Kyphosis
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Kyphosis
Kyphosis refers to an excessive forward (posterior convex) curvature of the vertebral column. The normal thoracic kyphosis measures 20-50° on a lateral radiograph; angles beyond this range are considered pathological. - Gray's Anatomy for Students
Normal Spinal Curvatures
The thoracic spine normally has a mild kyphotic curve. When this exceeds 50°, it becomes clinically significant. A sharp, angular kyphosis (gibbus deformity) is characteristic of vertebral collapse, classically from tuberculosis affecting a thoracic body. - Gray's Anatomy for Students
Classification / Types
1. Postural Kyphosis (Round Back)
- Most common type
- No structural vertebral body changes on imaging
- No sharp angulation
- Corrects with backward bending and prone hyperextension - distinguishing feature
- Treatment: hyperextension exercise program
- Miller's Review of Orthopaedics, 9th Ed
2. Scheuermann's Disease (Structural Kyphosis)
The most important structural cause of adolescent kyphosis.
Diagnostic criteria (radiological):
- Increased thoracic kyphosis >45°
- Anterior vertebral wedging of ≥5° at three consecutive vertebrae
- Disc space narrowing and end-plate irregularities
- Schmorl nodes (disc herniation through end-plates)
- Associated spondylolysis in 30-50% of cases
- Associated scoliosis in 33% of cases
Clinical features:
- More common in boys
- Affected patients are often overweight
- Kyphosis is not postural - it does NOT fully correct with hyperextension (key distinguishing point from postural kyphosis)
- Neurologic changes are rare; MRI indicated if present
- Aetiology is unknown
Treatment of Scheuermann's Disease:
| Severity | Indication | Management |
|---|---|---|
| 50-75° | Skeletally immature (Risser ≤2), progressive curve | Bracing - modified Milwaukee brace (often poorly tolerated) |
| >75° or failed PT | Severe or progressive curve with continued pain | Surgery - posterior fusion with multilevel osteotomies |
- Surgical fusion to the first lordotic disc and the vertebra touched by the posterior sacral vertical line
- Brace treatment improves deformity in ~63% of patients who comply regularly - Bailey & Love's Surgery, 28th Ed
3. Congenital Kyphosis
Uncommon but significant because neurologic deficits are frequent.
Cause: Abnormal embryological development - failure of vertebral body formation or segmentation.
Winter Classification:
| Type | Description | Prognosis |
|---|---|---|
| Type I | Failure of vertebral body formation (hemivertebrae, wedged vertebrae) | Most severe progression; highest risk of paraplegia |
| Type II | Failure of vertebral body segmentation (anterior unsegmented bar) | Slower progression |
| Type III | Mixed - failure of both formation and segmentation | Variable |
- Deformity usually progresses with growth; severity proportional to number of vertebrae involved and growth remaining
- Type I is subdivided further into: posterolateral quadrant vertebrae, posterior hemivertebrae, butterfly vertebrae, and anterolateral wedged vertebrae
- Campbell's Operative Orthopaedics, 15th Ed 2026
4. Other Causes of Kyphosis
| Cause | Notes |
|---|---|
| Trauma | Vertebral compression/burst fractures causing kyphotic deformity |
| Infection | TB (gibbus deformity), pyogenic spondylodiscitis |
| Osteoporosis | Age-related vertebral compression fractures (most common in elderly) |
| Bone dysplasias | Mucopolysaccharidoses, Kniest syndrome, diastrophic dysplasia |
| Neoplasms | Pathological fracture leading to kyphosis |
| Postlaminectomy | Especially in skeletally immature patients; total laminectomy without stabilization is contraindicated in growing children - may require anterior + posterior fusion |
- Miller's Review of Orthopaedics, 9th Ed
Gibbus Deformity
A sharp, angulated kyphosis at a single level - classically from tuberculous spondylitis (Pott's disease) destroying a vertebral body. This was prevalent before antituberculous medication became available. - Gray's Anatomy for Students
Evaluation
- Lateral standing radiograph - measure Cobb angle (T1-T12 or from apex)
- Adams forward bend test - assesses for rotational component; may show rib hump (see scoliosis differentiation)
- MRI - indicated for neurological symptoms, congenital kyphosis (rule out intraspinal anomalies), or atypical features
- Normal thoracic kyphosis: 20-50°; Scheuermann defined as >45° with structural wedging
Summary
| Type | Age | Structural | Correctible | Treatment |
|---|---|---|---|---|
| Postural | Adolescent | No | Yes (hyperextension) | Exercises |
| Scheuermann | Adolescent | Yes | No | Brace/Surgery |
| Congenital | Any | Yes | No | Surgery (often early) |
| Osteoporotic | Elderly | Yes | No | Medical + bracing |
| Post-traumatic | Any | Yes | Partial | Surgery/conservative |
Sources: Bailey & Love's Short Practice of Surgery 28th Ed | Miller's Review of Orthopaedics 9th Ed | Campbell's Operative Orthopaedics 15th Ed 2026 | Gray's Anatomy for Students
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