Insights and controversies in the management of Scheuermann’s kyphosis

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“With braces, you can take the credit or accept the fact you are probably not doing that much. I personally, I am not that optimistic about their effectiveness and therefore, do not use them that often” Peter Newton, orthopaedic surgeon at Rady Children’s Hospital in San Diego, California, USA, told delegates attending his talk Scheuermann’s kyphosis treatment at the 18th International Meeting on Advanced Spine Techniques (IMAST; 13–16th July, Copenhagen, Denmark).

 

Newton claimed that brace treatment was so “torturous” for patients that it encouraged them to stand with a better posture the next time they came to clinic to avoid further treatment with a brace. Therefore, any improvement observed on X-ray was probably because of a patient purposely changing their posture rather than any effect of the brace.

 

Another issue in the management of Scheuermann’s kyphosis, according to Newton, is which surgical approach to use (if surgical treatment is warranted). “Surgical treatment has traditionally been more of an anterior and posterior approach. But of late, many of us have moved towards a posterior approach using the Alberto Ponte procedure.” The benefits of a combined anterior and posterior approach are that it is associated with long-lasting correction and reduced recurrence.

 

The Ponte procedure involves posterior column shortening via segmental osteotomies.

“Probably, with less secure methods of fixation, the combined approach really was an requirement. But, with the idea of segmentally releasing posterior elements and completely exercising facet joints, you can provide enough correction at each level, and with solid fixation using pedicle screws, you can probably maintain the correction.”

 

A study by Geck et al (J Spinal Disord Tech 2007; 20: 586–93) found that using thoracic pedicle screw instrumentation as the primary anchor, the Ponte procedure was successfully performed in 17 patients with Scheuermann’s kyphosis with no exclusions for the size or the rigidity of the kyphosis. They concluded: “Results were as good as anterior/posterior historical controls with excellent correction and minimal loss of correction at final follow-up. This procedure avoids the morbidity and extended operative time attributed to the anterior approach.” However, as Newton noted, there is not much long-term data at present for the Ponte Procedure. “The procedure has only been popular for five or seven years.”

 

Whether hooks or screws should be used in the procedure is controversial. “I really try hard to protect the intraspine ligaments and the soft tissue at the top. Therefore, I finish with a hook which I think allows me to dissect a little bit less. A hook is also less rigid and I try not to compress very hard at the top of the construction.”

 

Whichever approach is used, whether posterior-only or combined, a key thing to avoid is over correction. “I have corrected less and less as time has gone on. I now just ‘tease’ people back to the upper normal range of around 50 degrees.” Also important is to do an MRI scan prior to the surgery. “Patients with Scheuermann’s are at higher neurologic risk, so I have made doing an MRI part of my routine.”