1. science
2. medicine
3. surgery

THE
SURGICAL
TREATMENT
OF
G.
From
The results
of surgery
the
Spinal
R.
Service,
with
Scheuermann’s
in 59 patients
mature
pre-operative
patients
treatment
combined
and posterior
It is stressed
The treatment
ofScheuermann’s
kyphosis
is usually
servative.
However,
with
marked
deformity,
or
resistant
to medical
treatment,
or with neurological
cit. surgery
may be indicated.
Opinions
relative
merits
ofposterior
spinal
surgery
bined
1969;
anterior
Bradford
et al.
1980;
and
differ
alone
posterior
spinal
surgery
1975; Taylor
et al. 1979;
et al.
Herndon
et
1981).
al.
The
Institut
Ccilot,
Berck
kyphosis
P/age
are reported
at an average
immature
patients,
in whom the iliac apophysis
alone is adequate
and is followed
by little loss
anterior
is important.
KYPHOSIS
D. C. CHOPIN
Surgery
of 56 months.
These show that in skeletally
to the body of the ilium, posterior
fusion
skeletally
SPECK,
SCHEUERMANN’S
results
that
conpain
defi-
surgery
is recommended.
the indications
Patients
tory
results
and
radiographs
severity
of pain
The clinical
(Stagnara
Bradford
Stagnara’s
technique
the median
sagittal
vertical
plumb-line
medical
studied
and deformity
assessment
before
ofdeformity
about
T7; the horizontal
plumb-line
to the skin
patients
maximum
cervical
and lumbar
lordosis
prominence
of the sacrum.
The term
used to describe
these
measurements.
for surgery
and
to determine
the
best
technique
of the kyphosis.
PATIENTS
lumbarf/#{234}c/ies
Between
1969 and 1982, 65 patients
were operated
upon
for severe
Scheuermann’s
kyphosis
in the Spinal
Surgery
Service
at the Institut
Calot.
Sixty-one
medical
records
were
available
for this
study:
and 16 female.
The mean
recognised
was 1 3 years
average
age
at surgery
there
were
45 male
patients
age at which
the deformity
(range
6 to 20 years)
and
was
I 7 years
5 months
history
of
was
the
( I 21 to 45
years).
There
was
a
family
kyphotic
spinal
together
of
records,
labora-
to
and
(1969),
deviation
plane.
The patient
which
touched
the
tions performed
at the Institut
Calot
have therefore
been
reviewed
in order
to refine
the criteria
used in selecting
for correction
a period
are limited.
METHOD
and their
reviewed
as to the
and com-
of opera-
In all cases
for surgery
were
follow-up
has not yet fused
of correction.
For
distance
over the
give
compare
the
after surgery.
was made using
being
assessed
stood
against
thoracic
spine
in
a
at
was measured
from the
spinous
processes
at the
and
the posterior
fl#{232}che (arrow)
The
was
and
cervical
an indication
of the
magni-
tude ofthe
kyphosis,
while the lumbarfl#{234}c/ie alone shows
the compensatory
lumbar
lordosis.
Radiographs
were measured
for kyphosis.
lordosis,
vertebral
deformity
and scoliosis
at four time intervals.
These
were
pre-operative.
initial
postoperative
in a plas-
terjacket.
12 months
after operation
without
any brace,
and at final follow-up.
All films were taken
standing.
In
addition,
pre-operative
flexibility
of the kyphosis
was
assessed
by an elongation
test. This
is a lateral
radio-
deformity
in 38%
of patients,
and 15% were noted
to
have some degree
of mental
retardation;
41 % had hamstring
contractures
on admission
for surgery.
Other
muscle
contractures
were not observed.
Although
all patients
had a significant
kyphosis
of
graph
taken
with the patient
on an auto-traction
table
(traction
to head
and pelvis)
with a bolster
under
the
apex of the kyphosis
and the patient
exerting
a longitudinal traction
force ofabout
20 kg.
Treatment.
