Postural Kyphosis

Key Points:

  • Postural spinal balance is maintained by a complex interplay of the disc complex, ligaments, and muscles surrounding the vertebra 
  • Normal thoracic kyphosis is considered to be 20˚-40˚ as measured from T2-T12 
  • Postural kyphosis will present with a more gradual, rounded deformity than Scheuermann’s kyphosis
  • The deformity is completely correctable on an exam or with improved posture
  • Education of the patient and family is the most effective treatment 

Description:

  • Posture is the relationship of the body to a vertical line passing through the body’s center of gravity
  • Spinal stability and maintenance of an upright posture against gravity are maintained by a number of structures:
    • The disc complex: nucleus pulposus and annulus
    • Ligaments: anterior and posterior longitudinal ligaments, ligamentum flavum, interspinous ligament, apophyseal joint ligaments
    • Muscles: long spinal muscles, short intrinsic spinal muscles, abdominal muscles (Harrison, 1999)
  • The spine will be in a relatively flexed position until the child begins walking upright
    • To counteract the head’s anterior position to the body’s vertical axis, cervical lordosis develops and centers the head over the pelvis
    • In order to match the flexed position of the hips and pelvis, the lumbar spine becomes lordotic 
    • Unchanged from its infantile position, the thoracic spine will remain kyphotic (Johnston, 2014)
  • Normal thoracic kyphosis is considered to be 20˚-40˚ measured from T2-T12 (Fon, 1976)
    • The most common causes of hyperkyphosis in the adolescent are postural round-back deformity or Scheuermann’s kyphosis (Roussouly, 1999) 

Epidemiology:

  • Postural kyphosis is a condition seen not infrequently in adolescents. Its specific incidence is not defined in the literature 
  • The condition is most common in children who are taller than their peers and in young, adolescent girls with early breast development who are self-conscious about their bodies (Warner, 2014) 

Clinical Findings:

  • Parental concerns over the deformity, more so than patient concern, are typically what brings the child to the attention of an orthopedist. 
  • A gentle rounding of the spine in the thoracic region will be seen on a forward bend test.
    • The kyphosis in postural kyphosis is not as sharp or angular as that seen in congenital or Scheuermann’s kyphosis (Warner, 2014). 
  • The deformity should be completely correctable on an exam or with changes in posture. 
    • The erector spinae muscles can contract to correct the thoracic kyphosis while contraction of the abdominal musculature will flatten the concomitant lumbar lordosis (Johnston, 2014).

Imaging Studies:

  • Radiographs should show no osseous abnormalities in true postural kyphosis.
  • Thoracic kyphosis can be assessed on a standard lateral radiograph with a Cobb angle measurement extending from the superior end plate of T2 to the inferior end plate of T12. 
    • The apex of normal thoracic kyphosis is the T6-7 disc space.
    • The thoracolumbar junction should be without kyphosis or lordosis. 

Treatment:

  • No medical treatment is required for this condition owing to its benign natural history.
  • A hyperextension brace is not indicated (Warner, 2014).
  • Core strengthening exercises may provide some benefit and improve the adolescent’s posture, though compliance with any exercise program is difficult to achieve in an adolescent patient. 
  • Education of both the parents and the patient may be the best treatment option (Johnston, 2014).
  • Surgery is not indicated in this condition.

Complications:

  • Postural kyphosis is a self-limiting condition that has no long-term sequelae. 

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References:

1.    Fon, GT., Pitt, MJ., and Thies, Jr., AC. Thoracic kyphosis: range in normal subjects. Am J Roentgenol. 1976;134(5):979-83.
2.    Harrison, DD., et. al. Sitting biomechanics part 1: review of the literature. J Manipulative Physiol Ther. 1999;9:594-609.
3.    Johnston, CE. Kyphosis. In: Tachdjian’s Pediatric Orthopaedics. 5th ed. Philadelphia, PA: Elsevier;2014:308-27.
4.    Roussouly, P. and Nnadi, C. Sagittal plane deformity: an overview of interpretation and management. Eur Spine J. 2010;19:1824-36.
5.    Warner, Jr., WC. and Sawyer, JR. Kyphosis. In: Lovell and Winter’s Pediatric Orthopaedics. 7th ed. Philadelphia, PA; Lippincott, Williams, & Wilkins;2014:739-90.

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