Scheuermann’s Disease and Scheuermann’s Disease and Sagittal Plane DeformitySagittal Plane Deformity

Donald S. Corenman, M.D., D.C.

Steadman Clinic- Vail, CO

Neckandback.com

What is the sagittal plane ?What is the sagittal plane ? “Side view” of the spine Composed of lordosis and kyphosis All curves add up to neutral Balances head over pelvis Physiological for chest cavity No significant muscle activity to

hold upright position Body strives to achieve this neutral

balance as less energy is expended

Sagittal ProfileSagittal Profile

Cervical and lumbar lordosis (Secondary)

Thoracic and sacral kyphosis (primary)

Vertebra are rectangular Curve structure from disc

architecture (trapezoidal) Abnormal alignment can be the

result of or cause problems

Weight Bearing of 3 ColumnsWeight Bearing of 3 Columns Lumbar Spine Ant. Column and Middle

Column support 2/3 of weight in normal sagittal alignment

Post. Column (facets) supports 1/3 of normal body weight

Middle column is fulcrum for motion

Thoracic Spine Ribs are thought to

support as much as 30% of weight of Thoracic region -also restrict lateral motion of thoracic spine.

Ant./Middle columns support > 75% of weight of T/S

Creep Behavior of Normal vs Creep Behavior of Normal vs Degenerative DiscsDegenerative Discs

Note that degenerative discs have more motion and less resistance than normal discs

Compensatory Posterior Compensatory Posterior Pelvic RotationPelvic Rotation

Pelvis had ability to rotate anteriorly and posteriorly to change sacral base angle

Posterior rotation reduces angle, reduces slip stress on L5 and flattens lumbar spine

This also opens lumbar canal (center of rotation is middle column- everything behind this point is distracted)

Compensatory Anterior Pelvic Compensatory Anterior Pelvic RotationRotation Anterior rotation increases

sacral angle and lumbar lordosis

Increases load on facets to greater than 50% load bearing

Decreases size of neural canal Aggravates facet disease,

spinal stenosis and spondylolysthesis

Normally is a result of hyperkyphosis of thoracic spine

Pelvic RotationPelvic Rotation

Normally, anterior pelvic rotation is the result of hyperkyphosis leading to increased lumbar lordosis and compensatory sacral and pelvic rotation

Posterior rotation is an active compensatory mechanism to increase volume in the canal as the result of spinal stenosis or DDD of L/S with flat back deformity

Hyperkyphosis/ Hyperkyphosis/ Scheuermanns’- Scheuermanns’-

Compensatory Mechanisms Compensatory Mechanisms and Effectsand Effects

Hyperkyphosis causes increased lumbar lordosis and cervical lordosis

Increased pressure on post column (facets) Increase ant pelvic rotation Increased demand on extensor muscles (fatigue

pain) Aggravation of preexisting defects

(spondylolysthesis)

Normal AlignmentNormal Alignment

Normal kyphosis 20-40 (45) Normal lumbar lordosis 40-60

(65) Normal sacral base angle

20-40

Causes of Abnormal Sagittal Causes of Abnormal Sagittal ProfileProfile

Antalgia (Stenosis or HNP) in lumbar spine Lumbar DDD (discs cause lordosis) Spondylolysthesis Scheuermann’s Disease Scoliosis Postural Roundback Deformity Fracture Senile Kyphosis

Causes of Flat Back PostureCauses of Flat Back Posture

Spinal Stenosis (flat back antalgia)

Pan lumbar DDD (structural flat back)

Spondylolysthesis (reduces slip angle)

Sagittal Profile of Lumbar Sagittal Profile of Lumbar StenosisStenosis

Compression of cauda equina posterior to center of rotation

Extension causes compression of cauda

Flexion reduces compression of cauda

Flat Back CompensationsFlat Back Compensations

1. Posterior pelvic rotation- contraction of hamstrings and abdominal muscles- stretching of anterior hip capsule- can only correct up to 20 degrees?

