Acıbadem Comprehensive Spine Center

Kyphosis (Gibbosity)

What is kyphosis and what causes abnormal kyphosis?

Kifoz Nedir? When we observe the spine from the back, we see a straight column which is consists of vertebrae aligned on top of the other, and has a projection that passes exactly from the midpoints of the head and hip bone. On the other hand, when the spine is observed from the side, we see that it is not a straight line and there are some physiologic curves formed by each vertebra forming an angle with the others. For example, in the chest and back region there is a convex curve, whereas there is a concave curve in the lower back. (Figure 1)

The kyphosis in the chest and back areas shows significant variation between people. In other words, as you have observed in the people around you, some people slouch more, others stand more erect. This gibbosity has an acceptable physiological limit. This limit ranges between 20 and 55 degrees. When the angles are measured on an X ray taken from the side (lateral) with the patient is standing comfortably, this limit is between 20 and 55 degrees. This means that kyphosis of 20 degrees or 55 degrees are both within the normal limits. Therefore it is completely normal for one member of the family to be more or less gibbous than another.

What is a postural (caused by poor posture) or positional gibbosity?

The increase of a 35 degree kyphosis, measured during the above mentioned physiologic standing position, to for example 55 degrees as a result of poor posture is known as a positional gibbosity. This is the most common cause of gibbosity that families see in their children..

What is a structural curve or Scheuermann's kyphosis?

A structural gibbosity is a type of gibbosity which exceeds 55 degrees even during physiologic standing position and often caused by an underlying bone and/or soft tissue pathology. This gibbosity can be due to congenital spinal anomalies (congenital kyphosis), some bone diseases (skeletal dysplasia, neurofibromatosis, etc.), spinal infections (tuberculosis of the spine, etc.), an injury to the vertebrae caused by a spinal fractures,or various neuromuscular diseases.

However, the most common cause of a structural gibbosity in patients who are still growing is Scheuermann's disease which is caused by loss of the rectangular shape of the vertebrae which later acquire a wedge shape due to unknown causes.

When left untreated, Scheuermann's disease may result in an increase in the curve and may reach dangerous levels.

How can a gibbosity which requires treatment be differentiated from a postural gibbosity?

The two conditions can be differentiated from one another using a simple test that can be performed easily by families. If the gibbosity can clearly be corrected when the child is asked to stand up straight, it is most probably a postural gibbosity. The crucial point here is to determine which part of the gibbosity is corrected. If it is corrected at the most prominent point, there is no problem. Sometimes the most prominent part of the gibbosity cannot be corrected at all, yet there is some correction from the vertebrae above or below. Sometimes the gibbosity is not obviously corrected and only slightly corrected. In both of these cases, you may need to see your physician and receive professional help.

What are the causes of a postural gibbosity and how can they be prevented?

The main causes of a postural curvature are sitting in a poor position and inadequate levels of physical condition. Nowadays children spend most of their time at school or on the computer. Unfortunately, children avoid sports or games in which they have to move. This lifestyle causes the children spend the majority of their time in a poor sitting position and to have poor physical conditions due to the lack of sports activities. These two bad habits are the main causes of a positional gibbosity.

We wish to point out that heavy school bags which are often blamed for this condition are not actually the real causes. However, heavy school bags are not appropriate spinal health. They form the basis for back pain in childhood and in later life, and for herniated discs.

How can a postural gibbosity be corrected?

Parents mostly tell their children to stand up straight. The child often stands up straight when he or she is asked to do so, but then returns to the gibbous position. Then a second warning comes, followed by a third, however in addition to providing no benefit at all, these can lead to major conflicts and defiance between the child and the parents. We recommend that parents do not expect any benefit from repeated requests, and to avoid them. In order to prevent a postural gibbosity, the causes should be removed first. Preventing children from going to school or using the computer is unrealistic, but there are a few things that can be done.

First and foremost, you have to start with sitting habits. Ensuring that children's desks and chairs are in the right position, angle, and height, and adjusting the height of the monitor and the keyboard to appropriate position is a good start. In this way, we can ensure that our children get adapted to the ideal position which will keep their spines within physiologic limits. Another important issue is encouraging and motivating our children to participate in sports. Sports prevents postural gibbosity by improving the physical condition and increasing the strength and endurance of the muscles which keep the spine straight. The best proof for this is the fact that you complain less from gibbosity during the summer months when your child is physically more active. Doing sports activities for at least an hour three days a week helps to improve poor posture.

What are the causes of Scheuermann's kyphosis?

Scheuermann kifozu neye bağlı oluşur? Just as with idiopathic scoliosis, the cause of Scheuermann's diseases is not known. If you examine the structure of the spinal column, it is characterised by a significant wedging of 1 to 3 consecutive vertebrae in the centre of the gibbosity and also by the structural deformation of the discs between the vertebrae. There is no proven link between Scheuermann's kyphosis and a gibbous posture or carrying a heavy bag. (Figure-2)

What are the symptoms of Scheuermann's kyphosis?

Scheuermann's kyphosis generally occurs in children between the ages of eight and twelve: it is belived to affect boys and girls equally. There are two types of curves. In the first and most common type, the curve is in the back area. In the second type, it is at the point where the back joins the lumbar area. This may be associated with back and lower back pain. In some patients, kyphosis can occur in combination with slight scoliosis (sideways curve of the spine).

How is Scheuermann's kyphosis treated?

Brace treatment

Brace treatment may be suitable to treat moderately severe Scheuermann's kyphosis. There are various different types of braces which are used for this treatment. All are designed to prevent the curve from progressing while the child is growing. Braces provide counter support to prevent the curvature from progressing during the active growth phase of the skeleton. Braces do not correct the spine completely and cannot prevent the curvature from progressing in at least half of all patients. The biggest achievement that can be expected from a brace is prevention of the progression of kyphosis so that it remains at the degree it is diagnosed and does not reach the surgical threshold. The most popular brace for the treatment of kyphosis is the Milwaukee brace, The Boston brace, which raises the pelvis, can be used for some patients.

What are the prerequities of a successful brace therapy?

- Early diagnosis established during the patient's growth phase (curves detected before the first period in girls).
- A slight to moderate Scheuermann's kyphosis (60-75 degrees).
- Regular physical examinations by orthopaedic specialists.
- A brace customised to the patient.
- A compliant patient and a supportive family.
- Continuing to do normal activities such as exercises, dance education and athletics, discontinuation of the brace temporarily during these activities under the supervision of the physician.
- Use of the brace for at least 20-23 hours a day.

When is surgical intervention necessary?

Cerrahi tedavi ne zaman gereklidir? There is no definite agreement on the degree of curve in Scheuermann's kyphosis which requires surgical intervention. However, there is a general agreement that an operation is definitely necessary for curves above 75 degrees. Nowadays, the preferred method for this deformity is posterior instrumentation and fusion as for scoliosis (Figure 3). For very severe curves an osteotomy in which parts of the bone are removed, can also be added to the procedure. The patients can be ambulated the day after the operation and discharged after 5-7 days., A brace may be used in some patientss for a short period of time (3 months) following discharge. Children can go back to school approximately three weeks later. Sports such as walking and swimming are allowed after three months. Bike riding is allowed after six months. Contact sports (football, basketball etc.) are forbidden for the first year. At the end of the first year, the patients can return to their normal lives.

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