Spinal Diseases (Kyphosis)

What Is Kyphosis?

Known colloquially as hunchback, kyphosis is in fact an advanced form of the natural curvature that exists in our bodies. We all know that our back is slightly rounded and our lower back is slightly hollow. A hunch seen in the back or at the junction of the upper and lower back is considered natural to a certain degree. If this degree of hunching at the back region or at the junction of the upper and lower back exceeds 50 degrees, it can be referred to as kyphosis. Although kyphosis may seem to be merely a cosmetic problem, it actually brings with it very serious psychological problems such as depression, decline in school performance, communication problems with parents, and social adaptation difficulties.

When does kyphosis occur?

Kyphosis is seen more frequently in adolescent boys, and spinal growth does not occur in the way it should. Our vertebrae are rectangular in shape. Our spine grows as a result of these vertebrae growing equally on all sides. However, from around age 10, shape abnormalities begin to develop, particularly in the back and at the junction of the back and lower back. In other words, while the spine grows fully from our back, it grows less from our front and takes on a triangular rather than rectangular shape. In this case, the child cannot manage to stand upright. Some back pain may occur. The shape abnormality becomes noticeable between ages 15 and 16, and unfortunately, around ages 16 to 17, a doctor visit becomes necessary. It is at this stage that the hunch on the child's back becomes visible.

Causes of Kyphosis

1. Postural Kyphosis: This is a deformity that can usually be detected in children during school screenings. It is more common in adolescence and in girls. The curvature is below 60º, the spine is flexible, and there is no structural abnormality of the spine on X-rays.
2. Scheuermann Kyphosis:This is a structural curvature of the thoracic (upper back) and thoracolumbar (upper back + lower back) spine, seen in 0.4–8.3% of the population. It is more common in males (M/F: 7.3/1). Although there are many different interpretations of its etiology, the most widely accepted is avascular necrosis occurring in the ring apophyses of the vertebrae. It usually occurs during the adolescent growth spurt. Presenting complaints are either back or lower back pain or postural disorder. The diagnostic criteria are wedging of more than 5º in at least 3 adjacent vertebrae at the apex of the kyphosis and irregularity of the vertebral endplates, along with thoracic kyphosis exceeding 45º. Adolescents with mildly increased kyphosis that does not progress below 50º can be monitored with lateral X-rays taken every 4–6 months; monitoring is not required once growth is complete. In conservative treatment, a brace may be tried in adolescents with curvature between 50º and 80º. If the curvature exceeds 80º, surgical treatment is required. In surgical treatment, anterior release is generally combined with posterior instrumentation and fusion. Brace use is not required after surgery. The patient is mobilized as early as possible; the patient is sat up on the first day after surgery, and back exercises are started 6 months later.
3. Congenital Kyphosis: This develops due to a vertebral anomaly present at birth. The cause of the vertebral anomaly may be a formation defect, a segmentation defect, or a combination of both. Depending on a formation defect, a wedge vertebra, in which the vertebral body forms anteriorly in a wedge shape, or a hemivertebra, which develops when the front of the vertebral body does not form completely, can cause kyphosis deformity. Similarly, depending on a segmentation defect, kyphosis deformity can develop as a result of vertebral bodies being fused together or having a connecting band (unsegmented bar).
4. Paralytic Kyphosis: This is kyphosis that develops after diseases such as poliomyelitis, CP (cerebral palsy), and spinal muscular atrophy.
5. Myelomeningocele: Together with meningocele and myelomeningocele, kyphosis deformity may also be present at a rate of 8–15%.
6. Posttraumatic: Kyphosis deformity may develop following vertebral fractures due to wedging.
7. Inflammatory: Among infections, the first to come to mind are specific infections such as tuberculosis and brucellosis. Among inflammatory diseases, these are ankylosing spondylitis and rheumatoid arthritis.
8. After surgical procedures: Kyphosis may develop after fractures that were treated surgically but in which reduction was inadequate or fixation was insufficient.
9. Metabolic: It may develop as a result of osteoporosis, osteomalacia, and osteogenesis imperfecta.
10. Developmental: Kyphosis may develop as a result of conditions such as achondroplasia and mucopolysaccharidoses.

