When viewed from the side, the normal thoracic spine curves outward towards the back of the body. See Figure 1. This outward curve is called kyphosis. Hyperkyphosis is a term used to describe a type of abnormal increased outward curve of the thoracic spine. See Figure 1 C and D. Hypo-kyphosis is a term used to describe a type of abnormal decreased outward curve of the thoracic spine. The larger the abnormal curve, the more serious the problem.   If a thoracic hyper-kyphosis gets bad enough, it can limit the amount of space in the chest and cause cardiac (heart) and pulmonary (lung) problems.  In severe cases it can narrow the spinal canal where the spinal cord sits and put pressure on the spinal cord and nerves; this condition is called spinal stenosis.

 

            This condition has several possible causes and can develop in both children and adults. There are several main types of abnormal thoracic hyperkyphosis:

1.      Postural kyphosis,

2.      Scheuermann’s kyphosis,

3.      Congenital kyphosis,

4.      Osteoporosis induced kyphosis from vertebral fractures.  

 

            Postural kyphosis is the most common type of thoracic hyper-kyphosis or hypo-kyphosis.   This condition occurs more frequently in girls than boys and is typically first noticed during adolescence. It is caused by poor posture and a lengthening of the muscles and ligaments of the back in hyperkyphosis and a shortening in hypokyphosis. The vertebrae are typically shaped normally in postural kyphosis. This type of hyperkyphosis usually does not lead to a severe curve with a risk of neurologic, cardiac or pulmonary problems. This type of hypokyphosis may increase the chance of scoliosis, especially in young adolescent girls.

 

Scheuermann’s kyphosis also is also first noticed during adolescence. This type of thoracic hyperkyphosis is the result of a structural deformity of the vertebrae. It is more common to develop scoliosis (kyphoscoliosis) with Scheuermann’s kyphosis than with the other types of kyphosis.  

 

 

            Thoracic hyperkyphosis can be congenital, which means that you are born with it. A person born with some sort of defect, such as incomplete formation of a part of the spine, may end up with an increased kyphosis in the thorax. When a child has congenital thoracic hyperkyphosis, there are generally additional birth defects in other areas of the body.

Degeneration of the intervertebral disc can lead to hyper-kyphosis of the thorax. A hyper-kyphotic thoracic spine will degenerate faster than a normal kyphotic thoracic spine. This loss of disc integrity can allow the weight of the upper body to increase the thoracic lateral curvature into a hyperkyphosis. This process may steadily get worse over many years.

Thoracic hyperkyphosis can occur as the result of an injury or multiple injuries to the spine. In an extreme injury the vertebral body can compress and fracture into the shape of a wedge. This causes that section of the spine to collapse into a hyper-kyphosis.   Less extreme injuries, like a moderate spinal whiplash can damage the ligaments along the spine and result in a deformation of the thoracic spine into a hyperkyphosis.  

Less common causes of thoracic hyperkyphosis include infections or tumors in the spine, systemic (whole body) diseases that affect the spine such as ankylosing spondylitis and radiation therapy for cancer in the thorax. Children especially who have had radiation therapy to the thorax may have altered growth in the thorax vertebrae, leading to future problems with hyperkyphosis.

 

            The symptoms and severity of kyphosis vary. Symptoms can start as just a chronic strain and muscle fatigue of the upper or mid back muscles and progress to severe deformity, neurologic deficits, heart and lung problems and chronic pain. General symptoms include:^1-14

·         Movement may become limited, making it difficult to move the body fully or to walk very long,

·         Chronic thoracic pain may be present, especially if the hyperkyphosis is associated with degenerative changes,

·         Severe hyperkyphosis in the elderly is also associated with an increased chance of falls, a reduced ability to take care of one’s self,

·         Reduced activity,

·         Decreased appetite,

·         Sleep disorders,

·         And even an early or premature death has been reported in some studies when severe rigid thoracic hyper-kyphosis is present. See Figure 3 and ask yourself a question: “Does the model at the far right look healthy?”^15-17

 

 

            With a kyphotic deformity, the spinal cord and nerve roots may be stretched where the spine bends forward. The spinal cord is the body’s connection to the brain. When it is under constant tension, damaged or compressed, the body loses some of its ability to function properly. If pressure builds up on the spinal cord, it can cause myelopathy. Myelopathy may impair normal walking, hand and finger use, grip strength and bowel and bladder function. Doctors take these symptoms very seriously because severe myelopathy that is not treated may lead to permanent nerve damage. 

