Post on 12-Jul-2015
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