Scheuermann disease, (juvenile kyphosis), is a growth disturbance with curving deformity of the thoracic or thoracolumbar spine in adolescents that causes an increase bowing or rounding of the back in the sagittal plane. It is defined by anterior vertebral wedging of at least 5° in 3 or more adjacent vertebral bodies. It is most commonly seen in the thoracic spine. Often, it produces pathologic thoracic kyphosis (>40°; normal is 20°-40°). Type 1 Scheuermann’s disease involves the thoracic spine, whereas type 2 involves both the thoracic and lumbar spine.1 Scheuermann’s disease presents as a postural deformity and subacute thoracic pain in adolescents.1
The etiology of Scheuermann disease remains undetermined.1 It is characterized by defective growth of the vertebral cartilage endplate, which probably results from a predisposing genetic background that affects the quality of matric components and chondrocytes. An autosomal-dominant mode of inheritance is suspected.2
There have been many other etiologic theories, including mechanical factors, increased growth caused by excess growth hormones, osteoporosis caused by calcium metabolism abnormalities, inflammatory disease, hypovitaminosis, and others, but there has been no definitive association with Scheuermann disease and any of these etiologies.3 One theory is that during growth there is a discordant vertebral endplate mineralization and ossification which causes disproportional vertebral body growth resulting in the classic wedge-shaped vertebral bodies.1
Epidemiology including risk factors and primary prevention
The prevalence rate of Scheuermann disease in the United States is between 1% and 8%.1
The sex ratio is 2:1 for male to female.1
Patients generally are affected between ages 12 and 17 years, and the diagnosis is rarely made in patients younger than 10 years.1
Three adjacent wedged vertebral bodies of at least 5° each are pathognomonic for Scheuermann disease. Anatomic findings may also include a thickened anterior longitudinal ligament with narrowed intervertebral disks. The vertebral bodies are wedged, and traumatic disk herniations through the endplates (Schmorl nodes) are often found.
While the pathophysiology of Scheuermann disease is unknown, there have been some suggested components to explain this condition. This includes abnormal collagen to proteoglycan ratios, dural cysts, childhood osteoporosis, biomechanical stressors such as tight hamstrings, and growth hormone hypersecretion.1 Histologic changes include abnormal vertebral endplate cartilage, irregular mineralization, altered endochondral ossification, and decreased collagen to proteoglycan ratios.1
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Type 1 (Classic): thoracic spine involvement only, apex of curve T7-T91
Type 2: thoracic and lumbar involvement, apex of curve T10-T121
Signs and Symptoms:
- Pain: there is a 50% incidence of severe thoracic back pain in patients with thoracic deformities and a higher incidence of back pain in patients with thoracolumbar and lumbar deformities.
- Progressive deformity: starting initially as a poor posture, deformity may get worse over time. The thoracic kyphosis curve is usually between 45° and 75°.
- 15% to 20 % patients are associated with scoliosis.2
Specific secondary or associated conditions and complications
Kyphosis of around 95° can present with neurologic compromise or myelopathy which is often triggered by trauma.2,4 However, there are cases showing neurologic compromise with a kyphosis of only 53° to 56°.5
Kyphotic curves greater than 100° with the apex of the curve located in the upper thoracic region can produce restrictive lung disease.6 There is a decrease in lung volume and impedance on the movement of ribs, consequently affecting the mechanics of the respiratory muscles.
Progressive cosmetic deformity and chronic back pain are potential complications.1 Cosmetic concerns should be specifically and aggressively discussed with the individual patient because these concerns may be the driving force behind the patient’s decision process.
Essentials of Assessment
- Adolescents aged 12 to 17 years of age usually present after a postural deformity or “hunchbacked” appearance was noted by patient, parent, or on school screening.
