The Spine Journal 2 (2002) 49–56

Scheuermann kyphosis: long-term follow-up
C.L. Soo, MD, Philip C. Noble, PhD, Stephen I. Esses, MD*
Barnhart Department of Orthopedic Surgery, Baylor College of Medicine, 6560 Fannin, Suite 1900, Houston, TX 77030, USA Received 3 October 2000; accepted 12 October 2001

Abstract

Background context: There is considerable controversy as to the optimal treatment of Scheuermann kyphosis. Proposed modalities have included exercise, bracing and surgery. Purpose: The purpose of this study was to document the functional capacity and radiographic findings in adults who have been previously treated for Scheuermann kyphosis. Study design: A cohort study of all patients with Scheuermann kyphosis treated in a single institution using three different treatment modalities: exercise and observation, Milwaukee bracing and surgical fusion using the Harrington Compression System. Patient sample: Sixty-three patients were evaluated at a mean of 14 years after treatment (10 to 28 years). Outcome measures: Two different functional evaluation instruments were used. Radiographic evaluation was carried out in 38 patients (60%). Methods: Patient interviews were conducted using a specially designed questionnaire. Patients were then asked to undergo standing radiographs. Patients were divided into groups depending on the location of their kyphosis and the manner in which they had been treated. Standard statistical analysis was then carried out. Results: At time of follow-up evaluation there were no differences in marital status, general health, education level, work status, degree of pain and functional capacity between the various curve types, treatment modality and degree of curve. Patients treated by bracing or surgery did have improved self-image, which they attributed to their treatment. Patients with kyphotic curves exceeding 70 degrees at follow-up had an inferior functional result. At time of final follow-up there were no statistical differences in degree of kyphosis and mode of treatment. Conclusions: By carefully selecting the appropriate treatment for patients with Scheuermann kyphosis on the basis of the patient’s age, spinal deformity and the severity of back pain, it is possible to achieve a similar functional result at long-term follow-up. Despite different treatment protocols, patients with Scheuermann kyphosis tend to achieve a similar functional result at long-term followup. © 2002 Elsevier Science Inc. All rights reserved.
Scheuermann kyphosis; Exercise therapy; Bracing; Spinal fusion

Keywords:

Analysis of outcome by method of treatment Patients receiving each of the three treatment modalities differed in terms of their age and sex and the anatomic location of their deformity, but not with respect to their marital status, general health or educational background. Male patients predominated in the groups treated with observation and exercise (78%) and bracing (66%), whereas approximately half (54%) of those treated with surgery were feFDA Device/drug status: Not applicable. Nothing of value received from a commercial entity related to this research. * Corresponding author. Barnhart Department of Orthopedic Surgery, Baylor College of Medicine, 6560 Fannin, Suite 1900, Houston, TX 77030, USA. Tel.: (713) 986-5740; fax: (713) 986-5741.

male. Patients treated with bracing were younger (12.2 years) than those receiving observation and exercise (13.6 years, pϭ.01) and those treated surgically (13.5 years, pϭ.02) at both the time of onset of the deformity and at the time of initial treatment (14.0 years vs. 19.9 years, pϭ.002, and 21.1 years, pϽ.0001). Most patients (53, 84%) presented with deformities of the thoracic spine. Only two patients had lumbar curves; both were treated with surgery. Of the eight patients with thoracolumbar kyphoses, four (50%) were treated with bracing and three (38%) with surgery. There were also significant differences among the three treatment groups with respect to the severity of the spinal curvature and the effect of each treatment on the kyphotic deformity. Before treatment, patients in the exercise group had an average kyphotic curvature of 57.5Ϯ2.3 degrees,

