Radiology Rounds #16

Clinical History

A 16 y.o girl comes to the office accompanied by her mother. They both report that over the last few years, the teenager has developed a progressive hunchback with intermittent mid-thoracic pain. The patient reports that the deformity has become cosmetically unacceptable to her, and that she wants it corrected. She is otherwise in excellent health, and specifically denies any fevers, chills, sweats, skin rashes, abdominal pain, peripheral arthritis, or nocturnal back pain.

Physical examination reveals a healthy young woman with a pronounced thoracic kyphosis, anteriorly positioned shoulders, and a slight forward protrusion of the head. Her hamstring muscles are tight as well. Her deformity remains fixed through flexion and extension, and there is no spinal tenderness to palpation. A routine laboratory evaluation is unremarkable. PA and lateral spine films are obtained.

Radiographic Films

xray image
Film 1

xray image
Film 2

Radiographic Findings

Her spine films reveal an exaggerated thoracic kyphosis with anterior wedging (loss of height) of the thoracic vertebrae and reactive sclerosis (red arrows). The vertebral endplates have markedly irregular contours that the radiologist reported as epiphysitis. Indentations in the vertebral contours (schmorls nodes) are noted as well (yellow arrows).

xray image
Film 1

xray image
Film 2

Diagnosis and Discussion

Correct Diagnosis: Scheuermann Kyphosis

Discussion:
Scheuermanns kyphosis was first described in 1921 in adolescent patients with marked thoracic kyphosis and was initially termed kyphosis dorsalis juvenilis. It is a relatively common cause of juvenile kyphosis, affecting between 1-8% of the population by some estimates. It is generally discovered in young adolescents when they present with increased kyphosis, intermittent back pain, or both. The etiology of Scheuermanns disease is unknown, although the presence of cartilaginous (Schmorls) nodes indicating intervertebral disk herniation through the end plate suggests that congenital weakness of the end plates may be a possible mechanism. Altered biomechanical loading and juvenile osteoporosis have also been proposed as potential etiologies as well.

The typical radiographic findings include anterior vertebral wedging, Scmorls nodes, endplate irregularities, and kyphosis, usually in the thoracic spine. The diagnosis is made when at least three adjacent vertebrae demonstrate >50 of wedging. A subgroup of more athletic and active patients has been described with disease limited to the lumbar spine (apprentice kyphosis), with increased loading of an immature spine thought to be the major pathophysiologic mechanism accounting for the damage seen. The kyphosis in this condition is smooth and rounded; an acute angular kyphosis on X-ray suggests infection or fracture.

Treatment for the pain associated with Scheuermanns kyphosis is usually symptomatic, and as a first step includes physical therapy and bracing. Corrective surgery is performed with excellent results in patients with severe (>75%) kyphosis, intractable pain, or in those where the deformity is causing too great a psychological strain. Patients do quite well on long term follow up regardless of the treatment modality selected, and the condition is not associated with any increased risk of systemic illness or malignancy.

References:

  1. Wenger DR, Frick SL. Scheuermann kyphosis. Spine 24(24):2630-9, 1999.
  2. Soo CL, Noble PC, Esses SI. Scheuermann kyphosis: long-term follow-up. Spine J 2(1):49-56, 2002.
  3. Resnick D, Niwayama G. Intravertebral disk herniations: cartilaginous (Schmorl’s) nodes. Radiology 126(1):57-65, 1978.

Updated: July 9, 2012

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