- History of deformity, the progression over time, body image dissatisfaction, restrictive lung disease, hamstring tightness, and in rare cases, neural impairment (numbness, weakness, bowel or bladder issues), as well as family history are obtained.6
- Pain generally is subacute in the hyperkyphotic region without a clear episode of precipitating trauma. The pain is worse after activity and at the end of the day and improves with rest.1,6 It tends to improve with skeletal maturity. However, long-term follow-up suggests an increased prevalence of back pain in adulthood.6
- Spine range of motion examination, including assessment of rigid kyphosis, lordosis and scoliosis, and overall flexibility. Kyphosis can be measured with gravity-dependent inclinometers.7 Adam’s forward bending test helps to differentiate a relatively sharp angulation from postural irregularities. Spinal range of motion should be evaluated in all planes of motion at each visit: flexion/extension, right/left lateral bending, and right/left rotation. Serial imaging can help with monitoring the degree of progression. Functional range of motion as well as the degree of deformity should be tracked to help guide the appropriate intervention and prognosis.1
- In Scheuermann disease, the rigid kyphosis does not flatten with forward bending, extension, or lying supine (in contrast to the curvature of poor posture).1,8 Scoliosis, tight hamstrings, and compensatory cervical or lumbar hyperlordosis may be present.1
- Spine palpation.
- May be tender above and below the apex of the kyphosis.
- Joint range of motion examination.
- Hamstring tightness may be present. There may be hip and shoulder joint contractures.
- Neurologic examination.
- Although, neurologic deficits are extremely rare, a thorough neurologic exam should be completed.
Clinical functional assessment: mobility, self care cognition/behavior/affective state
FIM assessments may be helpful in assessing day to day activities of daily living and mobility. For example, there are certain patients that may use a wheelchair as a result of cardiopulmonary or mechanical limitations, and serial FIM assessments can document their functional course.
No genetic markers or laboratory studies exist to confirm the diagnosis of Scheuermann disease.1
Anteroposterior (AP) and lateral radiographs of the entire thoracolumbar spine should be obtained. Standing lateral spine radiographs are necessary for the diagnosis. Diagnostic criteria includes anterior wedging of ≥5° in at least three adjacent vertebral bodies and rigid hyperkyphosis > 40o. 1,9 Hyperkyphosis is described as a Cobb angle > 40o.1
Besides vertebral wedging, typical radiographic findings are irregularities of the vertebral endplates, disc herniation, Schmorl’s nodes, narrowing of the disc spaces, and scoliosis. 1,10 Concomitant spondylolysis/spondylolisthesis may occur in patients with lumbar pain.
Schmorl’s nodes and Modic changes (endplate MRI signal change) on lumbar MRI, back pain and physical function restrictions seem to be more prevalent among patients with Scheuermann’s disease. 11 Evidence of increased pain, suspicion of rapid progression, and/or neurologic compromise (focal neurologic deficits) would require immediate imaging.
Magnetic resonance imaging (MRI), computed tomography (CT) scan, and CT myelography can be helpful adjunctive studies if surgery is planned in, to evaluate coexistent thoracic spinal stenosis, syrinx, or other intrathecal abnormality.
Supplemental assessment tools
Pulmonary function tests may be used to assess lung function of these patients; they are used prior to any surgical procedures (e.g., spinal fusion).
Early prediction of outcomes
Patients with a kyphotic curve less than 60o at skeletal maturity typically have no long-term sequelae.1 One third of the patients with curves of 74° or more failed bracing and progressed to surgery.12
Social role and social support system
Familial and social support should be assessed as they are important for patients to maintain both physical and mental health.
Scheuermann patients typically have less physically demanding jobs. However, there is no correlation with decreased level of education, absenteeism from work, medication use, or social interactions.
Rehabilitation Management and Treatments
Available or current treatment guidelines
No established clinical guidelines exist.
At different disease stages
Treatment should be tailored to each individual based on symptoms, age, and nature of the curve.
