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198 IV Deformity
(1) Increased rate of symptomatology if lumbar spine is involved
(a) Some patients develop lumbar spondylolysis later.
6. Physical examination
a. Increase in thoracic kyphosis (rigid)
b. Compensatory lumbar and cervical lordosis
(1) Round shoulders
(2) Head forward
c Muscle tightness and contractures are seen typically in the ham-
strings.
d. Thirty percent have an associated mild scoliosis.
7. Radiographic findings
a. Early
(1) Disordered endochondral ossification
(2) Irregular end plates
(3) Narrowing of the intervertebral disk space
(4) Schmorl’s nodes
b. Intermediate
(1) Vertebral wedging
(2) Increasing kyphosis greater than 45 degrees
(a) More than 5 degrees of anterior wedging in three or
more vertebrae at the apex of the kyphosis (Sorenson’s
criteria)
c. Late
(1) Degenerative changes
(a) Osteophytes
(b) Facet hypertrophy
d. Standing lateral and supine hyperextension views are used to assess
rigidity of the curve
8. Treatment
a. Observation is indicated for mild deformity with minimal symptoms.
b. Bracing indications
(1) Vertebral wedging greater than 5 degrees
(2) Kyphotic curves between 45 and 65 degrees and 1 to 2 years of
growth remaining
(a) Milwaukee brace for apex above T9
(b) Thoracolumbar Sacral Orthosis (TLSO) for apex below T9
and thoracolumbar curves
(3) Curve correction and wedging improvement of 40% can be ex-
pected after 6 to 12 months.
(4) Brace should be weaned with skeletal maturity, but loss of cor-
rection is expected after 10 years.
c. Exercise
(1) Stressing pelvic tilt, abdominal strengthening, spinal flexibility,
and thoracic spine extension exercises is an important part of
the treatment plan
9. Surgery
a. Indications
(1) Severe deformity after growth completion with unrelenting
pain
Chapter 18 Kyphotic Spinal Deformities in Children and Adults 199
(a) Typically 75 degrees and 10-degree wedging in three or
more contiguous vertebral bodies
(2) Resistance to bracing after 6 months
(3) Neurological signs or symptoms
b. Techniques
(1) Posterior-only instrumented fusion
(a) Curves less than 75 degrees and bending correction to less
than 50 degrees
(b) Posterior instrumentation should extend the entire
kyphotic region, and distally it should include one lordotic
vertebra (usually L1 or L2).
(2) Anterior fusion (transthoracic approach) followed by posterior
fusion and instrumentation
(a) Curves greater than 75 degrees with minimal bending cor-
rection (50 degrees)
c. Postoperative protocol
(1) TLSO for 6 to 9 months until solid fusion
d. Complications
(1) Pseudarthrosis and instrumentation failure (greater in posterior
fusion alone)
(2) Loss of correction
(3) Infection
(4) Pulmonary complications
(5) Neurological deficits
D. Neuromuscular kyphosis (Fig. 18–1)
1. Associated conditions
a. Poliomyelitis
b. Anterior horn cell diseases (spinal muscular atrophy)
c. Cerebral palsy
d. Charcot-Marie-Tooth disease
e. Muscular dystrophy
f. Friedreich ataxia
2. Lack of the extensor muscle strength contributes to development of a
kyphotic deformity
3. Natural history is progressive even after skeletal maturity.
4. Treatment
a. Bracing until the patient is 11 to 12 years old to maximize truncal
height
b. Posterior fusion with instrumentation in milder and flexible
curves
(1) Compression instrumentation is preferred over Luque rods with
sublaminar wires for correction of kyphosis.
(2) Combined anterior and posterior fusion with instrumentation
in severe fixed deformities
E. Myelomeningocele
1. Congenital
a. It is generally not recommended to correct deformity at birth be-
cause of the lack of bone stock and associated problems.
200 IV Deformity
2. At 3 to 5 years of age, posterior resection followed by of correction of
kyphosis
a. Posterior instrumentation should be applied two to three vertebrae
proximal to the apex.
b. Followed by 6 to 9 months of bracing
F. Developmental or paralytic kyphosis
1. The deformity is progressive, because the extensors of the spine
(sacrospinalis and quadratus lumborum muscles) rotate anteriorly to
increase flexion force.
2. Treatment
a. Bracing is indicated for young patients with mild deformity.
b. Posterior fusion involving long fusion to the sacrum
c. Anterior release and fusion followed by posterior fusion with com-
pression instrumentations
G. Posttraumatic kyphosis
1. Acute or late secondary to severe compression fractures, burst frac-
tures, or fracture-dislocations
2. More common for unstable fractures after conservative treatment
3. Symptoms include deformity, pain, and neurological deficit.
4. Treatment
a. Observation and conservative treatment if the deformity causes
mild pain that is controllable
b. Surgery is most commonly done by a combined anterior and poste-
rior fusion.