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. The curve now measures 56 degrees.9 degrees for the brace group (pϭ. brace group. The brace group experienced the lowest severity of back pain and the least fatigue with work activities. 53. the average postoperative deformity of the surgical group was 37. The curve has been reduced to 37 degrees.50 C.02). As a result.6Ϯ3. Patients treated with exercise and observation experienced a negligible change in deformity (average reduction.0 degrees). At follow-up. 1 and 2). In addition.L. There were few differences among the three groups with respect to impairment of daily living activities because of back pain. 51.002). 2.4 degrees.5 degrees. turning or twisting.2 degrees) in the average curvature of the brace group and a substantial loss (20. Nonetheless. and surgical fusion by 36.4 vs. their ability to perform personal care activities or their level of social activities. Soo et al. whereas patients treated with surgery reported the greatest levels of fatigue and back pain. a limited number of radiographs were available to document the change in curvature of patients in the brace and exercise groups. patients in the bracing and the exercise groups had a similar degree of curvature after treatment (51.2 degrees). especially those who had undergone surgery. and 73. 1. surgery group.3 degrees) of correction in the surgery group (Figs. approximately 20 degrees less than patients in both the brace and exercise groups (pϭ. there appeared to be no change in the kyphotic deformity in the exercise group. (Left) Standing lateral radiograph of patient with Scheuermann kyphosis before bracing. Nonetheless. / The Spine Journal 2 (2002) 49–56 compared with 64. In comparison. the average deformities of all three groups at follow-up were relatively similar (exercise group. sit for more than 1 hour. Patients treated with exercise or bracing also reported approximately one third as many days of restricted activity because of back pain compared with the surgery group. pϭ. The ability of patients to sleep through the night. pϭ. There were minimal differences among the three treatment groups in terms of their ability to work without restriction. However. In addition. (Middle) Standing lateral radiograph of the same patient in a Milwaukee brace. The kyphotic deformity measures 60 degrees.0008. 59. Sixty percent of patients believed that the severity of their spinal deformity had not changed during the period since treatment. This perception did not vary significantly with the method of treatment.0002).5Ϯ1.1 degrees.2 degrees.1 degrees. whereas bracing reduced the kyphosis by an average of 13. a minimal increase (1. (Right) Follow-up standing lateral radiograph at 10 years after treatment. and running. despite the larger preoperative curvature of the surgical patients. 44% percent of patients believed their height had not changed. no differences were reported in the patients’ sexual activities. Patients treated with surgery or brace believed there was a perceptible improvement Fig.0 degrees for the surgery group (pϭ.64). to perform tasks that involved lifting or sitting. the ex- tent to which back pain interfered with each patient’s work or the frequency of missing days at work because of back pain (Table 1).5 degrees. patients treated with bracing reported the lowest severity of pain in performing daily living activities. They also had the least difficulty in sleeping through the night. travel long distances by car. 57. climb stairs or bend or kneel posed a similar degree of difficulty to all three groups. The loss of surgical correction corresponded to approximately half of the total reduction in curvature achieved intraoperatively. whereas the surgery group had the greatest tolerance of standing.

Soo et al. There was no difference regarding sex distribution. Analysis by anatomic location of the deformity Patients with thoracic.L. In addition. The small subgroup of eight patients with thoracolumbar curves reported worse general health than those with thoracic or lumbar deformities (pϭ. Curve measures 36 degrees. The curve measures 79 degrees. (Middle) Postoperative radiograph of same patient. 50 degrees. to climb several flights of stairs. Moreover. in physical appearance and self-image as a result of their treatment. standing. No differences were reported in the severity of pain or fatigue resulting from work or the number of days missed from work because of back symptoms. range.004). their personal care and their ability to perform sexually. / The Spine Journal 2 (2002) 49–56 51 Fig. During work activities. to walk. sit or to perform work tasks requiring reaching or bending did not vary with curve level. stand. 2. the patients reported no significant differences in their social life. the ability to lift objects. to run or to turn or twist. Patients in all three treatment groups reported no difference in difficulty buying clothes or problems wearing any kind of clothes. 30 patients had curves of less than 70 degrees (mean. marital status. thoracolumbar or lumbar kyphoses did not differ in terms of gender or education level of the patient. to sit or to stand for more than 1 hour. (Left) Preoperative standing lateral radiograph of patients with Scheuermann kyphosis.C. Patients with curves of more than 70 degrees did report greater difficulty in standing. range. their age at onset of the deformity and at the time of their initial visit. Patients with larger curves at follow-up tended to have more deformity before treatment. The number of days on which activity was limited by back pain was also similar for each group. The current work status of the patients was not related to the level of curvature. At follow-up. The degree of deformity did not correspond to the ability of patients to perform any of the activities of daily liv- ing. Similarly. 29 to 68 degrees) and 8 patients had curvatures greater than 70 degrees (mean. they also experienced twice the severity of back pain as the less kyphotic . general health and educational level between patients with deformities greater than or less than 70 degrees at follow-up. to walk more than a mile. the functional capacity of patients with curves greater than 70 degrees was highly variable. Analysis by the severity of the kyphotic deformity At the time of most recent follow-up. The curve again measures 79 degrees. although this effect was not statistically significant because of the small number of cases and the variability of the data. (Right) Follow-up lateral radiograph at 10 years after treatment. The patient’s ability to perform physical activities were also unaffected by the type of Scheuermann kyphosis. it was not possible to identify an association between the severity of the kyphotic deformity and the ability of patients to perform lifting. The level of the deformity was also unrelated to each patient’s perception of the cosmetic appearance of their back or their assessment of their change or self-image. reaching or bending in their work activities. 78 degrees. lifting and carrying. 70 to 90 degrees). there was no difference in the extent to which both groups required adjustments to their work environment or the difficulty experienced in performing occupational tasks. and activities necessitating turning and twisting. Consequently. sitting. These activities included the ability to sleep through the night.

