KYPHOSIS

Kyphosis is a disease characterized by the forward curvature of the spine, also known as hunchback. When viewed from the side, the human spine has anatomically sequential opposing curves (in the neck, back, lower back, and pelvis). Kyphosis is most commonly observed as a disease in the thoracic (back) region. The disease can be congenital, or result from abnormal development, postural disorders, or various diseases. The incidence of hunchback is between 0.4% and 8.3%. The male-to-female ratio is 7.3/1. It is most often observed during the active growth of skeletal bones between the ages of 11-15 and as curvature in individuals over 50 years of age. As a result of the disease, the spine has a curved shape in the sagittal plane – externally, this manifests as a prominent hump.

WHAT IS COBB ANGLE?

The Cobb angle is a method of measurement. A horizontal line is drawn along the upper edge of the vertebra at the upper end of the thoracic curve, and a second horizontal line is drawn along the lower edge of the vertebra at the lower end. The angle formed by the intersection of perpendicular lines drawn from each of these horizontal lines is measured. In measurements of the angle between the T5 upper endplate and the T12 lower endplate, values ranging from 10 to 40 degrees have been reported. In measurements made by Boulay using true Cobb angles (the angle between the upper endplate of the most tilted cranial vertebra at the top and the lower endplate of the most tilted vertebra at the bottom), values between 33.2 and 83.5 were found.

KYPHOSIS CLASSIFICATION

The classification made by Winter and Hall in 1978 for kyphosis deformity is still used today.

• Congenital kyphosis;
• Postural kyphosis;
• Scheuermann’s kyphosis;
• Paralytic kyphosis;
• Myelomeningocele kyphosis;
• Post-traumatic kyphosis;
• Inflammatory kyphosis;
• Post-surgical kyphosis;
• Metabolic kyphosis;
• Developmental kyphosis;

Congenital Kyphosis

The occurrence of this type of kyphosis is a result of the impact of traumatic factors on the fetus during fetal development. The cause of vertebral anomalies can be a formation defect, segmentation defect, or a combined anomaly. Curvature appears after birth. Kyphosis develops due to adjacent vertebral bodies being fused (block vertebra) or the presence of a connecting band (unsegmented bar) resulting from a segmentation defect.

This type of kyphosis can develop in isolation or combined with lateral curvature. In congenital kyphosis, the apex of the deformity can be located anywhere in the spine. This type of curvature is continuously progressive.

Congenital kyphosis is accompanied by anomalies in the development of the spine and adjacent structures (spinal dermoid cysts, fistulas, sagittal spinal stenosis) and other organs in more than 10% of cases. Congenital kyphosis is usually accompanied by neurological symptoms.

For the diagnosis of congenital kyphosis, examination, neurological status investigation, and radiological examination are used.

Congenital kyphosis practically cannot be treated with exercises and medication. At an early age, surgical treatment is recommended, including stabilization of the deformed spine to prevent further deterioration.

Postural Kyphosis

This is a deformity (postural defect) that is mostly overlooked in children and can be detected during school screenings. It is accepted as a normal variation of the round back deformity. It is stated that this deformity, which is especially seen in some athletes, is an expression of increased chest cage capacity. Some clinical features are:

• Appears during juvenile and adolescent periods;
• More common in girls;
• Curvature is usually below 60 degrees;
• It is flexible;
• There are no vertebral anomalies on X-ray;

Scheuermann’s Kyphosis

It was first described by Danish Radiologist Scheuermann in 1920. It is a hunchback that is above 55 degrees on standing X-rays and is usually caused by an underlying bone or soft tissue pathology. Just as in idiopathic scoliosis, its cause is unknown. X-rays show that the vertebrae lose their rectangular shape and become wedged. If Scheuermann’s disease is left untreated, it can result in an increase in the hump and reach dangerous levels.

Scheuermann’s kyphosis is usually seen equally in girls and boys between the ages of 8 and 12. Typically, the curvature is seen in 2 types:

• Thoracic type, where the curvature is in the back region (most common type)
• Thoracolumbar type, where the curvature is at the junction of the back and lower back regions

In addition to the hunchback, mild scoliosis (lateral curvature of the spine) and back and lower back pain may also be present.

 

Paralytic Kyphosis

Some paralytic diseases, just as they cause scoliosis, can also cause kyphosis. These are mostly neurological or muscular diseases such as poliomyelitis, CP (cerebral palsy), and spinal muscular atrophy.

Myelomeningocele Kyphosis

Due to a developmental anomaly in the spine, the posterior bony elements do not form, and the back wall of the canal through which the spinal cord and nerves pass remains open (spina bifida). Neural structures can herniate outward through this cleft (meningocele and myelomeningocele). In such a case, various degrees of loss of neural function and paralysis may occur. Along with this condition, kyphosis deformity is also present in 8% to 15% of cases.