(1) Anterior decompression with anterior instrumentation alone
may be done if adequate correction has been achieved and the
instrumentation is stable.
(2) Posterior-only transpedicular osteotomy may be done if there is
no neurological compression.
H. Postsurgical kyphosis
1. Usually observed after laminectomy for spinal cord tumors and sy-
ringomyelia
2. Fusion is recommended when extensive laminectomy has been
performed.
3. Severe deformity is approached with a combined anterior and poste-
rior fusion.
I. Infectious kyphosis (Fig. 18–3)
1. Infection may be caused by tuberculosis and pyogenic osteomyelitis.
2. Thoracolumbar junction is most commonly affected.
3. Treatment
a. Antibiotic treatment includes long-term intravenous antibiotics and
bracing.
b. Anterior debridement and fusion indications
(1) Unresponsive to medical treatment
(2) Multiple-level involvement
(3) Spinal cord compression
(4) Presence of an abscess
Chapter 18 Kyphotic Spinal Deformities in Children and Adults 201
c. Progressive kyphosis needs anterior and posterior procedures
J. Inflammatory kyphosis (ankylosing spondylitis)
1. Characterized by loss of a lumbar lordosis and increased cervical and
thoracic kyphosis
2. Primary location of disabling deformity should be assessed
3. Hip flexion contracture should be corrected first.
a. May avoid the need for spinal surgery
4. Lumbar osteotomy is indicated for significant loss of lumbar lordosis.
a. Types of osteotomy
(1) Smith-Peterson opening wedge extension osteotomy
(a) Typically performed at L2–L3 and L3–L4 junction followed
by instrumentation and fusion
(b) The angle of correction corresponds to the spine flexion
deformity on standing.
(c) Apex of osteotomy should be anterior to the neural tube
and at the junction of posterior longitudinal ligament and
intervertebral disk.
(2) Pedicle subtraction osteotomy
(a) Does not lengthen the anterior column
Figure 18–3 A 65-year-old man with old tuberculosis who had a posterior fusion 40 years prior.
Despite severe kyphosis, this patient was ambulatory with minimal symptoms. (A) Lateral radi-
ograph showing severe angular kyphosis. (B) Sagittal T2-weighted magnetic resonance image
showing an old granuloma and spinal cord compression at the apex of the kyphotic deformity.
202 IV Deformity
(i) Closing wedge osteotomy shortens the vertebral column
and is safer neurologically.
(b) Posterior resection of the lamina, pars, and pedicles are
performed followed by a vertebral wedge resection.
K. Flatback syndrome
1. Etiologies
a. Distraction of the lumbar spine (Harrington instrumentation)
b. Lumbar fusion with loss of lordosis
2. Clinical findings
a. Sagittally imbalanced posture
b. Back pain with referred pain down to legs
c. Transition syndrome above and below kyphosis
d. Compensatory hip and knee flexion contractures
3. Treatment
a. Conservative treatment with nonsteroidal antiinflammatory drugs,
physical therapy, range of motion exercises, pain management
4. Surgery
a. Lumbar osteotomy to balance the sagittal contour of the spine
(1) Pedicle subtraction osteotomy
(2) Smith-Peterson osteotomy
Suggested Reading
Bradford DS, Ahmed KB, Moe JH, Winter RB, Lonstein JE. The surgical management of patients with
Scheuermann’s disease. J. Bone Joint Surg Am 1980;62A:705–712
Chang KW, Chen HC, Chen YY, et al. Sagittal translation in opening wedge osteotomy for the correction
of thoracolumbar kyphotic deformity in ankylosing spondylitis. Spine 2006;31:1137–1142
Denis F, Burkus JK. Classification and treatment of posttraumatic kyphosis in the thoracic and lumbar
spine. Seminars in Spine Surgery 1993;5:187–198
Jansen RC, van Rhijn LW, van Ooij A. Predictable correction of the unfused lumbar lordosis after thoracic
correction and fusion in Scheuermann kyphosis. Spine 2006;31:1227–1231
Lonner BS, Kondrachov D, Siddiqi F, et al. Thoracoscopic spinal fusion compared with posterior spinal fu-
sion for the treatment of thoracic adolescent idiopathic scoliosis. J Bone Joint Surg Am 2006;88:
1022–1034
Lonstein JE. Neurologic deficits secondary to spinal deformity. A review of the literature and report of 43
cases. Spine 1980;5:331–355
Lowe GP, Menelaus MB. The surgical management of kyphosis in older children with myelomeningocele.
J. Bone Joint Surg Br 1978;60B:40–45
Robertson JR, Whitesides TE Jr. Surgical reconstruction of late post-traumatic thoracolumbar kyphosis.
