The normal spine appears straight for its entire length when viewed from the back. When viewed from the side, there are two visible curvatures. There is a forward curvature called 'kyphosis' on the upper side that extends from the shoulders to the rib cage, while in the lumbar region, there is a backward curvature known as 'lumbar lordosis'. These curvatures ensure that the head and trunk are kept in balance on the pelvis.

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Normal thoracic spines have a slight kyphosis, angled between 20 and 45 degrees, starting from the 1st vertebra and extending to the 12th vertebra. If this curvature of the upper spine exceeds 45 degrees, it is called “hyperkyphosis”. Scheurmann's kyphosis is the most classic form of hyperkyphosis and occurs as a result of wedging of the vertebrae during adolescence. Although the cause of this event is not known exactly, it is thought to be multifactorial and is more common in men.

 

Congenital (congenital) kyphosis

The lateral view of the normal spine on direct radiography is almost rectangular. The anterior aspect of the thoracic spine is smaller than the posterior (to form kyphosis). The lumbar vertebra, on the other hand, has the opposite structure to create lordosis.

In congenital kyphosis, that is, in congenital kyphosis; There is more curvature formation than the expected regional kyphosis. Patients with congenital kyphosis and scoliosis may also have defects in other organ systems. Once the diagnosis has been confirmed by radiographs, additional tests may be ordered to look for abnormalities of the spinal cord, heart, and gastrointestinal tract. MRI (Magnetic resonance imaging) is useful in evaluating the potential for abnormal growth and the development of spinal deformity.

 

Clinically, it is important to evaluate the child's leg strength and gait pattern. Advanced kyphosis can cause severe compression on the spinal cord, resulting in compression and myelopathy (disruption in the spinal cord structure) in the nerves coming out of the spinal cord. Children with nerve compression may have a delay in starting to walk.

 

In patients with congenital kyphosis, there is a defect in the separation of the vertebrae (segmentation defect) or a structural formation defect (formation defect). The deformity usually progresses as the child grows. Especially in the first year of life, due to the rapid progress in skeletal development, the progression of the deformity is expected at a high level. The segmentation defect progresses more slowly and surgical intervention may not be necessary until adolescence.   

 

Observation is often the first line of treatment in young children with spinal deformities.

Each time the patients come to the examination, the differences in the direct radiographs are measured and significant changes are recorded. Cases of severe or progressive congenital kyphosis deformities greater than 45 degrees or kyphosis with neurological weakness are often treated surgically.  

An early surgical approach usually gives the best results and stops the progression of the curvature. Depending on the nature of the deformity, the surgical procedure to be performed also varies.

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"In situ fusion" as surgical treatment

The surgical choice for progressive kyphotic deformity is complete fusion or arthrodesis of the deformed spine (fusing the vertebrae together). Fusion  must include a top normal spine and a bottom normal spine.

 

The bone graft taken from the patient or obtained from the tissue bank is used by placing it from the posterior (back). In severely angled curves, additional bone graft can be placed anteriorly (from the front).

 

With bone grafts, 4-6 weeks are needed until complete union tissue is formed. During this period, the patient should be supported with a plaster or corset until complete union occurs.

 

"Instrumented fusion" and "osteotomy" as surgical treatment

Progressive kyphotic curvatures may require instrumentation (rod, hook and screws) in older children. If the spinal cord cannot tolerate techniques to lengthen the spine, the surgeon may consider removing the spine that is causing the deformity. Postoperative corset or plaster use is the same until union is detected on period direct radiography.

An osteotomy may also be needed to straighten the spine. Correction can be achieved by removing the posterior bone of the spine. Sometimes it may be necessary to remove the anterior part of the spine. This process can be done from the front or, where appropriate, from the back (from the back). Your surgeon may also recommend different surgeries involving anterior and posterior interventions.

 

Developmental kyphosis

Hyperkyphosis can be divided into postural and structural. Postural kyphosis disappears when the patient stands straight. There is no spinal deformity in patients with postural kyphosis.

 

“Scheurmann kyphosis” is defined as hard (structural) kyphosis. It is most commonly seen between the ages of 12-15. Abnormal kyphosis is best detected with the patient bent forward.

 

Patients with “Scheurmann's disease” often present with poor posture and back pain. Back pain is often seen in the first years of adolescence and decreases with age. The pain increases with daily activities.

 

Kyphosis is often symptomatic and its apex is often found in the middle and lower regions of the thoracic spines rather than the upper side.

 

In which situations is observation recommended in treatment?

·       Postural hyperkyphosis

·       Curvatures less than 60 degrees during growth

      60-80 degree curves with incomplete growth

Controls are made with standing radiographs on a long scoliosis cassette every 6 months. If the child has pain, an exercise program is often recommended.

 

corset treatment

If the deformity is moderately severe (60-80) and the patient has not completed his osseous development, brace treatment can be recommended in the treatment accompanied by an exercise program.

 

Full-day use of the corset (20 hours a day) is recommended until maximum improvement is achieved.

During the completion of skeletal development, the use of corsets in the last year can be reduced to 12-14 hours a day. Corset use should be continued for at least 18 months in order to achieve a complete and permanent recovery.

 

Spinal fusion as surgical treatment

If the kyphotic deformity is severe (more than 80 degrees) and the patient has increased back pain, surgical treatment may be recommended. A serious improvement is achieved with surgical treatment and there is no need for post-operative corset use.

 

As a result of fixing the screws placed on the vertebrae with rods, the spine is straightened and elongated. Often, surgeries are performed with interventions from the back. Patients can return to their normal daily activities within 4-6 months. The change achieved by surgical correction is visible.

 

traumatic kyphosis

Posttraumatic kyphosis is frequently seen in the thoracolumbar and lumbar regions. Patients with this type of kyphosis often also have neurological damage, such as paralysis. Kyphosis may be associated with chronic pain. Causes of pain; lumbar muscle weakness, infection, progressive deformation and  compression of the spinal cord or nerve roots.

 

Kyphosis treatment aims to correct and stabilize the deformity, reduce pain and improve neurological functions. Flexible deformities can be treated with posterior fusion and instrumentation (connecting the vertebrae with screws and rods). Fixed deformities often require more serious surgery involving the removal or cutting of the vertebrae.