For asymptomatic kyphotic angles less than 60°, treatment consists of stretching, lifestyle modification, NSAIDs, and plus/minus physical therapy. Most patients fall in this category and patients typically do well without significant long-term sequelae.1
Bracing is considered efficacious in skeletally immature adolescents. It is indicated for both symptomatic and asymptomatic Scheuermann’s disease
or mild with kyphosis of 60 to 80o.1,2 Typically, a Milwaukee brace can be used.1,12 Other braces used include a kyphologic brace or a thoracolumbosacral orthosis-style Boston brace.1 The brace is expected to be worn for about 16-24 hours a day until the individual reaches skeletal maturity. Typically, braces do not improve the curve but rather impede progression.1
In a retrospective, observational study released in 2017, conservative treatment with Milwaukee brace and physiotherapy was effective for halting kyphosis progression in 97.5% of Scheuermann’s kyphosis, which could be advised for cases up to 90° of kyphosis before skeletal maturity.13
For curves with an apex below T9, a thoracolumbosacral orthosis (e.g., 4-valve orthosis, Gschwend erection corset) may be used.14
To date, surgical strategies in Scheuermann disease remains controversial.15 Surgery is indicated in patients with greater than 75° kyphosis causing unacceptable deformity or with associated pain, or neurologic deficit/spinal cord compression.1 Spinal fusion is typically a combination of anterior release and fusion as well as posterior instrumentation and fusion.1,15,16 Most patients will experience improvements in symptoms as well as improved curve deformity. The most common complication following surgery is pseudoarthrosis.1
As stated above, most patients are successfully treated with conservative measures. Pain typically improves after skeletal maturity is reached; however, patients with Scheuermann kyphosis are at increased risk of chronic back pain when compared to the general population.1
Coordination of care
Multiple specialists, including physiatry, psychology, physical therapy, and occupational therapy, should be involved with patient care. These specialists can coordinate a comprehensive biopsychosocial approach to improve and preserve function and quality of life.
Patients may benefit from a coordinated and conservative program that may include rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy on an outpatient basis. For those that may require surgical intervention, the patient typically is hospitalized for a recovery time after the operation. Patient care focuses on pain control, mobility training, and patient education, which requires the multidisciplinary team.
Patient & family education
Patient and family education is essential throughout the treatment process. Patients who are treated with bracing need to be educated on an appropriate wearing schedule and brace donning and doffing techniques. Spinal extension exercises and hamstring stretching should also be incorporated. Education is necessary for postural and body mechanics improvement.
Measurement of treatment outcomes including those that are impairment-based, activity participation-based and environmentally-based
The FIM (for adults) and WeeFIM (for kids) may be useful. Other questionnaires such as Scoliosis Research Society Instrument (SRSI), Oswestry Low Back Pain Disability and, the Barthel Index, useful in this condition where there are no cognitive deficits.
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
Watchful waiting is generally the best treatment course.
Cutting Edge/ Emerging and Unique Concepts and Practice
Video-assisted thoracoscopic surgery (VATS) is a promising technique in the treatment of kyphosis as an alternative to open thoracotomy for anterior release procedures. This technique is more expensive than open thoracotomy, but with fewer complications.17 Combined VATS release and posterior spinal fusion is a viable option for the treatment of the more severe and rigid curves.18
A systematic review of treatment approaches for Scheuermann kyphosis concluded that surgery affords superior correction and maintenance of correction relative to bracing. Posterior-only fusion may provide greater correction and similar loss of correction compared to anterior-posterior approaches along with a smaller complication profile. This posterior-only approach has concomitantly gained popularity over the combined anterior-posterior approach in recent years.18
A unique development that has been successfully applied to patients with osteoporotic kyphosis is the Spinal Proprioceptive Extension Exercise Dynamic program.19 The dynamic effect of a weighted kypho-orthosis is to facilitate recruitment of back extensors. This orthosis increases a patient’s perception of spinal joint position to encourage extension rather then flexion, which helps patients with significantly reduced kyphosis and back pain, improved back strength, and increased level of physical activity.19
Gaps in the Evidence-Based Knowledge
Controversies and gaps in the evidence-based knowledge
Current controversies in the treatment of patients with Scheuermann disease revolve around bracing care and the surgical decision-making process. Proponents of bracing state that bracing postpones indefinitely the need for surgical intervention. Others believe that bracing does not affect the ultimate prognosis of the curve. Further study is also needed to address natural history of the disease and identify the prognostic factors of back pain during adulthood.2
- Mansfield JT, Bennett M. Scheuermann Disease. [Updated 2022 Aug 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499966/
- Palazzo C, Sailhan F, Revel M. Scheuermann’s disease: an update. Joint Bone Spine. 2014 May;81(3):209-14.
