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Kyphosis

Kyphosis, also known as hyperkyphosis, roundback, or hunchback, is an abnormal excessive convex curvature of the spine occurring in the thoracic and sacral regions. It contrasts with lordosis, an abnormal inward concave curvature of the cervical and lumbar spine. Kyphosis can result from several conditions, including degenerative disc disease, developmental abnormalities like Scheuermann's disease, osteoporosis, trauma, and multiple myeloma.

A normal thoracic spine has a slight kyphotic angle between 20° and 45°; exceeding this range leads to kyphosis. Scheuermann's kyphosis, the most classic form, results from wedged vertebrae developed during adolescence and is more prevalent in males.

High degrees of kyphosis can cause severe pain, discomfort, breathing and digestion difficulties, cardiovascular irregularities, and neurological compromise, often necessitating spinal fusion surgery.

A preoperative image of a 22-year-old man with Scheuermann's disease, a type of structural kyphosis
A preoperative image of a 22-year-old man with Scheuermann's disease, a type of structural kyphosis

Signs and Symptoms

Kyphosis is characterised by an abnormal bowing of the back, often seen as a slouching posture. This condition is distinct from scoliosis, where the spine curves sideways. Severe kyphosis can lead to debilitating symptoms such as severe pain, discomfort, breathing and digestion difficulties, cardiovascular issues, and neurological compromise. High degrees of kyphosis typically do not respond well to conservative treatments and may require surgical intervention.

Kyphosis (at far right) in comparison with other vertebral column disorders, including scoliosis and lordosis
Kyphosis (at far right) in comparison with other vertebral column disorders, including scoliosis and lordosis

Complications

Spinal fusion surgery for kyphosis carries an estimated 5% risk of serious complications, including inflammation, breathing impairments, bleeding, and nerve injuries. Some patients may require reoperation within five years post-surgery. The long-term outcomes of spine surgery remain unclear, and the procedure is often considered a cosmetic choice, with its cosmetic effects not necessarily stable over time.

Diagnosis

Classification

Several types of kyphosis are recognised:

  • Postural kyphosis: Commonly due to slouching, reversible in the young by correcting muscular imbalances. In the elderly, it may result from hyperkyphosis or vertebral fractures.
  • Scheuermann's kyphosis: Causes significant cosmetic deformity and pain, mostly affecting teenagers. It involves rigid vertebrae and discs that are irregular, herniated, and wedge-shaped.
  • Congenital kyphosis: Results from malformed or fused vertebrae in the womb, potentially requiring early surgical intervention.
  • Nutritional kyphosis: Due to deficiencies like vitamin D, causing rickets and spinal curvature.
  • Gibbus deformity: A form of structural kyphosis often following tuberculosis.
  • Post-traumatic kyphosis: Arises from untreated or ineffectively treated vertebral fractures.

Grading

Kyphosis severity can be assessed using the Cobb angle and sagittal balance, the horizontal distance between the centre of C7 and the superior-posterior border of the S1 endplate on a lateral radiograph.

Sagittal balance measurement
Sagittal balance measurement

Treatments

Diagnosis of kyphosis is typically made through observation and measurement, with X-rays confirming idiopathic causes like vertebral wedging. Osteoporosis as a cause can be confirmed with a bone density scan. Treatments vary depending on the cause and severity.

Brace

Modern brace for the treatment of a thoracic kyphosis. The brace is constructed using a CAD/CAM device.
Modern brace for the treatment of a thoracic kyphosis. The brace is constructed using a CAD/CAM device.
Modern brace for the treatment of lumbar or thoracolumbar kyphosis. The brace is constructed using a CAD/CAM device. Restoration of the lumbar lordosis is the main aim.
Modern brace for the treatment of lumbar or thoracolumbar kyphosis. The brace is constructed using a CAD/CAM device. Restoration of the lumbar lordosis is the main aim.

Physical Therapy

In Germany, the Schroth method is a standard treatment for Scheuermann's disease and lumbar kyphosis, involving specific physical therapy exercises. In China, spinal care mattresses are used to correct kyphosis during sleep.

Surgery

Severe cases may require surgical treatment, such as kyphoplasty, a minimally invasive procedure aimed at returning the damaged vertebra to its original height.

Society and Culture

People Affected by Condition

Notable individuals affected by kyphosis include Şehzade Cihangir, Mahmud I, Godfrey IV, Duke of Lower Lorraine, and Benjamin Lay.

Popular Culture

Quasimodo, from Victor Hugo's The Hunchback of Notre-Dame, is one of the most well-known depictions of kyphosis, portraying the hunchback as a destitute and pitiable outcast. Early horror films popularised the hunchbacked Igor as a stock character assisting a mad scientist.

Illustration of The Little Hunchback, a story from One Thousand and One Nights
Illustration of The Little Hunchback, a story from One Thousand and One Nights

Self-assessment MCQs (single best answer)

What is another name for kyphosis?



Which condition is characterised by an abnormal inward concave curvature of the spine?



Which of the following is NOT a potential cause of kyphosis?



What is the normal kyphotic angle range of the thoracic spine?



Scheuermann's kyphosis is most prevalent in which demographic?



Which type of kyphosis is typically due to slouching and is reversible in the young?



What is the estimated risk of serious complications from spinal fusion surgery for kyphosis?



Which method is a standard treatment for Scheuermann's disease in Germany?



In what type of kyphosis does the condition result from malformed or fused vertebrae in the womb?



Who is one of the most well-known fictional characters depicted with kyphosis?



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