The surgical
treatment
can be divided
into
at least 60 (Cobb
angle),
46% had pain as their presenting complaint
and a further
16% admitted
to some pain.
The pain was situated
either
over the kyphosis
or in the
three
lumbar
region
and
No patient
presented
There
G.
Speck.
FRACS
Suite
17, Cabrini
Victoria,
Australia.
R.
was usually
of a mechanical
with neurological
deficit.
Orth,
Medical
C. Chopin,
MD, Chefde
Service Chirurgie
Orthopedic
Plage,
France.
D.
Requestsfor
reprints
should
Orthopaedic
Centre,
Service
du Rachis,
be sent
1986 British
030l-620X/862034
Editorial
Society
$2.00
VOL.
2. MARCH
68-B.
No.
Surgeon
Isabella
Street.
986
to Dr
of Bone
Institut
nature.
Joint
is no
thoracic
normal
Malvern
Calot.
D. C._Chopin.
and
phases:
preparatory.
operative
and reparative.
The preparatory
phase
is intended
to increase
the
flexibility
of the kyphosis
within
the physiological
range.
Surgery
F-62600
3144,
Berck
agreement
as to the
amount
kyphosis
but the consensus
limit of 40 to 45 (Roaf
1980; Stagnara
ci al. 1982).
tractures.
auto-elongation
of the
normal
suggests
an
1960; Bradford
Physiotherapy
to stretch
and night
traction
were
upper
ci al.
conused
routinely.
Plaster
jackets
were used for progressive
correction
of the kyphosis
in those
curves
which.
initially.
were not sufficiently
flexible;
these jackets
were made on
a Cotrel
to diminish
casting
the
frame
lumbar
with
the
lordosis.
patient
The
positioned
patients
so as
were
then
159
190
G.
progressively
padded
to reduce
and then the thoracic
kyphosis.
eight
weeks.
An elongation
test
tion
near
to confirm
physiological
The
rection
and
three
a scoliosis
used on the
the convexity.
usually
took six to
done
before
operacould
with
with
inferiorly.
of more
the
This
was
be
lordosis
reduced
was to maintain
of the preparatory
this was achieved
rods,
generally
superiorly
lumbar
bilateral
at least
30
concave
side with
Posterior
fusions
to
Scheuermann’s
Risser
sign
Stage
Table
werejudged
V gives an analysis
of
to be skeletally
mature:
Table
the corphase.
In
four
posteriorly
was
mature
patients
surgery.
Anterior
autogenous
rigid part
nine
had
disc
(range
anterior
excision
tibia and/or
of the kyphosis.
bone
rod
grafting
and
after
surgery
and the following
analysis
ofthese
patients.
Deformity.
All the patients
were
5.4
(2.0
13.0)
on
the
Lumbar
7.3
(4.0-12.0)
4.3
(2.0
8.0)
The fl#{232}cherepresents
line which just touches
the lordosis
Table II. Overall
515 results
based
with
improvement
was reduced
Kyphosis
the
then
are
Lumbar
a
follow-up
based
Table
patients
lordosis
III.
Average
(47 patients)
with
ofthe
kyphosis.
The height
ofthe
by 40%
and the lumbar
lordosis
20
corrected
toSS
by 36
(Table
to 41
and
the
lumbar
on an
the clinical
kyphosis
also was
lordosis
by
II).
at final
kyphosis
follow-up
corrections
of P<0.l
is within
the normal
range
(Stagnara
et a!. 1982).
Negative
values
for the apical
vertebrae
were found
in two patients,
mdicating
wedging
in the reverse
direction
to that found
in
in
skeletally
immature
( degrees)
38
33
30
62
2+3(n=34)
74
39
34
37
56
(n=6)
75
40
42
42
4
*
The
have
numbers
fusion
by 5
Table
IV.
