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Round Back / Kyphosis

Definition :
Kyphosis is a forward rounding of your upper back (thoracic spine). Some rounding is normal, but the term "kyphosis" usually refers to an exaggerated rounding, more than 40 to 45 degrees. This deformity is also called round back or hunchback.

The thoracic spine consists of the middle 12 vertebrae, which connect to your ribs. With kyphosis, your spine may look normal or you may develop a hump. Kyphosis can occur as a result of developmental problems; degenerative diseases, such as arthritis of the spine; osteoporosis with compression fractures of the vertebrae; or trauma to the spine. It can affect children, adolescents and adults.

Mild cases of kyphosis may cause few problems. But severe cases may affect your lungs, nerves and other tissues and organs, causing pain and other problems. Treatment for kyphosis depends on the cause of the curvature and its effects. It may range from physical therapy to braces to surgery.

Different types of kyphosis have different causes.

Types of kyphosis in children and adolescents
For children or adolescents, the most common types include :

  • Postural kyphosis. This type mainly becomes apparent in adolescence. The onset of postural kyphosis generally is slow. It's more common in girls than in boys. Poor posture or slouching may cause stretching of the spinal ligaments and abnormal formation of the bones of the spine (vertebrae). Postural kyphosis often is accompanied by an exaggerated inward curve (hyperlordosis) in the lower (lumbar) spine. Hyperlordosis is the body's way of compensating for the exaggerated outward curve in the upper spine.
  • Scheuermann's kyphosis. Like postural kyphosis, Scheuermann's kyphosis typically appears in adolescence, often between the ages of 10 and 15, while the bones are still growing. Also called Scheuermann's disease, it's about twice as common in boys as it is in girls. The onset may be accompanied by pain, generally mild, and fatigue. However, unlike postural kyphosis, Scheuermann's may deform the vertebrae so that they appear wedge-shaped, rather than rectangular, on X-rays. There may be another finding, known as Schmorl's nodes, on the affected vertebrae. These nodes are the result of the cushion (disk) between the vertebrae pushing through bone at the bottom and top of a vertebra (endplates). The cause of Scheuermann's kyphosis is unknown, but it tends to run in families. Some people with this type of kyphosis also have scoliosis, a spinal deformity that causes a side-to-side curve. Adults who developed Scheuermann's during childhood may experience increased pain as they get older.
  • Congenital kyphosis. A malformation of the spinal column during fetal development causes kyphosis in some infants. Several vertebrae may be fused together or the bones may not form properly. This type of kyphosis may worsen as the child grows. After trauma and infection, congenital kyphosis is the next most common cause of paralysis of the lower body (paraplegia).

Causes in adults
For adults, the bone-thinning disease osteoporosis may be associated with compression fractures of the vertebrae that result in kyphosis. Other disorders that may cause a curvature of the spine, resulting in either kyphosis or scoliosis, include :

  • Degenerative arthritis of the spine, which can cause deterioration of the bones and disks of the spine
  • Ankylosing spondylitis, an inflammatory arthritis that affects the spine and nearby joints
  • Connective tissue disorders, such as Marfan syndrome, that may affect the connective tissue's ability to hold joints in their proper position
  • Tuberculosis and other infections of the spine, which can results in destruction of joints
  • Cancer or benign tumors that involve the spine, impinging on bones of the spine and forcing them out of position
  • Spina bifida, a birth defect in which part of the spine doesn't form completely, and which causes defects of the spinal cord and the bones of the spine
  • Conditions that cause paralysis, such as cerebral palsy and polio, and which stiffen the bones of the spine.

Risk Factor :
Certain groups of people are at higher risk of kyphosis :

  • Adolescent girls with poor posture, who are at greater risk of postural kyphosis
  • Boys between the ages of 10 and 15, who are at greater risk of Scheuermann's kyphosis
  • Older adults with osteoporosis, who are at greater risk of spinal fractures that can cause kyphosis
  • People who have certain ailments, such as Marfan syndrome, which affects connective tissue

When to seek medical advice :
Because kyphosis often produces no signs and symptoms, it may go unnoticed until a routine physical examination or until a school screening for scoliosis. However, other people may notice pain, or kyphosis may cause a noticeable rounding of the shoulders or a hump on the upper back.

Have your child examined if you see any of the signs of kyphosis. Also, if you develop any of the signs, see your doctor for an examination to determine whether you need further evaluation, such as a bone density screening test for osteoporosis.

Although rare, kyphosis can lead to serious health problems, such as physical deformity, breathing difficulties or damage to internal organs that are affected by the postural changes. So it's important to see a doctor if you see experience indication of kyphosis.