How is kyphosis diagnosed?

Through clinical examination and a simple X-ray examination, it can be determined whether the hunch seen in your child is a bone disorder or a postural disorder. Parents have a very important role here. In particular, during childhood, we may have been exposed to remarks from our parents such as "Stand up straight, or you'll become hunched." In fact, this guidance is correct. If a child can maintain a correct posture when instructed to stand up straight, this hunch is a temporary condition. However, if the child tries to stand correctly but cannot maintain the position and reverts to the previous posture, this must be taken seriously and a specialist should be consulted. Kyphosis is a postural disorder; if it is dismissed on the assumption that it will correct itself over time, it progresses. It is a problem that can be solved with non-surgical methods, but it becomes one that can only be solved with surgery. Therefore, parents need to be much more careful.

How is it treated?

After a hunch is diagnosed, a treatment plan is determined according to its degree. If the hunch can be brought under control and corrected with non-surgical treatment methods, the disease is followed up with an arrangement involving physical therapy applications such as exercise, posture training, muscle strengthening, strengthening of the abdominal and back muscles, performing sit-ups, reverse sit-ups and push-ups, and repeating these throughout the day. However, if the desired result cannot be achieved despite all these exercise and physical therapy movements and the degree of curvature continues to increase, brace treatment is started. Brace treatment is an important, difficult, and attention-requiring treatment. A brace suited to the location and degree of the hunch is designed specifically for the individual, determined through the joint work of a brace technician and a spine surgeon. Depending on the degree of the hunch, these braces may need to be worn continuously for 10–20 hours until skeletal growth is complete. A brace used specifically for the individual and under appropriate conditions can correct the disease without the need for surgery. However, if a hunch does not improve despite the brace, surgical intervention is required. In our country, unfortunately, kyphosis is wrongly perceived as a postural disorder that will go away on its own, so patients generally need to see a doctor only when the hunch becomes visible, around ages 16 to 17. Therefore, surgery for such conditions takes place between ages 16 and 18. Our wish is, if we can catch kyphosis at a time when surgery is not needed, to provide the necessary treatment with non-surgical methods. With today's advanced anesthesia techniques and intensive care units, the risk of complications in surgery has fallen below 2%. Postoperative mobility varies depending on the degree of the hunch and the region involved. Since movement is eliminated in the part of the spine where screws are placed, the earlier kyphosis surgery is performed, the more freedom of movement is ensured. Surgery is performed with the shortest possible segment, and efforts are made not to restrict the patient's range of motion. One day after surgery, the patient is helped to stand and walk, and mobility is increased as days pass. Because the screws used are very strong, a brace is not used except in very rare cases. The patient may begin sports activities such as swimming and cycling within 4–6 months.

What can happen if kyphosis is not treated?

If kyphosis is not addressed in time, it is a disease that affects not only the lower back and back region but also the internal organs. In people with kyphosis who do not receive the necessary treatment, as age advances, the rib cage deforms and begins to compress the heart and lungs. By preventing adequate oxygen exchange, it also slows the heart's rate of pumping blood and begins to affect all organs adversely. Since kyphosis also increases the hollowness of the lower back, as it progresses it reduces the flexibility of the lower back and paves the way for disc herniation, herniation in the back, muscle pain in the muscles that keep the spine upright, and arthritis.

Is it possible to protect our children from kyphosis?

The loads we place on our children's backs are not the direct cause of kyphosis; however, they do accelerate the onset and development of kyphosis, so do not forget! For this;

• Pay attention to ensure your child uses backpacks that do not exceed 8–10% of their body weight (4–6 kg).
• Make sure they carry their bag in the middle of the back.
• Adjust the bag straps so that they do not extend below the back region.
• Advise them to wear bags on both shoulders rather than one, with the support located in the middle of the back.
• Arrange the study environment at home to help them sit up straight. Choose a study desk and a chair with back support appropriate for their age and development.
• Make sure they sit in the correct position whenever they work at a desk.
• Ensure they take a break every 30–45 minutes during study sessions and do stretching and similar exercises.