Post-traumatic Kyphosis

In the event of a vertebral fracture, post-traumatic kyphosis is frequently observed. The probability of development depends on the severity of the injury, accompanying factors (damage to the back muscles), and compliance with the doctor’s prescribed regimen. As a rule, there are neurological disorders in post-traumatic kyphosis. Diagnosis takes into account the history of the disease (presence of injury), examinations, and data from additional methods (X-ray, CT scan of the spine).

Inflammatory Kyphosis

Kyphosis deformity can develop as a result of spinal infections or other inflammatory diseases of the spine. Among infections, specific infections such as tuberculosis and brucellosis come to mind first. Non-specific infections can have a similar result. Among inflammatory diseases, the first that come to mind are ankylosing spondylitis and rheumatoid arthritis. Post-surgical Kyphosis: Kyphosis can develop after fractures that are treated surgically but with insufficient reduction or inadequate fixation. In patients who undergo inadequate posterior fusion for any reason, kyphosis can form over time. In cases where laminectomy is performed, if posterior insufficiency occurs, kyphosis can develop. Metabolic Kyphosis: Kyphosis due to metabolic causes can develop mostly as a result of osteoporosis, osteomalacia, and osteogenesis imperfecta. Developmental Kyphosis: Achondroplasia and mucopolysaccharidoses fall into this group.

WHAT ARE THE CAUSES OF KYPHOSIS?

Various theories have been proposed regarding the causes of hunchback:

• Avascular necrosis (Scheuermann – 1920); This is the most accepted theory.
• Biochemical changes (Ippolito-Ponseti): Histochemical studies have shown that endochondral ossification is disrupted due to proteoglycan abnormality.
• Abnormality in bone density (Bradford-1976): Bradford reported that the change occurring in the vertebrae is a form of osteoporosis.
• Microfractures: First proposed by Lambrinudi in 1934. He reported that microfractures in the vertebral apophyses due to chronic trauma cause the wedging in the vertebrae.
• Mechanical factors;
• Malnutrition;
• Vitamin deficiency;
• Endocrinopathy;
• Genetics;

WHAT ARE THE SYMPTOMS OF KYPHOSIS?

In the early stages, kyphosis begins with mild pain as a result of muscle spasms, and then manifests as sensations up to acute pain when nerve roots are compressed. The following symptoms may be observed as the disease develops:

• Numbness of hands, feet, and fingers;
• Weakness in the extremities;
• Impairment of lung and heart functions;
• Head and neck pain;
• Postural deformity;
• Disc herniation;
• Neurological signs may develop in advanced cases due to spinal stenosis;
• Scoliosis;
• Increased lordosis above and below the kyphosis;

In the initial stages, the deformity is unstable and the spine easily regains its natural shape in a horizontal position. Therefore, it is quite difficult to detect kyphosis in the early stages, as its symptoms have not yet become systemic. Over time, the curves begin to fix, leading to deformity of the spinal discs and later to vertebral deformities.

Externally, kyphosis is usually not noticed by the patient themselves. In later stages, a change in the chest occurs – it becomes hollow, the shoulders move forward and the scapulae backward, and the position of the head changes – it drops. Gradually, the changes affect other parts of the spine – usually the lumbar region.

HOW IS KYPHOSIS DIAGNOSED?

The diagnosis of kyphosis is based on anamnesis and objective data. The Professor examines the patient for spinal distortion and detects the presence of accompanying diseases. Spinal palpation, and examination of neurological, cardiovascular, respiratory, and internal organs are performed. The most informative diagnostic method is X-ray. Magnetic Resonance Imaging (MRI) is rarely used. MRI helps determine the state of bones and muscles to identify pathological changes. WHAT IS THE TREATMENT FOR KYPHOSIS? If you carry the symptoms of kyphosis, you can consult us. You can ensure an accurate diagnosis with Prof. Dr. Erol YALNIZ. Kyphosis that has reached an advanced level requires surgical operation. It is very important that you have surgery at the right address and receive the required treatment in a healthy way. The Professor takes into account the cause of the disease, the degree of curvature, the patient’s age, and the presence of complications for kyphosis treatment. The classification of kyphosis is very diverse as mentioned above, and the treatment style varies from person to person – exercise, bracing, or surgery is recommended.

When Do You Need Surgical Treatment?

• Significant pain that does not stop with medications, bracing, and exercises;
• Rapid progression of the disease;
• Presence of cardiac anomalies, respiratory failure, neurological complications;
• An impressive cosmetic defect that prevents the patient from leading a normal life and working.

 

Spinal stabilization in kyphosis

The procedure is primarily aimed at balancing the deformity and preventing the progression of the curvature. If necessary, decompression of the spinal nerves is performed. Sometimes it is necessary to work close to the spinal cord, which requires a highly qualified surgeon. This surgical operation is possible in our Private Ekol Hospital with Prof. Dr. Erol YALNIZ!