In mild cases, kyphosis may produce no noticeable signs or symptoms. However, signs and symptoms may include :
  • Slouching posture or hunchback
  • Mild back pain
  • Spinal stiffness or tenderness
  • Fatigue

Your doctor will take a history of your condition and conduct a physical exam. The exam may include the following :

  • Forward bend test. Your doctor will ask you or your child to bend forward from the waist while the he or she views the spine from the side. With kyphosis, the rounding of the upper back may become more obvious in this position.
  • Neurological functions test. Although neurological changes accompanying kyphosis are rare, your doctor may check for them by looking for weakness, changes in sensation or paralysis below the site of the kyphosis.
  • Spinal X-ray. Your doctor may take an X-ray to confirm the kyphosis, determine the degree of curvature and detect any deformity of the vertebrae, which helps identify the type of kyphosis. For example, the appearance of wedge-shaped vertebrae or other features on X-ray differentiates between postural kyphosis and Scheuermann's kyphosis. In older people, X-rays may show arthritic changes in the spine, which may contribute to an increase in pain.
  • Pulmonary function tests. Your doctor may also use tests to measure breathing to assess any breathing difficulty caused by the kyphosis.
Complications :
Kyphosis may cause the following complications :
  • Body image problems. Adolescents, especially, may develop a poor body image from having a rounded back or from wearing a brace to correct the condition.
  • Deformity. The hump on the back may become prominent over time.
  • Back pain. In some cases, the misalignment of the spine can lead to pain, which can become severe and disabling.
  • Breathing difficulties. In severe cases, the curve may cause the rib cage to press against your lungs, inhibiting your ability to breathe.
  • Neurological symptoms. Although rare, these may include leg weakness or paralysis, a result of pressure on the spinal nerves.
Treatment for kyphosis depends on the cause of the condition and the signs and symptoms that are present.

Less serious cases
In some cases, less aggressive types of treatment are appropriate :

  • Postural kyphosis. This type of kyphosis doesn't progress and may improve on its own. Exercises to strengthen back muscles, training in using correct posture and sleeping on a firm bed may help. Pain relievers may help alleviate any pain.
  • Structural kyphosis. For kyphosis caused by spinal abnormalities, treatment may depend on your age and sex, the severity of your symptoms and how rigid the curve in your spine is. With Scheuermann's kyphosis, monitoring for progression of the curvature may be all that's recommended if you have no symptoms. Anti-inflammatory medications may help relieve pain. General conditioning exercises and physical therapy may help alleviate symptoms.

More serious cases
More serious cases of kyphosis require more aggressive treatment. The primary approaches are bracing and, as a last resort, surgery. With children and adolescents, the sooner that treatment begins, the more effective treatment may be in halting the deformity.

When bracing is necessary
If your teenager is still growing and has a curve of at least 45 degrees but less than 75 degrees, your doctor may recommend bracing. Wearing a brace may prevent further progression of the curve and may even provide some correction.

There are several types of braces for kyphosis. Your doctor can discuss with you which brace would be most effective for you.

Children who wear braces usually can participate in most activities and have few restrictions. However, a brace may feel uncomfortable and awkward at first. Your child must wear the brace as prescribed for it to be effective. Once the bones are fully grown, your child can be weaned off the brace according to your doctor's instructions.

There are different types of braces for treating kyphosis in adults, varying from postural training devices to rigid body jackets. The goal of bracing in adults is typically to control pain.

When surgery is necessary
Spinal surgery carries many risks, so your doctor may recommend surgery only if you or your child has any of the following :

  • A curvature greater than 75 degrees
  • Kyphosis that continues to worsen
  • Debilitating pain that doesn't respond to medication
  • Neurological problems, such as paralysis, as a result of the kyphosis

Your doctor may recommend surgery if you have an infant with congenital kyphosis, in order to straighten the spine.

The goal of surgery is to reduce the degree of curvature. This is commonly done by fusing or joining the affected vertebrae. Doctors typically perform the surgery through incisions in the back, using general anesthetic.

Fusing the vertebrae involves connecting two or more of them with pieces of bone taken from the pelvis. Eventually, the vertebrae fuse with the bone pieces to prevent further progression of the curve. Doctors attach metal rods, hooks, screws or wires to the spine to hold the vertebrae together while the bones fuse, which may take several months. Doctors leave the metal in the body to help support the fused area even after the bones have fused.

A drawback of spinal fusion is that it stops growth in that area of the spine. A child's ultimate height isn't affected greatly because the leg bones and the unaffected portion of the spine continue to grow normally.

The complication rate for spinal surgery is high. Complications include bleeding, infection, pain, nerve damage, arthritis and disk degeneration. If the surgery fails to correct the problem, a second surgery may be needed.

Other procedures
Procedures called vertebroplasty and kyphoplasty have been developed recently to treat vertebral fractures. These procedures involve injecting a type of inert cement into the affected vertebrae. They can be effective in controlling pain associated with compression fractures.

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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