working (d) ___Restricted due to back pain.: _____________________ Sex: __________ Phone: ________________________________ W ________________________________ H ________________________________ Marital status: ___________ General health: ___________ Age of onset: ___________ Age at initial visit: ___________ Education level (a) Above college ___________ (b) College ___________ (c) High school ___________ (d) Below high school ___________ Radiographs Type of Scheuermann’s: ___________________________________ (From to ) Apex of curve: ___________________________________ Wedging: ___________________________________ Degree of curve (thoracic kyphosis/lumbar lordosis) Pre RxPost RxNow __________________________________________ Rx: _____(a) OBS exercise (b) Milwaukee brace (c) Spinal fusion Pain and function Work What is your current work status? (a) ___Unrestricted. sitting.L. working (b) ___Unrestricted.O. / The Spine Journal 2 (2002) 49–56 Name: _________________________________________________Address: _________________________________________________ D. unemployed (e) ___Not able to work at all due to back pain The extent that your work involves lifting. reaching or bending (a) How much of your work involves lifting _____% (b) How much of your work involves walking _____% (c) How much of your work involves standing _____% (d) How much of your work involves sitting _____% (e) How much of your work involves reaching or bending _____% Do you have back pain at work? _____(yes). Soo et al. walking.B. standing. unemployed (c) ___ Restricted due to back pain.52 Table 1 Demographic and Outcome Measurement Demographic C. have you had any of the following problems with your work due to back pain? (a) Cut down the amount of time you spent on work _____ (b) Accomplished less than you would like _____ (c) Were limited in the kind of work you could do _____ (d) Had difficulty performing your work _____ (e) Had no problems _____ In the past 4 weeks. how many days of work have you missed due to back problems? _____ Severity of back pain related to work_____(0–10) (0 ϭ no pain. _____(no) To what extent does your back pain interfere with your work? (a) No interference _____ (b) Small amount _____ (c) Moderate amount _____ (d) Totally incapable of work _____ To what extent has your back pain caused you to modify your work so that you can do your job? (a) No adjustment to work _____ (b) Mild adjustment _____ (c) Moderate adjustment _____ (d) So much adjustment that you have to change your job _____ During the past 4 weeks. 10 ϭ intolerable pain) Treatment for this back pain Type of treatment (a) Narcotics (b) Prescription (c) OVC (d) None Frequency_____(times/day) Relief_____(yes/some/no) (continued) .

in performing the following tasks? (On a scale of 0–5. basketball (k) Hiking (l) Others Frequency of sports_________(times/week) Back pain related to sport_________ (yes/some/no) Severity_____(0–10) (0 ϭ no pain. kneeling. 10 ϭ intolerable pain) To what degree do you rely on pain medications for you to be comfortable while performing daily activity? (a) None_____ (b) Some_____ (c) All the time_____ Type_____ (a) Narcotics (b) Prescription (c) OVC Relief_________(yes/some/no) Most sports involvement (a) Golf (b) Jog (c) Tennis. 1 ϭ minimally difficult. Ping-Pong (I) Fishing (j) Football. has your curve changed? (a) Increased_____ (b) Remained the same_____ (c) Decreased_____ 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Very difficult 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 53 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 (continued) .) 0 1 (p) Turning and twisting 0 1 (q) Bending. reaching 0 1 How many days a week are your activities limited by back pain?_____ How severe is your back pain in performing daily activities?_____(0–10) (0 ϭ no pain.L. 0 ϭ not difficult at all. 10 ϭ intolerable pain) Treatment for this back pain Type_____ (a) Narcotics (b) Prescription (c) OVC (d) None Frequency_________(times/day) Relief_________(yes/some/no) Cosmesis Since the last visit to the Methodist Hospital. 3 ϭ fairly difficult. 2 ϭ somewhat difficult. going out. Soo et al.C. 10 ϭ the back is so tired you can only lie down) Daily activity How much difficulty do you experience. / The Spine Journal 2 (2002) 49–56 Table 1 Continued Degree of back fatigue related to work_____(0–10) (0 ϭ no fatigue at all. 5 ϭ unable to do) Not difficult (a) Sleep through the night 0 1 (b) Sitting more than 1 hour 0 1 (c) Stand more than 1 hour 0 1 (d) Sex (N/A) 0 1 (e) Walking more than a mile 0 1 (f) Walking a few blocks 0 1 (g) Walking one block 0 1 (h) Traveling in a car 0 1 (i) Personal care 0 1 (j) Climbing several flights of stairs 0 1 (k) Climbing one flight of stairs 0 1 (l) Lifting or carrying grocery 0 1 (m) Moderate activity (moving a table. house cleaning) 0 1 (n) Running 0 1 (o) Social life (dancing. etc. baseball. soft ball (d) Walk (e) Weight lifting (f) Swimming (g) Skiing (h) Bowling. games. due to back pain.

