What is the treatment for Scheuermann's kyphosis?

Treatment of Scheuermann's Kyphosis

For adolescents with Scheuermann's kyphosis and curves <50° who are still growing, bracing is the first-line treatment; for curves >70-75°, progressive deformity despite bracing, intractable pain, or neurologic deficits, surgical correction via posterior spinal arthrodesis is indicated. 1, 2, 3

Conservative Management

Physical Therapy and Medical Management

• Initiate physical therapy focusing on strengthening exercises for the thoracic spine extensors and core musculature as first-line treatment 1, 3
• Add short-term anti-inflammatory medications (NSAIDs) for pain control 3, 4
• Implement behavioral modifications to avoid positions that exacerbate symptoms 3
• Note that physical therapy alone cannot alter the natural history of the disease but provides symptomatic relief 1

Bracing for Skeletally Immature Patients

• Apply thoracolumbosacral orthosis (TLSO) bracing for adolescents with progressive curves <50° who have remaining skeletal growth 5, 1, 2
• Bracing is most effective when initiated early, before the curve exceeds 50° 1
• Continue bracing until skeletal maturity is reached 2
• If bracing fails to control progression, proceed to surgical evaluation 2, 3

Critical caveat: We cannot reliably predict which curves will progress, making it difficult to determine absolute effectiveness of bracing, though current evidence supports its use in growing patients with moderate curves 1

Surgical Indications

Absolute Indications for Surgery

• Kyphosis >70-75° with documented progression 2, 3, 4
• Intractable pain refractory to conservative management (minimum 3 months) 3, 4
• Neurologic deficits or compromise 5, 3, 4
• Unacceptable cosmetic deformity causing significant psychological distress 2, 3
• Cardiopulmonary compromise from severe deformity 4

Surgical Approach Selection

Posterior-only approach with pedicle screw fixation is safe and effective for most cases 5, 4

• Perform posterior spinal arthrodesis with instrumentation extending the entire length of the kyphosis 3, 4
• Add Smith-Peterson osteotomy for rigid deformities requiring greater correction 5
• Extend instrumentation distally beyond the end vertebral body to the first lordotic disc to prevent distal junctional kyphosis 3
• Consider anterior release (via thoracotomy or VATS) combined with posterior fusion only for extremely rigid curves 2

Surgical Correction Principles

• Limit correction to no more than 50% of the original deformity to minimize risk of neurologic complications 3, 4
• Address all sagittal balance parameters, not just thoracic kyphosis correction 5
• Evaluate and correct negative sagittal balance when present 5

Common Pitfalls and Complications

Surgical Complications to Monitor

• Wound infection (most common postoperative complication) 4
• Loss of correction 4
• Distal junctional kyphosis if instrumentation not extended adequately 3
• Neurologic injury if correction exceeds 50% 3, 4

Natural History Considerations

• The natural history remains controversial regarding long-term pain and disability 1
• Long periods of severe stenosis can lead to irreversible spinal cord damage 6
• Most adolescents present for cosmetic concerns; adults more commonly present with pain 3

Age-Specific Treatment Algorithms

For Adolescents (Skeletally Immature)

1. Curves <50° with growth remaining → TLSO bracing 1, 2
2. Curves 50-70° → Continue bracing if compliant; consider surgery if progression despite bracing 2, 3
3. Curves >70-75° → Surgical correction 2, 3, 4

For Adults (Skeletally Mature)

1. Symptomatic curves → Physical therapy, NSAIDs, behavioral modification for 3 months minimum 3, 4
2. Persistent pain or progressive deformity → Surgical correction 4
3. Neurologic symptoms → Urgent surgical evaluation 5, 3