Spine 1985;10:307–312
Winter RB, Moe JH, Lonstein JE. The incidence of Klippel-Feil syndrome in patients with congenital scol-
iosis and kyphosis. Spine 1984;9:363–366
V
Miscellaneous
19 Spinal Tumors
20 Spinal Infections
21 Rheumatoid Arthritis
22 Seronegative Spondyloarthropathies
23 Pediatric Cervical Spine Disorders
19
Spinal Tumors
I. Evaluation
A. History
1. Pain (localized versus radicular) is the most common chief complaint
(85% of patients).
a. Other common presenting symptoms include motor weakness
(41%) and a palpable mass (16%).
2. Pain secondary to a spinal tumor is typically localized, progressive, un-
relenting, nonmechanical, and worse at night.
a. Patients do not have relief with rest.
3. Systemic signs and symptoms
a. Fevers/chills
b. Lethargy
c. Unexplained weight loss
4. Neurological symptoms may be present, such as weakness, sensory
changes, or bowel and bladder changes.
5. Age may help to narrow the differential diagnosis.
a. In older patients, metastasis and multiple myeloma are more common.
6. A history of a primary tumor elsewhere in the body raises the concern
of metastases.
a. See Table 19–1 for risk factors.
B. Physical examination of the spine should include palpation, range of mo-
tion, and neurological examination.
1. Neurological examination
a. Detailed motor examination
b. Sensory examination
(1) Light touch
(2) Pinprick
(3) Vibration
(4) Assessment of long tract findings
(a) Reflexes
2. Physical examination of potential metastatic foci (Table 19–2)
205
206 V Miscellaneous
C. Laboratory studies
1. Helpful in differentiating tumor from infection
a. White blood cell count (WBC), erythrocyte sedimentation rate, and
C-reactive protein should all be elevated with infection and normal
or slightly elevated with tumor.
(1) Exception is lymphoma, which is associated with an elevated
WBC
2. Multiple myeloma is associated with protein spikes on serum or urine
analysis.
3. Thyroid-stimulating hormone and free T4 levels are useful in identify-
ing thyroid disease.
4. Prostate specific antigen (PSA) is useful for prostate cancer.
Table 19–1 Common Metastatic Spine Tumors
Primary Tumor Risk Factors
Breast cancer First-degree relative
History of increased estrogen exposure (early menarche,
late menopause, nulliparity, prolonged hormone
replacement therapy)
Radiation exposure
Prostate cancer Increased age (45 y)
Bladder outlet obstruction
Thyroid cancer Iodine excess/deficiency
Radiation exposure
Lung cancer History of smoking
Renal cell carcinoma Tobacco use
Table 19–2 Classic Physical Exam Findings in Metastatic Spine Tumors
Primary Tumor Physical Exam Findings
Breast cancer Hard, fixed, nontender breast mass
Nipple retraction
Skin erythema or edema
Prostate cancer Large, hard, nodular prostate on digital rectal examination
Thyroid cancer Painless, palpable thyroid
Lung cancer Baseline change in cough
Hemoptysis
Renal cell carcinoma Classic triad of hematuria, flank pain, and abdominal mass
Tobacco use
Chapter 19 Spinal Tumors 207
5. Calcium and phosphate are commonly associated electrolyte abnor-
malities that may need to be corrected.
6. Radiological evaluation (Table 19–3)
7. Magnetic resonance imaging (MRI) differentiation of infection, frac-
ture, and tumor (Table 19–4)
D. Tumor types
1. See Tables 19–5 to 19–8
E. Staging
1. Weinstein-Boriani-Biagini system
a. Three-dimensional description of tumor invasion
(1) Anatomic zones
(a) Twelve pie-like zones starting at the spinous process and
rotating clockwise
(2) Involvement of different vertebral layers
(a) Extraosseous soft-tissue
(b) Intraosseous (superficial)
(c) Intraosseous (deep)
(d) Extraosseous (extradural)
(e) Extraosseous (intradural)
(3) Specification of the spinal segment(s) involved
F. Treatment
1. Goals
a. Establishment of a definitive diagnosis
b. Maintenance of neurological function
Table 19–3 Diagnostic Imaging of Spine Tumors
Imaging Study Advantages Disadvantages
Plain Simple screening method Low sensitivity (50% of
radiography Helpful in diagnosis (benign versus cancellous bone loss is needed
malignant) for radiographic identification
of bone destruction)
Bone scan Most sensitive tool for metastases Low specificity (cannot
(osteoblastic lesions) differentiate fracture, infection
and neoplasm)
CT Best for evaluating bone destruction Ineffective as a screening tool
Important for preoperative planning
MRI High sensitivity especially when used Extent of cord compression does
with gadolinium not consistently correlate with
Provides information about soft tissue symptoms or outcome
component
Helpful in evaluating spinal cord
compression
Myelography Good visualization of epidural Invasive
metastasis and cord compression
Angiography Selective embolization of the Invasive
neoplasm may decrease bleeding
during surgery