2. Bent knee stance- changes femoral-ground angle from 90 to whatever is necessary to balance spine (30 degree deficit- 20 from pelvis and 10 from bent knee)

Preop DDD with Flat Back Preop DDD with Flat Back SyndromeSyndrome

Postop Sagittal BalancePostop Sagittal Balance

Female age related kyphosisFemale age related kyphosis

Senile KyphosisSenile Kyphosis

Osteoporosis related

Females 6:1 males Prevention

(detection)

New New Insufficiency Insufficiency Fracture in Fracture in

Senile Senile Osteoporosis Osteoporosis with Kyphosiswith Kyphosis

Postural HyperkyphosisPostural Hyperkyphosis Found in same age group as Scheuermann’s No changes of vertebral endplate/ Schmoral’s No rigidity- corrects with extension Can progress

Scheuermann’s KyphosisScheuermann’s Kyphosis

Normal Vertebral Normal Vertebral DevelopmentDevelopment

Cartilaginous Ossification Vertebral endplate cartilage- starts to ossify by age

10 Endplates penetrated by arterioles- creates stress

riser.

8 yr old vertebra8 yr old vertebra Note nonossified cartilage- no ring

apophysis at this stage of development

Ring Apophysis at 10 yearsRing Apophysis at 10 years

Note ossification of cartilage and expansion of height of vertebra occurs here

Compressive Forces on Compressive Forces on Endplate of Normal DiscEndplate of Normal Disc

Note stress on center area of normal disc

Forces causing cantilever Forces causing cantilever bendingbending

Note- the greater the angulation, the greater the forces causing further angulation

Metabolic Metabolic

Patients tend to have increased growth hormone This increases endochondral growth plate width Alteration of endochondral growth plate New bone formation uneven in plate This potentially weakens growth plate Penetrating arterioles create stress risers Mechanical deformation (increased kyphosis)

increases stress on anterior column Heuter Volkman principle- increased compression

reduces growth plate viability

Scheuermann’s DiseaseScheuermann’s Disease

1921- Holger Scheuermann Noted vertebral wedging- growth

disturbance of vert. endplates with progressive kyphosis

Sorenson- incidence 0.5-8% population Males > Females 85/15

Scheuermann’s associated Scheuermann’s associated conditionsconditions

Dural cysts Legg Calve Perthes disease Hypo/hypertonia Infection Endocrine disorders Patients tend to be taller 10-20 degree scoliosis in 20-30% of patients

(benign course)

Thoracic vs Thoracolumbar Thoracic vs Thoracolumbar typetype

T-L/S type more common in males with heavy physical activity or hard labor

T/S type has 30% increased incidence of hamstring tightness

T/S type has asso. interesting clinical sign- increased kyphosis leads to increased skin pressure against back of chair- leads to increased skin pigmentation

Scheuermann’s Clinical OnsetScheuermann’s Clinical Onset

Symptoms can be prepubescent (10 yrs) Pain associated with endplate fracture Pain associated with compensatory

mechanisms (hyperlordosis of cervical and lumbar spine- facet imbrication and muscle fatigue)

Endplate pain normally recedes at completion of growth

Appearance of Normal vs Appearance of Normal vs ScheuermannsScheuermanns

Sagittal Balance vs Sagittal Balance vs ScheuermannsScheuermanns

Scheuermann’s DefinitionScheuermann’s Definition

(Bradford) irregular endplates Loss of disc height Wedging of one vertebra > 5 degrees Kyphosis > 40 degrees (Sorenson) wedging of 3 vertebra > 5 degrees EXCEPTIONS- rigid kyphosis without wedging

but consistent with Scheuermann’s, irregular endplates without kyphosis

Endplate Failure with Endplate Failure with Schmoral’s nodesSchmoral’s nodes

Failure normally occurs at arteriole penetration

Disc herniates into body of vertebra

Can start degenerative disc cascade

Natural History of Natural History of ScheuermannsScheuermanns

Murry- 61 Scheuermanns followed for 30 yrs, compared to 34 non Scheuermanns

64% of Scheuermanns significant variable back pain

15% of control group had back pain Curves over 70 degrees tend to progress

Thoracic Scheuermanns Thoracic Scheuermanns TreatmentTreatment

Physical therapy for early Scheuermanns Brace before skeletal maturity (risser sign) Criteria: curve 50-75 degrees 40% passive correctability of curve Apex of curve T6-8- Milwaukee brace Apex of curve below- TLSO with

outriggers 12-18 months of brace treatment 22hrs/day

Risser SignRisser Sign

Growth of apophysis of iliac crest Signals how much growth remains

Scheuermanns Treatment Scheuermanns Treatment GoalsGoals

Desired goal is to have 50 degree curve after brace discontinued

May lose up to 75% of correction when brace D/C’d

As in scoliosis- final goal is to prevent progression of curve- not to correct it