What is the management approach for patients with kyphosis?

Management Approach for Kyphosis

Surgical intervention is strongly recommended for patients with kyphosis exceeding 50 degrees to prevent complications including pain, spinal cord compression, cardiopulmonary dysfunction, and cosmetic concerns. 1

Clinical Assessment and Indications for Treatment

Types and Evaluation

• Kyphosis may develop due to:

  • Congenital anomalies
  • Scheuermann's disease
  • Degenerative disc disease
  • Inflammatory conditions
  • Infectious causes (especially tuberculosis)
  • Trauma
  • Iatrogenic causes 2

• Key diagnostic measurements:

  • Measure intercondylar/intermalleolar distance to assess severity of deformity 3
  • Radiographic assessment of kyphotic angle (Cobb method)
  • MRI without IV contrast is the gold standard for evaluating spinal cord compression 4

Indications for Surgical Intervention

• Kyphotic angle >50° in tubercular kyphosis 1
• Kyphotic angle >70-75° in thoracic Scheuermann's kyphosis 5
• Kyphotic angle >25-30° in thoracolumbar Scheuermann's kyphosis 5
• Neurological deficit or risk of neurological compromise
• Intractable pain unresponsive to conservative measures
• Cardiopulmonary compromise
• Significant cosmetic concerns affecting quality of life 5
• Progressive deformity despite conservative treatment

Treatment Algorithm

Conservative Management (for mild kyphosis <50°)

1. Pain management:

   • Strong opioids for severe pain 4
   • NSAIDs for inflammatory pain
   • Calcitonin therapy (200 IU daily) for pain reduction 4

2. Physical therapy:

   • Targeted exercise programs for symptom improvement 4
   • Core strengthening and postural training

3. Bracing:

   • Consider in skeletally immature patients with flexible deformities
   • Limited evidence for effectiveness in adults

4. Nutritional supplementation:

   • Calcium (1000-1200 mg/day) and vitamin D (800 IU/day) 4
   • Bisphosphonates for osteoporotic cases

Surgical Management

For Tubercular Kyphosis (>50°)

Sequential steps for kyphosis correction:

1. Anterior decompression and corpectomy
2. Posterior column shortening
3. Posterior instrumentation
4. Anterior bone grafting
5. Posterior fusion 1

• Internal kyphectomy (gibbectomy) is preferred for late-onset paraplegia with severe healed kyphosis 1

For Scheuermann's Kyphosis

Three main surgical approaches:

1. Posterior-only (PO) approach:

   • Currently most popular due to reduced complications
   • Lower blood loss and shorter operative time
   • Appropriate for most cases with modern instrumentation 6

2. Anterior-only (AO) approach:

   • Rarely used as standalone procedure
   • May be considered for specific cases with primarily anterior pathology

3. Combined anterior-posterior (AP) approach:

   • For severe rigid deformities
   • Higher complication rates but potentially better correction 6

For Degenerative or Post-traumatic Kyphosis

• Vertebral augmentation (vertebroplasty or kyphoplasty) for compression fractures 4
• Surgical decompression for bony compression causing cord compression
• Surgical fixation for spinal instability 4

Complications and Monitoring

Common Complications

• Hardware failure
• Loss of correction
• Proximal junctional kyphosis (PJK) 6
• Neurological deterioration
• Infection

Monitoring

• Regular radiographic assessment to evaluate correction maintenance
• Neurological status monitoring during treatment 4
• Pain and functional outcome assessment

Special Considerations

• Spinal cord should be kept under direct vision during correction to prevent elongation 1
• Careful selection of upper and lower instrumented vertebrae is critical to achieve balanced spine and reduce junctional kyphosis risk 5
• In children, kyphosis may continue to increase even after healing of tubercular disease, requiring close follow-up 1

Pitfalls to Avoid

• Delaying treatment in progressive kyphosis, as this leads to worse outcomes and more difficult correction
• Overcorrection leading to sagittal imbalance - remember that positive sagittal balance is more difficult to compensate than negative balance 2
• Focusing only on kyphosis correction without addressing overall sagittal balance
• Neglecting nutritional status and bone quality before surgical intervention

The primary goal of kyphosis management is to correct sagittal alignment, restore spinal balance, prevent neurological complications, and improve quality of life through appropriate intervention based on the severity and etiology of the deformity.