myKyphosis

Kyphosis refers to any abnormal amount of forward curvature in the spine. Although it can occur at any location in the spine, it is most commonly observed in the thoracic region, where it is often referred to as a "hunchback" deformity. There are many potential causes of kyphosis in adults, but the most common two are a result of 1) osteoporosis and 2) previous spinal surgery.

Osteoporosis refers to the condition in which a person's bone becomes weaker and more porous with age. Although it can affect males, it most commonly affects women who are post-menopause. Eventually, the bone weakens to the point where the spine cannot support the weight of the body and it buckles, resulting in what is called an osteoporotic compression fracture. Although these types of fractures are not dangerous, they do alter the shape of the spine, causing people to gradually bend forward as if they were hunched over.

 A similar process can occur after spinal fusion surgery. Because the fused portion of the spine no longer moves, the remaining spine above the surgery site has to make up for the loss of motion. This results in greater wear and tear of the portion of the spine above the fusion. With time, a person may notice that he or she is gradually leaning forward.

 Regardless of cause, the most common complaint other than cosmetic deformity that accompanies kyphosis is pain. The pain is generally localized in the area of the deformity and may be quite severe in intensity. It is also often related to physical exertion, but may be present even at rest. In severe cases, an individual may lose the ability to stand up straight.

Despite the often severe level of pain and discomfort it causes, kyphosis is generally not dangerous. For most patients, a combination of physical exercises to strengthen postural muscles along with non-steroidal anti-inflammatories is sufficient. For people who fail to improve with these methods, who have a progressively worsening deformity, or who have an inability to functionally stand, referral to a spine surgeon who is fellowship trained in spinal deformity, specializes in adult deformity and a member of the Scoliosis Research Society is a good next step. Surgical treatment for this condition can be technically demanding so it is appropriate to discuss all treatment options.

Overview

If you have healthy bone, it takes a considerable amount of force to break your back. The most common causes of spinal fracture are falls from a height and motor vehicle accidents. When vertebra are injured and fracture, collapse is often the result. In cases where the collapse is significant, abnormal stresses arise in the adjacent facet joints and disks, often causing pain. Pain can also be caused by muscle fatigue from trying to compensate for the stooping posture and stand straight. Premature arthritic changes in the involved and adjacent joints can also occur.

Mild fractures in the upper, middle, and lower back can be tolerated fairly well if the hips are not arthritic and the rest of the spine is healthy and flexible. The only treatment required is symptomatic relief with analgesics and a daily exercise program to keep the spine core muscles strong. Occasional brace wear can also be helpful for some. Most people never need anything more than this.

If the fractured vertebra collapses to the point of causing > 20 – 30 degrees of kyphosis, pain will likely result. In such severe cases, the decision to proceed with surgical correction is made on an individual basis based on clinical and radiographic factors. Typically, surgery is not urgent unless there is progression of the deformity, neurologic compromise, and pain unresponsive to conservative care.

Osteoporosis and Spine Fractures

Osteoporosis is a skeletal disorder in which bones become fragile and are more likely to break. If not prevented or treated, osteoporosis can progress painlessly until a bone breaks. These broken bones, called fractures, are most likely to occur in the hip, spine or wrist. Possible causes include hormonal imbalances, pregnancy, metabolic diseases, cancer, or in otherwise healthy people over age 60 to 65.

 Twenty-eight million Americans are at risk for developing osteoporosis. Every year, there are 1.5 million new fractures in people who have soft bone caused by osteoporosis. Of these, 700,000 people annually sustain spine fractures, 300,000 hip fractures, 250,000 wrist fractures and 250,000 fractures of other bones, all as a result of osteoporosis. With 700,000 spine fractures a year, this translates to one compression fracture every 45 seconds. After a patient sustains their first compression fracture, the risk of an additional fracture goes up more than five fold.

Problems and Challenges

Problems Associated with Compression Fractures

When soft osteoporotic bone breaks, patients describe onset of significant back pain. Pain can be in the upper or lower back. When the fracture occurs, severe pain can cause a patient to be bedridden for a few weeks. If the vertebra collapses, a deformity forms in the back and the patient begins to hunch forward. This posture can lead to difficulty with breathing and digestion, problems standing up straight, increasing back pain, decreased ability to walk even medium distances, and an overall decrease in the quality of life. When the fracture settles and the patient begins to slouch forward, additional vertebrae are much more likely to fracture, increasing the problem and the hunching forward even further.

The Human Cost of Compression Fractures

The pain from a fractured vertebra causes a decrease in the level of activity. Patients describe the inability to be up and walking and performing daily activities. Often, depression sets in. Patients develop a lower self esteem as they become more reliant on others for their daily care. Anxiety is common as patients are concerned about their increasing dependence on others.