Most authors agree that the upper limit of the normal thoracic kyphosis is 40 to 45 degrees [3–9].11]. has your height: (a) Increased_____ (b) Remained the same_____ (c) Decreased_____ As a result of treatment for your round back.4. do you feel your self-image is: (a) Worse_____ (b) Unchanged_____ (c) Moderately improved_____ (d) Greatly improved_____ Since the treatment for your round back. The natural history of Scheuermann kyphosis has not been clearly defined. and 0. / The Spine Journal 2 (2002) 49–56 Since the last visit to the Methodist Hospital.8].4. This is in contrast to the suggestion that untreated kyphosis is not only a psychological handicap but also a source of significant and disabling thoracic back pain [3.19.21]. the degree of kyphosis should not be used as the only consideration in selecting an appropriate treatment for Schuermann disease. Nine percent of patients were unemployed because of back pain.54 Table 1 Continued C. do you feel your physical appearance is: (a) Worse_____ (b) Unchanged_____ (c) Moderately improved_____ (d) Greatly improved_____ As a result of treatment for your round back. This kyphosis. Neurologic sequelae from untreated Scheuermann kyphosis has been reported only rarely [14. This pain. Therefore. Bracing has been recommended for skeletally immature patients with a thoracic curve less than 70 degrees and with wedging less than 10% [3. why? (a) Cannot tolerate it_____ (b) Not helpful_____ (c) Painful_____ (d) Better option_____ group and reported that their pain had a greater influence on their working ability. Surgical treatment has been advised for those patients who have completed their growth and who have a structural kyphosis that is large and cosmetically unacceptable [16.20.L. It has been thought that a kyphosis of greater than 65 degrees may continue to increase even after skeletal maturity [5]. and an apparent kyphosis [1–2]. It has been suggested that observation and exercise should be used for the skeletally immature patient who has a thoracic kyphosis less than 50 degrees [3. how has the cosmetic appearance of your back changed? (a) A lot worse_____ (b) A little worse_____ (c) No change_____ (d) Moderately improved_____ (e) Greatly improved_____ Since the treatment for your round back. Furthermore. They found that patients who were untreated had more intense back pain than the general population. The frequency of missed days was 0. narrowing of intervertebral disc spaces. detachment of the epiphysial ring anteriorly. Murray et al.8].4. this pain did not influence the patient’s working ability and rarely required treatment.0 for those less than 70 degrees.6. Schmorl node formation. [13] followed 67 patients to document the natural history of this entity. however. However. Sorenson reported that 50% of patients with Scheuermann kyphosis had thoracic back pain during their adult life [12].88 days in 4 weeks for patients who had a curve greater than 70 degrees.7. however. Soo et al. irregularity in the vertebral end plates. do you feel buying clothes is: (a) No change_____ (b) Less difficult_____ (c) More difficult_____ Before the treatment for your round back. A variety of treatment modalities have been proposed for Scheuermann kyphosis.4. did not interfere with the type of job and days missed from work when compared with the general population.7. Surgery . is derived as an average value and is only indicative and not normative [10.18. did you have a problem wearing clothes? (a) Yes_____ (b) No_____ Would you recommend the type of treatment you received for your round back to your friends who had a similar condition? (a) Yes_____ (b) No_____ If not. there was no difference in limitation of recreational activity or exercise because of back pain.15].8]. Discussion Scheuermann kyphosis is characterized by wedging of three adjacent vertebrae of 5 or more degrees.17.

