What is the management approach for Scheuermann disease?

Management Approach for Scheuermann's Disease

The management of Scheuermann's kyphosis should follow a stepwise approach based on deformity severity, skeletal maturity, flexibility of the curve, and presence of symptoms, with observation and exercise programs appropriate for mild deformities, bracing indicated for moderate flexible deformities in growing patients, and surgical correction reserved for severe kyphosis (>75°) with progression, refractory pain, or neurological deficits.

Understanding Scheuermann's Disease

Scheuermann's disease is the most common cause of structural kyphosis in adolescence, characterized by:

• Anterior wedging of ≥5° in three or more contiguous vertebrae
• Vertebral end plate irregularity
• Disc space narrowing
• Reported prevalence of 0.4% to 8% of the general population
• Equal distribution between sexes
• Primarily genetic etiology with a dominant autosomal inheritance pattern

Assessment Parameters

When evaluating a patient with suspected Scheuermann's kyphosis, focus on:

• Degree of kyphosis (measured by Cobb angle)
• Skeletal maturity/remaining growth
• Curve flexibility
• Presence and severity of pain
• Cosmetic concerns
• Neurological status
• Functional limitations

Treatment Algorithm

1. Mild Deformity (Kyphosis <50°)

• Observation
• Physical therapy and exercise programs
  • Core strengthening
  • Postural training
  • Hamstring stretching
• Regular follow-up every 4-6 months during growth

2. Moderate Deformity (Kyphosis 50-75°)

• Bracing indicated for:
  • Flexible curves
  • Patients with significant remaining growth
  • Motivated patients
• Brace specifications:
  • Milwaukee brace or custom thoracolumbosacral orthosis
  • Full-time wear (16-23 hours daily)
  • Continue until skeletal maturity
• Important considerations:
  • Approximately one-third of patients may experience some loss of correction after bracing completion 1
  • Early intervention (before curve exceeds 50°) appears more effective 2

3. Severe Deformity (Kyphosis >75°)

• Surgical correction indicated for:
  • Progressive curves despite conservative treatment
  • Refractory pain
  • Neurological complications
  • Significant cosmetic deformity affecting quality of life
• Surgical options:
  • Posterior-only (PO) instrumented fusion
    • Advantages: Reduced blood loss, shorter operative time, fewer complications 3
    • Suitable for more flexible curves
  • Combined anterior-posterior (AP) approach
    • Indicated for very rigid and large curves
    • Can be performed conventionally or through video-assisted thoracoscopic surgery
  • Extent of fusion should include the entire Cobb angle and stop above the first lordotic disc 4

Special Considerations

Pain Management

• NSAIDs for symptomatic relief
• Activity modification during acute pain episodes
• Physical therapy focusing on core strengthening and posture

Follow-up Protocol

• For non-surgical cases:
  • Every 4-6 months during growth
  • Radiographic evaluation to monitor progression
• Post-surgical:
  • Regular follow-up to monitor hardware integrity and fusion status
  • Watch for complications such as proximal junctional kyphosis

Common Pitfalls to Avoid

1. Misdiagnosing as poor posture or "slouching"
2. Delaying treatment in progressive cases
3. Inappropriate fusion levels leading to sagittal decompensation
4. Hypercorrection during surgery
5. Inadequate follow-up during growth spurts

Prognosis

Most patients with Scheuermann's kyphosis can expect:

• Stabilization of deformity at skeletal maturity
• Resolution of symptoms in mild to moderate cases
• Good long-term outcomes with appropriate treatment

The natural history remains somewhat controversial, with conflicting reports regarding the severity of pain and physical disability in untreated cases 2. However, early intervention for progressive cases offers the best chance for preventing severe deformity and associated complications.