An Alternative Bracing Approach to Scheuermann's Disease: A Case Study
Miguel Gomez, MD Patrick Flanagan, CO Thomas Gavin, CO
Scheuermann's disease manifests itself as a thoracic or thoracolumbar kyphosis classically characterized by anterior wedging of 5 degrees or more of three adjacent thoracic vertebral bodies. Bracing has been shown to be effective in controlling a progressive curve in the adolescent patient. These adolescent patients typically present for medical attention because of pain or cosmetic deformity or both. Early treatment may be limited to observation and exercises, whereas patients who have kyphosis of up to 75 degrees and growth remaining may benefit from bracing. For the more common thoracic form with apices superior to T8, the Milwaukee Brace's effectiveness has been documented and is usually the treatment of choice. This purpose of this article is to document a case for the treatment of the thoracic form of Scheuermann's disease (apice T6-7) with an underarm thoracolumbosacral orthosis. A custom thoracolumbosacral orthosis was measured and fabricated as an alternative to the Milwaukee brace to treat a 71-degree kyphosis with an apice of T6-T7. Initial in brace correction was 49%. At a fourteen-month follow-up, out -of-brace correction was maintained at 27% of the original kyphosis. These results indicate that a thoracolumbosacral orthosis my be a viable alternative to the Milwaukee brace in treating Scheuermann's disease with high apices. (J Prosthet Orthot. 2002;14:109-112.)
Key Indexing Terms: Scheuermann's kyphosis, spine, discogenic disease, bracing, thoracolumbosacral orthosis
Scheuermann's disease, or juvenile discogenic disease, was first described in 1921 by Holger Shceuermann, who described it as a typically juvenile kyphotic disorder that could be distinguished from postural kyphosis on the basis of peculiar rigidity,1 Although many theories have been proposed, the cause of Scheuermann's Disease is unknown. Currently under investigation are the role of juvenile osteoporosis, hereditary factors, biomechanical factors, and a variety of other causes. The disease is identified radiographically by the appearance of vertebral wedging in the thoracic or thoracolumbar spine and disturbs the growth of the vertebral endplates.2,3
The incidence of Scheuermann's disease varies according to the literature. Sorensen4 reported a 0.4% to 8% incidence in the population. Bradford5 noted an incidence of up to 10%. The incidence between males and females also varies according to the literature. Murray6 reported a male to female predominance of 2.2 to 1, while Winten reported that the ratio was nearly equal.
Clinically, these patients range in age from 10-15 years with pain being the predominant clinical symptom.8 Upon forward bend, the patient with Scheuermann's disease will present with an area of sharp angulation near the apex of the kyphosis, usually around T7. When standing, the patients appear "slouched" with a rounded shoulder appearance. Ascani and La Rosa noted that Scheuermann's patients often have a more athletic body stature and present with contracture of the pectoral muscles and hamstrings.9
Radiographically, Bradfords suggested the following criteria be used in indentifying Scheuermann's kyphosis in the adolescent patient:
- Irregular upper and lower vertebral end-plates.
- The apparent loss of disc space height.
- Wedging of more than 5 degrees in one or more vertebrae.
- The presence of a hyperkyphosis greater than 40 degrees.
The apices of these curves will usually be located in one of two regions
- The more common thoracic form of Scheuermann's will have an apex between T7 and T9
- The thoracolumbar form will have an apex between T10 and T12
Among the documented methods for nonoperative treatment for Scheuermann's are corrective casts, the Boston Brace ( Boston Brace International, Inc. Avon, MA.USA) and the Milwaukee brace. Sachs et al. reviewed 132 patients and found an initial mean correction of 50% using the Milwaukee Brace. The mean full-time wearing period was 14 months, and the part-time period was 18 months. Apical wedging improved from a mean of 8.4 degrees prior to treatment to 8.1 degrees after treatment.10
Winter noted that some thoracolumbar types of kyphosis have been managed with underarm braces, but only the Milwaukee brace will be beneficial for those patients with the thoracic form of the disease,11 Peveraro et al, suggested an underarm orthosis with four valves to control kyphosis without the unaes-thetic neck ring of the Milwaukee brace. 12 However, Ascani and LaRosa felt that this brace should be used only on curves with apices below T9.9 Gutowski and Renshaw13 have reported on the use of the Boston lumbar and modified Milwaukee orthoses for Scheuermann's kyphosis. Compliant patients had an average improvement in kyphosis of 27% in the Boston group and 35% in the Milwaukee group after an average of 26-monts follow-up.
The authors present a Scheuermann's case study where a custom thoracolumbosacral orthosis (TLSO) was used to treat a patient with Scheuermann's disease who had an apex superior to T8. This is the first case in a series of Scheuermann's cases that are being treated in the same manner. It is the intention of the authors to publish the results of these multiples outcomes when available. To the best of each author's knowledge, this is the first documented case involving the treatment of Scheuermann's kyphosis with an apice superior to T8 with a custom fabricated TLSO.
An active 16-year-old male patient diagnosed with Scheuermann's disease was referred to our clinic in November 2000 with a height of 5 feet 6 inches and a weight of 150 pounds. He was an avid soccer player. He reported back pain as a symptom. The apex of the kyphosis was T6-7, and the curvature measured 71 degrees (Figure 1 ). Originally, the orthopedic surgeon had recommend a Milwaukee brace, the standard treatment for hy-perkyphosis with apices superior to T8. Due to the fact that the patient was very active and sensitive about his appearance in a Milwaukee brace, the doctor prescribed a TLSO.