40
I to 4 describe
appeared
how
radiographically:
Correction
shown
of
many
quarters
of the iliac
non-appearance
vertebral
by the amount
is indicated
deformity
ofwedging
in skeletally
ofapical
Average
vertebra
wedging
V. Results
of surgery
by 0. and
immature
Final
5.7
13.5
(5 to 25)
(-3to
9.7
4.5
in skeletally
Kyphosis
apophysis
(in degrees)
Pre-operative
Site of
fusion
of4.5
of
55
(34-83)
78
1 (n=7)
Stage
shown
value
41
(13 83)
12)
Follow-up
(months)
Table
average
77
(60-I
Final
between
the groups
are not statistically
significant.
The effect of surgery
on the wedging
of the vertebral
body
in the skeletally
immature
patients
(Risser
sign
the
Final
Postoperative
sign*
Wedging
and
Pie-operative
analysis
of the corsign at the time of
in Table
IV. The
t-test,
a significance
(degrees)
Elongation
test
surgery
in skeletally
immature
patients.
Good
correction
of the kyphosis
is shown
on the pre-operative
elongation
test, and the immediate
postoperative
kyphosis
measurement is similar.
The slight differences
in loss of correction
4 or less) is shown
have,
in a paired
lordo-
Preoperative
patients,
Table
III shows
a more detailed
rection
obtained
related
to the Risser
(lumbar
75
(44-108)
correction
of
Risser
0+
satisfied
from a plumbto the apex of
results
ofsurgery
on 35 patients)
the
reduced
by 40% (Table
I, Figs I to 6). The normal
value
given for cervical
and lumbar
lordoses
is 3 cm for each.
Assessing
the overall
results,
radiologically
the kyphosis
was
the distance
the kyphosis
Curvature
Stage
results
who
sign
(cm)
8.9
(4.5-ISO)
Kyphosis
12 months’
a
(45
Cervical
fusion
consolidates
and, in the skeletally
immature,
when
the vertebral
body
remodels.
During
the first two weeks
after operation
the patients
were nursed
supine,
followed
patients
deformity
was
surgery
in four patients,
being two to four weeks.
is the period
during
which
RESULTS
had at least
of
Final
system
over
by an average
ofsix
months
in a plasterjacket
further
12 months
in a plastic
brace.
the I 2 patients
10 with a Risser
Pre-operative
rib was performed
in the most
The anterior
surgery
was per-
formed
after
the posterior
delay between
the operation
The reparative
phase
Fifty-nine
correction
patients
had
sign Stage
I.
Fl#{232}che
4 to I 3). Seven
skeleas well as posterior
and
Clinical
Correction
full extent
of the instrumented
levels
using autogenous
iliac crest bone graft
supplemented,
in five of the earlier
cases,
with a tibial
graft.
The average
number
of levels
fused
tally
I.
one
of these
the other a Risser
patients
, a distraction
a compression
were performed
disease;
0 and
patients)
Harrington
three
hooks
In a further
than
D. C. CHOPIN
first
kyphosis
aim of the operation
obtainable
at the end
50 patients
compression
with
that the
levels.
R. SPECK,
mature
patients
( I2
14)
patients)
(degrees)
Follow-up
Anterior
+ posterior
(,i=6)
Posterior
(n=6)
only
Preoperative
Postoperative
Final
(months)
82
(60-I
44
45
50
12)
83
(60-
44
58
68
107)
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
THE
Fig.
SURGICAL
TREATMENT
I
Fig.
VOL.
68 B, No.
male
with
2, MARCH
191
KYPHOSIS
2
Fig. 5
Fig. 4
A 17-year-old
OF SCHEUERMANN’S
Scheuermann’s
1986
kyphosis
measuring
after operation.
75
from T8 to Tl2.
Figures
with correction
maintained
1 to 3-Before
at 40
operation.
Fig.
3
Fig.
6
Figures
4 to 6-Three
years
192
G.
Table
l.
Pitients
s ith at least
Risser
1.evels
Case
sign
fused
Kyphosis
levels
I
0
TIIL2
T6L2
2
I
T5
T4l2
3
3
T3LI
4
3
T2
5
3
6
I0
loss
of correction.