- Lowe TG. Current concepts review: Scheuermann disease. J Bone Joint Surg Am. 1990;72:940-945.
- Lonstein JE, Winter RB, Moe JH, et al. Neurologic deficits secondary to spinal deformity. A review of the literature and report of 43 cases. Spine (Phila Pa 1976). 1980;5:331-355.
- Ryan MD, Taylor TK. Acute spinal cord compression in Scheuermann’s disease. J Bone Joint Surg Br. 1982;64:409-412.
- Murray PM, Weinstein SL, Spratt KF. The natural history and long-term follow-up of Scheuermann kyphosis. J Bone Joint Surg Am. 1993;75:236-248.
- Lewis JS, Valentine RE. Clinical measurement of the thoracic kyphosis. A study of the intra-rater reliability in subjects with and without shoulder pain. BMC Musculoskelet Disord. 2010;11:39.
- Ginsburg GM, Bassett GS. Back Pain in Children and Adolescents: Evaluation and Differential Diagnosis. J Am Acad Orthop Surg 1997; 5:67.
- Lowe TG. Scheuermann’s disease. Orthop Clin North Am 1999; 30:475.
- Bradford DS. Juvenile kyphosis. Clin Orthop Relat Res. 1977;128:45–55.
- Leena Ristolainen, Jyrki A. Kettunen, Heidi Danielson, Markku Heliövaara. Magnetic resonance imaging findings of the lumbar spine, back symptoms and physical function among male adult patients with Scheuermann’s disease. Journal of Orthopedics 21 (2020) 69-74.
- Sachs B, Bradford D, Winter R, et al. Scheuermann kyphosis. Follow-up of Milwaukee-brace treatment. J Bone Joint Surg Am. 1987;69:50-57.
- Etemadifar MR, Jamalaldini MH, Layeghi R. Successful brace treatment of Scheuermann’s kyphosis with different angles. J Craniovertebr Junction Spine. 2017;8(2):136–143. doi:10.4103/jcvjs.JCVJS_38_16
- Karimi, M. T. (2016). Effect of brace on kyphosis curve management: A review of literature. Health Rehabil. 1(1): 1-4.
- Lee CH, Won YI, San Ko Y, Yang SH, Kim CH, Park SB, Chung CK. Posterior-only versus combined anterior-posterior fusion in Scheuermann disease: a systematic review and meta-analysis. J Neurosurg Spine. 2020 Dec 25;34(4):608-616. doi: 10.3171/2020.7.SPINE201062. PMID: 33361485.
- 2022 Apr;51(4):339-348. German. doi: 10.1007/s00132-022-04239-4. Epub 2022 Mar 15. PMID: 35290495.
- Papagelopoulos PG, Mavrogenis AF, Savvidou OD, Mitsiokapa EA, Themistocleous GS, Soucacos PN. Current concepts in Scheuermann’s kyphosis. Orthopedics. 2008;31:52-58; quiz 59-60.22.
- Soto JH, Parikh SN, Al-Sayyad MJ, et al. Experience with combined video-assisted thoracoscopic surgery (VATS) anterior spinal release and posterior spinal fusion in Scheuermann’s kyphosis. Spine. 2006;30:2176-2181.
- Huq S, Ehresman J, Cottrill E, Ahmed AK, Pennington Z, Westbroek EM, Sciubba DM. Treatment approaches for Scheuermann kyphosis: a systematic review of historic and current management. J Neurosurg Spine. 2019 Nov 1;32(2):235-247.24.
Original Version of the Topic
Edward Hurvitz, MD. Scheuermann’s disease. 10/27/2015
Previous Revision(s) of the Topic
Yuxi Chen, MD, Andrew Bloomfield, MD, Amara Nasir, MD. Scheuermann’s disease. 7/30/2020
Clarice Sinn, DO
Nothing to Disclose