We readily acknowledge the weaknesses of the present study. For those rare instances in which there are neurologic signs or symptoms secondary to a severe Scheuermann kyphosis. most of whom had been treated with exercise and observation. Given that each modality was prescribed for a group of patients that differed in age.C. however. Many patients were busy at work and could not find time to do so.5. type of treatment and degree of kyphosis at time of final follow-up did not significantly affect functional outcome. Twenty-five patients (40%). This is clearly a much more flexible construct than other systems currently available. Nevertheless. did not complete the radiographic evaluation needed for this study. In addition. Indeed. they all underwent a posterior Harrington instrumentation and fusion procedure. surgery is also indicated.16].6.17. Sachs et al. despite the severity of some of the initial deformities and despite the obvious inadequacies of the stabilization achieved in this series using the Harrington Compression System. Farsetti et al. the length of follow-up. the detailed and objective functional outcome instrument and the unbiased. In cases in which bracing does not prevent progression of deformity.8]. The purpose of the present study was to document the long-term functional capacity of individuals treated for Scheuermann kyphosis through selective use of three different treatment modalities: exercise with observation. the amount of back pain was not significantly different from that of the general population.23. posterior instrumentation and fusion has been carried out for curves less than 70 degrees [8.7. The type of Scheuermann kyphosis. in view of advances in both the safety and efficacy of newer bracing methods and operative approaches to spinal fixation. general health or educational level of our patients as a function of the location of their kyphosis. Rather. Anterior fusion with instrumentation has also been proposed in treating the skeletally mature patient with a curve greater than 75 degrees or the skeletally immature person with a curve greater than 65 degrees. Nonetheless. at the time of final follow-up there was no difference in the degree of kyphosis among the three different groups. One drawback of our study is our inability to know what the outcome of our patients would have been without treatment. Soo et al.16]. It is interesting to note that such an approach maintains all patients at a relatively similar functional level. only 16 of 120 patients had mild pain after activity. It is retrospective. Many patients thought that their back was fine and they did not perceive a reason to spend additional time obtaining X-rays. Only four patients (3%) were unemployed because of back pain. This is primarily because of a loss of correction in the surgical group from the time of surgery to final follow-up. or with bracing. Indeed. interviews were carried out by telephone and there was a reliance on old medical records. At time of final follow-up there was no difference in the marital status. These reports do not allow comparison of patients treated by different methods. The latter may bias patient selection to those treated surgically. [9] have reported on patients treated by Milwaukee bracing.14. it is not possible to directly compare the results of each group or to extrapolate to the possible outcome if all patients had been treated with one single modality. the long-term radiographic evaluation. Most articles documenting results of surgical treatment for Scheuermann kyphosis have a short-term follow-up [16. One week later. there were no objective differences between these two groups of patients and the patients treated only by observation and exercise. severity of deformity and pain.18. Milwaukee bracing and surgical fusion with Harrington instrumentation. Some patients subsequently underwent surgery. It is of interest that those patients who had been treated with bracing or surgery believed that their self-image had been improved by their treatment. 94% of our patients reported a working status without restriction.23]. our results show that it is possible to successfully treat patients with Scheuermann kyphosis using a graduated set of interventions if the treatment modality is correctly matched to the severity of the initial pathology. Initially. an anterior release was carried out. Kyphosis of less than 75 degrees that is correctable to less than 50 degrees by hyperextension may be treated by a onestage posterior fusion and instrumentation [8.3. At time of final follow-up. / The Spine Journal 2 (2002) 49–56 55 has also been recommended for patients who have severe and disabling back pain in the area of the kyphosis when the pain cannot be controlled by nonoperative means [8. All patients scored well in their daily functional capacity and exercise activity. nontreating physician status of the primary investigator. there was no difference in self-image and perception of physical appearance among the three treatment groups as evidenced by the lack of difference in dressing. Patients treated surgically in this study all underwent a two-stage procedure. [4. Irrespective of the method of treatment. surgery has been recommended [4. we have demonstrated the long-term success of a three-tiered approach to the treatment and management of Scheuermann kyphosis in which different modalities have been prescribed to address deformities of different severity at initial presentation. Some of these patients showed a progression of the curve despite brace treatment. The ongoing challenge is to address the relative indications of each of these treatment methods. .8].4. Curves greater than 70 degrees have been treated with a combined anterior release and posterior fusion with instrumentation [6. At long-term follow-up.L. the type of treatment they received and the severity of their residual deformity.7. The small threaded Harrington compression rods were used with number 1259 hooks.21]. because we did not have access to a control group of individuals without spinal deformity or patients with Scheuermann kyphosis who went untreated.20.8. A variety of different surgical approaches have been discussed and used for the treatment of Scheuermann kyphosis. [22] reported on 12 patients treated with cast or brace. The strengths of this study are the large number of patients followed. There was only one patient who required narcotics for pain control during daily activity.2]. In general. occupation or degree of kyphosis. there was no correlation found between back pain.

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