical correction: Attempting to correct more than 50% of the initial deformity increases risk of complications 5

• Failure to extend instrumentation appropriately: Not extending to the first lordotic disc can lead to junctional kyphosis 5, 4

• Neglecting physical therapy: Even when bracing or surgery is indicated, physical therapy remains an important component of comprehensive treatment 6