 

            Finding the cause of your thoracic problem begins with a complete history and physical exam that usually consist of spinal range of motion studies, orthopedic tests, postural inspection and x-ray. The most common confirming test used to diagnose thoracic hyper or hypokyphosis is the lateral thoracic or full spine radiograph. To determine Scheuermann’s kyphosis, a radiographic finding of at least five degrees of abnormal anterior vertebral wedging at three neighboring vertebral bodies is necessary.   If your doctor finds any evidence of neurologic insult, you may also an MRI scan or Nerve Conduction Test performed. If you have any chest pain or shortness of breath, your physician may order additional tests to evaluate your heart and/or lungs.

 

            Physical therapies, such as ice, ultrasound, spinal manipulation or electric stimulation, may first be used to reduce any painful acute inflammation and restore motion. Once the patient has reached the sub-acute to chronic stage, structural and postural rehabilitative adjustments, traction and exercise may be applied. This would usually consist of:

·         Thoracic extension or flexion compression Traction to change the curvature to normal,

·         Thoracic postural Adjustments (See Figure 4),

·         Thoracic postural Exercises (See Figure 4),

·         Thoracic postural bracing (See Figure 4),

·         These methods have clinically been proven to effectively reduce and/or increase a thoracic kyphosis towards its ideal structural configuration.

 

            Medical treatment for thoracic hyperkyphosis depends largely on whether there is pressure on the spinal cord. If there is, surgery will usually be suggested.  Indications for surgery include a curve greater than 75 degrees, uncontrolled pain, and neurologic, cardiac, or pulmonary complaints. The goal of surgery is to reduce the hyperkyphosis. Total correction is usually not possible.

If the thoracic hyperkyphosis is primarily of the Postural type and causing pain and postural problems, anti-inflammatory and/or pain medications and a physical therapy program will usually be prescribed. While physical therapy has not proven helpful for changing the hyperkyphotic curve in the thorax, its goals are to maximize your spinal range of motion and strength and help you learn ways to manage your condition. 

           Scheuermann’s kyphosis is usually initially treated with a combination of physical therapy exercises and pain and anti-inflammatory medications. If the patient is still growing, a brace can be effective. Braces are often recommended for curves of at least 45 degrees and can be continued until the patient is no longer growing. Your physician will likely obtain routine x-rays to monitor the degree of kyphosis over time. 

            Congental kyphosis often involves surgery while the patient is an infant. Surgery earlier in life can help reduce the kyphosis before it continues to worsen.

            Thoracic hyperkyphosis caused by a painful collapse of the vertebral body due to osteoporosis are now being treated with a procedure called a kyphoplasty, whereby a balloon is inserted into the affected vertebra and filled with a liquid that hardens to restore the vertebral height.

            The most common complications from surgery for kyphosis include infection and failure of the bones to heal properly. Other more serious complications are much less common, but include injury to the nerves or blood vessels or complication related to anesthesia.

 

Several outcome investigations have been performed using a variety of conservative procedures aimed at restoration of the normal thoracic kyphosis in a variety of patient pain and health disorders.^18-27 The majority of these reports combine exercise, bracing, and/or passive 3-point bending traction with postural awareness in a multimodal treatment approach to reduce thoracic deformities. Collectively, these reports indicate that patients benefit from a multi-modal physical and chiropractic treatment approach aimed at improvement and/or restoration of an abnormal sagittal thoracic spinal alignment.^18-27

For example, in a small clinical trial, chiropractic adjustments combined with rehab procedures compared with rehab procedures alone was found to be superior in the reduction of thoracic hyper-kyphotic curvature.¹⁹                Thus, Chiropractic adjustments and rehabilitation procedures offer a safe and effective means of an initial course of treatment for patients suffering from thoracic kyphosis induced health disorders.

 

 

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