A supine, bivalved impression was taken of the patient. The patient was first positioned supine, ther a two inch beveled plastizote pad was place 1.25 cm below the apex of the kyphosis. The patient remained on the pad for fifteen minutes before the casl was taken in order to maximize viscoelastic relaxation/correction (creep-response) of the kyphotic deformity. The pelvis was stabilized in posterior tilt, and 5-inch (12.7 cm) plaster splints were applied horizontally from pubis to clavicles. After setting, the anterior impression was secured with straps and the patient was rolled prone. The 2-inch pad was placed under the sternum, the pelvis was manually stabilized, and 5-inch plaster splints were applied vertically until the impression was completed.
A custom, anterior opening TLSO was fabricated from this impression and fitted in December 2000. The TLSO was made of 3/16 inch rigid copolymer plastic and was lined with thermal foam. The posterior trimline was 2.54cm inferior to the apex of the kyphosis. The patient was seen again for follow-up one month after the initial visit. During this visit, 1.8cm thick pads were added bilaterally in the deltopectoral region and inferior to the apex of the kyphosis. The patient returned for follow-up every 2 months, at which time the progression of his deformity was monitored and necessary adjustments were made.
The duration of treatment and data collection for this case study were 14 months after the initial evaluation of the orthopedic surgeon. The same orthopedic surgeon measured the x-rays using Cobb technique.
The patient reported an average daily wearing time of 17 hours. Standing sagittal radiographs were taken approximately every 4 months by the orthopedic surgeon either with the patient wearing or not wearing the TLSO. The patient was instructed by the orthopedic surgeon not to wear the TLSO for a minimum of 6 hours before the scheduled radiograph in order to track possible progression of the kyphosis. Table 1 summarizes the radiographic results of brace treatment for the 14 months of treatment. After only one month, the in-brace reduction was nearly half that of the original kyphosis. The patient also reported relief of back pain after only one month in the brace. The latest radiograph with the patient out-of-brace shows a 27% reduction in the kyphosis.
|Date of Radiograph||10/11/00||1/11/00||5/24/01||10/21/01||3/5/02|
|In / out of TLSO||out||in||out||out||out|
Despite the high apex (T6-T7) of the kyphsis, the initial results of this case study are promising. The initial in TLSO-brace reduction of the kyphosis of 50% equaled Sach's study's results with the Milwaukee Brace.9 Furthermore, long-term results show a maintenance of curve correction even after the patient has been out of the brace for at least 6 hours. Percentage of correction is similar to that found by Gutowski and Renshaw and the Boston Brace, but they recommended the brace for flexible curves below 70° in magnitude with an apex at or below T7.
Our technique involved laying the patient supine for the casting. In addition, we felt that it was important that the patient's hips and knees were kept flexed during the casting in order to attempt to reduce the anterior tilt of the pelvis and specifically, the angle of L5-S1. We believe that by stabilizing the pelvis in this position and by utilizing the deltopectoral region to apply our primary point of force from anterior to posterior to "unbend" the kyphosis, we were able to achieve our results. Also, this technique allowed the patient to achieve good sagittal alignment (head over pelvis) using comfortable levels of force in the deltopectoral region.
Data are being collected on similar cases and will be used to corroborate or deny the results of this initial case study. Our case is only 14 months in duration . Further follow-up will be necessary to evaluate longer-ter results. Considering will be necessary to evaluate loner-term results. Considering that surgical correction for Shceuermann's usually does not exceed 50% of the original kyphosis, 14 our initial results from this case study indicate that a custom fabricated TLSO may be a viable option to treat this disease with apices as high as T6.
- Scheuermann HW. Kyphosis Dorsalis Juvenilis.Orthop Chir: 1921;41:305
- Ascani I, Ippolito E,Montanaro A. Scheuermann's Kyphosis: Histological, Histochemical and Ultrastructural Studies. Presented at 17lh Annual Meeting, Scoliosis Research Society, Denver, September 22-29,1982
- Ippolito E. Bellocci M. Montanaro A, Ascani E, Poneseti IV.Juvenile Kyphosis: An Ultra-structural Study. J Pediatr Orthop 1985:5:315
- Sorensen K. Scheurermann 's Juvenile Kyphosis, Copenhagen,Mundsgaard, 1964
- Bradford D. Juveile Kyphosis. Clin Orthop Rel Res
- Murray PM, Weinstein SL, Spratt KF. The Natural History and Long-Term Follow-Up of Scheuermann's Kyphosis..J Bone Joint Surg l993;75A;236-48
- Winter, R. The Treatment of Spinal Kyphosis. Int Orthop 1991,15:265-72
- Carlioz H. Dorsalgie de L'enfant, Dos Rouds. Maladie de Scheuermann. Ann Pediatr (French) 1989;36;642
- In: Weinstein SL (Ed). THE Pediatric Spine, Principles and Practice, New York: Raven Press, 1994
- Sachs, B, Bradford D, Winter R, et al. Scheuermann's Kyphosis: Long-Term Results of Milwaukee Brace Treatment of 132 Patients. Presented at 19th Annual Meeting, Scoliosis Research Society, Orlando, 1984
- In: Morrissy RT, Weinstein SL (Eds) Lovell & Winter's Pediatric Orthopaedics. Philadelphia: Lippincott-Raven, 1990
- Peveraro A, Bertini G, Baccino E, Rosso V.II Corsetto Tipo Zielke Nel Trattamento Del Dorso Curvo Giovanile, Prog Pat Vertl988; 11:73.
- Gutowski WT. Renshaw TS. Orthotic Results in Adolescent Kyphosis. Spine 1988;13;485-9.
- Tribus CB. Scheuermann's Kyphosis in Adolescents and Adults: Diagnosis and Managment. J AM Acad Orthop Surg 1998;6:36-43
The authors would like to thank the Ewert family for supporting their research efforts in this area and M&M Orthopedics for providing and recording radiographic data.
Prosthetics and Orthotics) for allowing me to reprint this article. JPO September 2002, pages 109-112