R.
SPECK,
showing
C.
CHOPIN
its cause
Angle
II
I).
of kyphosis
(degrees)
Postoperative
Final
Reason
63
28
45
Short
fusion
78
34
55
Short
fusion
Initial
for failure
T4
12
66
19
35
Short
fusion-subsequently
extended
to L2
II
T4
II
60
28
47
Short
fusion-subsequently
extended
to L2
T2
12
T3
LI
78
37
64
Infection
5
T3
12
T4
10
107
54
85
Wound
7
5
T410
T3
II
80
48
60
Short
fusion
8
5
T5
12
T3
12
85
60
83
Short
fusion
9
5
T5
12
T3
12
66
36
62
Short
fusion
Stage 5. and two with a Risser sign Stage 4 but with fused
vertebral
apophyses
at operation.
The six patients
who
had both anterior
and posterior
surgery
had only I loss
details
of blood
replacement
recorded
in 23 posterior
ofcorrection.
VII.
fusion
highly
whereas
alone
lost
significant.
the six patients
14 of
Three
who
correction;
patients
had
this
the
in
difference
is
latter
group
(Cases
7, 8 and 9 in Table
VI) had an inadequate
of fusion
and another
patient
had an infection
a wound
breakdown,
rods I 6 months
after
loss
eventually
operation,
ofcorrection
from
Loss of correction
patients;
their
details
2 had an inadequate
an extension
ofthe
requiring
followed
length
kyphosis
the final
had an
removal
total kyphoses
infection
with
of the rods
Although
present
significant
in 12 patients
6; Table
occurred
in Table
grossly
abnormal.
Stapht’lococcus
aureus
seven
after
months
scoliosis
of
pre-operatively,
gression
after fusion.
Pain. Twenty-eight
patients
had,
tion. significant
back pain requiring
Case
requiring
operation.
more
than
20
none showed
Table
the time
treatment.
was situated
either
in the thoracic
spine
sis or in the lumbar
spine;
it was usually
ture and fatigue.
A further
10 patients
was
pro-
of operaThe pain
over the kyphorelated
to poshad less severe
pain.
in
At follow-up
the lumbar
patients
was
had
a man
only
who
10 patients
and
two
in
mild
complained
the thoracic
of pain:
spine.
eight
Four
and
working;
one
symptoms
regularly
carried
were
50 kg
loads.
Another
patient
had a road traffic accident
five years after operation and sustained
a severe
crush
fracture
of L3 with an
angular
kyphosis
of 20 and lumbar
pain. The other
five
patients
who still had pain at follow-up
all had residual
kyphoses
of more than 60
There
were six patients
in the
.
whole
series
five ofthese
Complications.
with a final
had pain.
Regarding
kyphosis
blood
of more
loss
at
than
operation,
with
60
and
the
infection
final haematocrits
were
and in five combined
these
significant
6 in Table
5 and
VII.
Blood
replacement
after
Site of
operation
5
and
are
shown
There
were four instances
of infection:
required
removal
of the implants
and
Posterior
(ii=23)
only
Anterior
(n5)
+
One
at
fusions:
I and
of fusion.
Cases 3 and 4 show
to subjacent
levels, although
are not
posterior
and
fusions
tion
was successfully
treated
biotics
and suction
irrigation.
VI).
in nine
VI. Cases
mately
and
were
associated
kyphosis
(Cases
length
following
removal
of the
by progressive
54 to 85 (Case
of at least
10
are shown
anterior
posterior
breakdown
posterior
patient
had
in Table
three
ultitwo of these
progression
VI). The fourth
with
of
the
infec-
debridement,
anti-
surgery
Total blood
transfused
(units)
Final
haematocrit
(per cent)
5.4
(48)
37
(32
1 2.8
(8-18)
41
neurological
48)
(32-45)
complications
follow-
ing surgery,
illustrating
the difficult
problems
which
may
be encountered
in older
patients
with significant
associated
scoliosis.