 According to a 1998 study there is a significant decrease in the lung function in patients with thoracic or lumbar fractures. Each thoracic or upper back fracture causes a 9% loss of vital capacity of the lungs (Journal of American Respiratory Disease).

 In a retrospective analysis of five-year survival rates done at the Mayo Clinic, patients with osteoporotic compression fractures of the vertebra were found to have a worse than expected survival rate for the five years following the fracture. This decrease in survival rate was found to be similar to those patients who sustained a hip fracture. The most common cause of premature death was pulmonary disease, emphysema and pneumonia.

Conservative Treatment

Non Operative Treatment of Spinal Fractures

The usual treatment for compression fractures has been management with pain medication. Narcotic pain medicines are used for a few months until the pain decreases. Pain from fractured bone can last from three months to more than a year, depending on the circumstances and the severity of the broken bone.

After the pain from the fracture improves, patients need to build up bone strength. A few medications are available to increase bone density. The treatment is slow and continues for years. It is the only treatment we have at this point to increase bone mass and therefore should be used by patients who are at risk for osteoporotic compression fractures, and those who have had fractures in the past. By building the bone density, we hope to prevent future fractures. 

Immobilization of the spine with a brace can help decrease pain from broken vertebra. The most appropriate brace is a soft elastic waistband with Velcro straps. Sometimes metal strips or a plastic insert in used in the back of the brace for added support. The brace is only helpful for fractures of the lower back.

Scheurmanns Kyphosis is a condition that involves growth plate abnormalities in the growing vertebra of the spine. It is first noticed in the teenage years and occurs in both boys and girls. What parents notice most is a slumping or slouching posture. It is very common for parents to remind their teens to stand up straight and "stop slouching." Pain, when present, can occur in any area of the back that is involved with these growth plate abnormalities. The most common site is in the upper back or thoracic spine. Pain in this case can occur between the shoulder blades as it relates to the slumping or slouching-forward spine, or it can occur in the low back where the spine has to arch excessively to compensate for the humped-forward section above it.

While the spine is still growing, scheurmanns kyphosis can be treated with a modified Milwaukee type brace. This is a brace that takes stress off the front of the spine allowing the growth centers to grow more normally. The typical trapezoid shape vertebra of scheurmanns kyphosis can evolve into more square-shaped vertebra with braceware. If the teenage growth spurt is already complete, bracing is no longer an option. For treating adults with scheurmanns kyphosis, a brace won't help.

For severe cases, where posture and spinal balance are of concern, and in cases of significant back pain, surgical correction may be indicated.

Current techniques for the typical kyphosis occurring in the upper back involves surgery in two parts. The first part surgery is a thoracoscopic release and removal of multiple discs through the area bent forward. The discs are then replaced with bone grafts usually from the bone bank. The scars from this surgery are betw 4-6, 1-2 inch scars on the side of the chest, beneath the right arm. Cosmetically they are typically quite acceptable.

The second part of the surgery involves an incision in the back part of the spine where rods, hooks and screws are inserted in the back part of the spine. The slumping forward posture is gently and slowly corrected. The newest techniques involve multi-planar adjusting spinal screws (Medtronic) which allows for very controlled, gradual and incremental correction of the kyphosis in a manner that is safe and highly effective.

Degenerative kyphosis is a condition of the aging spine. When the spine ages, the discs commonly settle. When this occurs in the upper back, patients can become slumped forward in their posture. When it occurs in the low back, patients develop a stooped-forward posture. In either case, degenerative kyphosis usually leads to significant back pain and can also be associated with spinal stenosis or nerve compression.

Conservative care for this condition can include physical therapy to improve flexibility. Patients are encouraged to be as active as they can be, and to adopt a daily exercise program to build flexibility and strength in the trunk muscles.

When conservative care is not effective and pain is a significant problem, surgical solutions can be entertained. Patients must be in generally good health, and a full medical work-up including MRI and XRay imaging is performed.

When surgery is indicated, all areas of the spine with significant nerve compression are addressed by removing the bone spurs causing the nerves to be pinched. New generation multi-planar adjusting screws (Medtronic) can be placed in the spine to gently and gradually reduce and effectively correct the slumping-forward posture, and lock it in a new straightened, normal spinal contour. 

The results with surgery in patients with degenerative kyphosis and lumbar flat back are often life-changing for patients. It is not unusual to have patients regain energy, stamina, strength, and social confidence in addition to getting rid of significant pain when their degenerative kyphosis is addressed surgically.