Adolescent kyphosis (Scheuermann’s disease) | Calvé’s disease | Ankylosing spondylitis

Question 1

Scheuermann kyphosis

Answer 1

• Growth related disorder where the anterior part of vertebra grows slower than the posterior part of vertebra, leading to Hyperkyphosis especially in the Thoracic spine [Lumbar form is called Atypical Scheuermann disease]
• Back pain may or may not be present
• Typical in male, adolescent
• Genetical AD pattern accepted
• Can also be due to Osteonecrosis of anterior apophyseal ring, disc herniation material, relative osteoporosis
• > 40 degrees kyphosis in thoracic spine on Lateal Xray [Cobbs angle] | Anterior wedging > 5 degrees in three or more adjacent vertebral bodies

Treatment:
- Physcial therapy [to strenthen back muscles]
- NSAIDs for back pain
- Bracing or Casting if kyphosis > 60 degrees
- Posterior Spinal fusion +/- Osteotomy [if kyphosis > 75 degrees and/or persistent severe back pain and/or neurological compications/cord degenerations, disc degenerations]

Untreated can lead to:
- Chronic back pain
- Permanent deformity
- Spondylolysis and/or Spondylolisthesis
- Degen disc disease
- Restrictive lung disease in severe kyphosis
- Schmorl nodes and blood supply problem sto end plate, Disc herniation

Question 2

Ankylosing Spondylitis summary

Answer 2

It is a chronic seronegative autoimmune spondyloarthropathy

Presence of bridging spinal osteophytes, enthesitis, sacroiliitis, uveitis

Dx is HLA-B27 antigen presence, bilateral sacroiliitis and ocular exam showing uveitis

Question 3

Ankylosing Spondylitis Presentation

Answer 3

• Lumbosacral pain and stiffness [worse in morning, may get better during day]
• Females 4:1 ratio, in 3rd decade and older
• Neck and upper thoracic pain in later stages
• Sciatic
• Loss of horizontal gaze
• Shortness of breath

Physical Exam findings:
- Limited chest wall expansion [< 2cm expansion more specific than HL:A-B27 presence]
- Schober test [decreased spine motion]
- Kyphotic spine deformity [Chin-on-chest | Chin-brow-ro-vertical angle > 30 degrees]
- FABER test causes pain [felxion, abduction, external rotation of ipsilateral hip]
- Mennel test

Question 4

Ankylosing Spondylitis Treatment Conservative

Answer 4

• NSAIDs
• COX2 inhibitors
• TNFalpha blocking agents
• DMARD [Tofacitinib]
• Physical therapy on maintaining flexibilty

Question 5

Ankylosing Spondylitis Tretment Surgical

Answer 5

If Spine Trauma present:
- Immobilization
- Spinal decompression with instrumented fusion [high rate of complications]

Spine deformity:
- Lumbar Osteotomy [restore sagital balance and horizontal gaze]
- Cervicothoracic Osteotomy [reduce brow-to-chin angle]

Large Joint Arthritis:
- Total Hip replacement
- Bilateral Total Hip Arhtroplasty