He was a man of45
at the time of operation,
with
a 1 12
kyphosis
from
T3 to Tb,
a right
thoracic
scoliosis
from T5 to Tl0 of62
and a vital capa-
‘,
city 47% of normal,
He had one month
of
halo-traction.
In January
1981
he had
osteotomies
with a contraction
rod from T3
distraction
rod from TI to L I He had no
pre-operative
six posterior
to Tl0 and
neurological
.
a
deficit
immediately
after operation
but four hours
later
he developed
an incomplete
spinal
cord lesion of BrownS#{233}quard type. He had motor
loss on the right side and
sensory
loss on the left. He was immediately
returned
to
theatre
and
neurological
with
all implants
recovery.
halo-traction,
then
were removed,
resulting
in full
For
three
weeks
he continued
had
an anterior
fusion
to TlO using fragmented
rib grafts
and tibial
from T3 to T9. Two weeks
later a posterior
THE
JOURNAL
OF
BONE
AND
from
strut
fusion
JOINT
T2
grafts
from
SURGERY
THE
C7
to LI
was
performed,
contractor
from T4
had to be reattached
follow-up,
using
after
compared
was 43
,
TREATMENT
a distraction
rod
OF
with
operation,
the
with the
and stable.
kyphosis
was
postoperative
He had no
film,
neuro-
thoracic
demonstrates
especially
the
the
in
fragillower
Five
patients
developed
two
before
pressure
and
three
with conservative
treatment.
There
were no thrombo-embolic
deaths
due to surgery.
sores
after
under
operation.
nor
treatment
of
or simply
observation,
kyphosis
is certainly
exercises,
depending
on the
0. 1 or 2, we feel that rarely
By increasing
the flexibility
prevent
any
in
patients
of growth.
skeletally
immature
Stage 3 or 4 and a severe
thoracic
or thoracolumbar
posterior
outlined.
The
fusion
if ever
of the
patients
symptoms
and
technique
of
the
posterior
ofhooks
and
possible
should
five inferiorly.
should
be placed
under
the
ity ofthe
lowermost
thoracic
VOL.
68-B,
No.
2, MARCH
1986
4 and
anterior
However,
and
it is
lower
fusion
part
limit
includes
the apex
of the curve,
and
of the
kyphosis
to
inferiorly.
In assessing
the adequacy
of correction
it is worth
recalling
the high incidence
of pain
in patients
with a
residual
kyphosis
of more
than 60
Inadequate
correction is especially
likely to occur
in this group
of skeletally
mature
patients
where
the curve
is less mobile,
if there is
inadequate
preparation
for surgery
or if the surgery
is
observation,
severe
cases,
with
kyphosis
be avoided.
bracing
requiring
for the
patients
when
required;
major
surgery
earlier
and
by careful
in this
can.
way
in
most
with
a Risser
sign
preparatory
treatment
instrumentation
is
REFERENCES
Bradford
DS, Ahmed KB, Moe JH, Winter
RB, Lonstein
JE. The surgical management
of patients
with Scheuermann’s
disease:
a review
of twenty-four
cases managed
by combined
anterior
and posterior
spine fusion. J Bone Joint Surg [Am] 1980:62
A:705
12.
Bradford
DS, Moe
JH,
Montalvo
FJ, Winter
RB. Scheuermann’s
kyphosis
and roundback
deformity:
results
of Milwaukee
brace
treatment.
J Bone Joint Surg [Am] l974:5
A : 74U 58.
Bradford
DS, Moe
JH,
Montalvo
FJ, Winter
RB. Scheuermann’s
kyphosis:
results of surgical
treatment
by posterior
spine
arthrodesis in twenty-two
patients.
J Bone Joint Surg [Au:] 1975:57
A:
439 48.
Stagnara
P. Deviations
%lt’rlCluir
(Paris).
the full length
of the kyphosis
respectively.
In operating
on
number
superiorly
to the
ofcorrection
over
loss
should
of the
The anterior
the most
rigid
extends
loss
Herndon
WA,
posterior
125 30.
articular
process
full correction
combined
results.
a Risser
Stage
fusion
is then performed
in compresin tension
as occurs
if it is performed
as
important.
The instrumentation
and fusion
must extend
over the whole
length
of the kyphosis.
A comparision
of
the postoperative
loss of correction
between
2 1 patients
with a short
fusion
and the 38 with a fusion
extending
ferior
allow
with
sign
is surgery
mdispine using the
kyphosis,
especially
in the lower
spine,
we recommend
a
following
(those
a Risser
inadequate
to mobilise
the curve.
Finally,
a plea should
be made
more
effective
management
of these
not surgical.
physiotherapy
methods
already
outlined,
one can usually
achieve
a
physiological
kyphosis
which
can be treated
with a brace
while awaiting
maturation
of the vertebral
body and the
completion
For
system.
Anterior
sion rather
than
especially
severity
(Stagnara,
du
Peloux
and
Fauchet
1966;
Bradford
et al. 1974).
In the skeletally
immature
patient
with a Risser
sign
Stage
cated.
patients
with
.
Scheuermann’s
with a curve
of less than
60
Treatment
may be with a brace,
those
flexibility,
especially
in younger
patients.
The posterior
surgery
is performed
as previously
described
but with
one important
modification
of the facet-joint
excision:
the superior
and inferior
processes
are both
excised
to
allow
reduction
of the kyphosis
with
the compression
All
DISCUSSION
The
mature
5 and
fused ring apophyses)
we believe
posterior
surgery
offers
the best
the
healed
problems
skeletally
Stage
the first procedure.
of the kyphosis.
spine.
plasterjackets,
For
sign
I 93
KYPHOSIS
not essential
that the anterior
surgery
be performed
first,
except
in the rare case of anterior
synostosis.
The preparatory
phase
still allows
some
degree
of increase
in
There
was one case of a broken
rod above
the lower
hook
at six months.
The kyphosis
progressed
from
a
post-operative
value
of 33
to 40
at 12 months
but
showed
no further
progression
at two years.
Seven
fractures
of transverse
processes
occurred
during
these operations:
two each at TI 1 and Tl2 and
one each at Tl, T2 and T5. This
ity of the transverse
processes
SCHEUERMANN’S
a
to Tl 1; the upper
distraction
hook
to TI after a further
two weeks.
At
41 months
73
a loss of 3
and his scoliosis
logical
dysfunction.
SURGICAL
gives a 6.6 and 2.6
the facet joints
the in-
be generously
kyphosis.
The
resected
maximum
be used, preferably
The
hooks
below
laminae
in view of the
transverse
processes.
to
five
T9
fragil-
Roaf
Emans JB, Micheli
U, Hall
fusion
for
Scheuermann’s
R. Vertebral
[Br] 1960:42
growth
B:40
and
59.
JE. Combined
anterior
and
kyphosis.
Spine
1981 :6:
its mechanical
control.
et deformations
Appareil
Loeo,noteur
sagittales
1969:4.
J Bone Joiiui
du
rachis.
1 .01
: I 5865
Surg
Encyel
E 10.
Stagnara
P, De Mauroy
JC, Dran G, et a!. Reciprocal
angulation
vertebral
bodies
in a sagittal
plane: approach
to references
for
evaluation
ofkyphosis
and lordosis.
Spine
1982:7:335
42.
of
the
Stagnara
P. du Peloux J, Fauchet
R. Traitement
orthop#{233}dique ambulatoire de la maladie
de Scheuermann
en p#{233}rioded’#{232}volution. Reu’
ChirOrthop
1966:52:585
600.
Taylor
TC, Wenger
DR, Stephen J, Gillespie
management
of thoracic
kyphosis
in
Surg[Am]
1979:61
A:496
503.
R, Bobechko
adolescents.
WP. Surgical
J Bone Joint