Scheuermann’s disease is a hyper-kyphosis of the spinal vertebrae and intervertebral discs characterized by anterior wedging of ≥ 5⁰ within three or more adjacent vertebral bodies. The thoracic spine is commonly implicated although thoracolumbar or lumbar region can manifest the disease. Scheuermann’s disease is additionally denominated as Scheuermann’s kyphosis, juvenile kyphosis or juvenile discogenic disease.
Disease Characteristics of obscure aetiology, the disease is commonly discerned within adolescents of 12 years to 17 years and is exceptional in children below 10 years. Scheuermann’s disease is the commonest cause of kyphotic deformity in adolescents [1,2]. Mode of disease transmission remains undetermined although a hereditary component contributes to genesis of the disease. Disease incidence is enhanced within monozygotic twins, in contrast to dizygotic twins [1,2].
Disease prevalence appears at around 1% to 8%. A male predominance is observed with a male to female proportion of 2:1 [1,2]. Scheuermann’s disease is categorized as Type I or Classic subtype wherein the thoracic spine is incriminated with curve apex of kyphosis from thoracic vertebral body 7 to vertebral body 9(T7 toT9). Type II wherein the thoracic and lumbar spine is implicated, and curve apex appears at thoracic vertebral body 10 to vertebral body 12(T10 toT12). Type II is likely to progress and engender the disease in adulthood [1,2]. Sorenson et al categorized Scheuermann’s disease as anterior wedging of three or more adjacent vertebrae of around ≥ 5° with an absence of concurrent congenital, infectious, or traumatic disorders of the spine [1,2].
Disease Pathogenesis of obscure pathogenesis, Scheuermann’s disease demonstrates a genetic inheritance. It is posited that
mineralization and ossification of vertebral endplate may be discordant during skeletal growth with disproportionate expansion of vertebrae and consequent occurrence of classic wedge-shaped vertebral bodies engendering kyphosis [3,4]. Additional findings include aberrant collagen to proteoglycan ratio, cysts of the dura, osteoporosis occurring during childhood, hypersecretion of growth hormone and appearance of biomechanical stressors as tight hamstring muscles [3,4]. Alternatively, mechanical, metabolic and endocrinologic factors are posited to contribute to occurrence of Scheuermann’s disease [3,4].
Scheuermann’s disease demonstrates a structural deformity of vertebral bodies and spine wherein kyphosis of thoracic region appears at around 45⁰ to 75⁰ along with vertebral wedging ≥ 5⁰ of 3 or more adjacent vertebrae. Wedge shaped vertebral bodies engender the characteristic, rigid hyper-kyphosis which accentuates upon forward bending and is not relieved with extension or adopting a prone or supine position. However, aforesaid hyper-kyphosis can be counteracted by lumbar and cervical hyper-lordosis [3,4]. Cervical lordosis can be enhanced by protrusion of head wherein shoulders are positioned anteriorly. Mild to moderate scoliosis is an accompaniment. Tight hamstring muscles are exemplified along with muscle stiffness, fatigue, and decreased flexibility of the torso. Neurologic deficits are uncommon [3,4]. A cosmetic or postural deformity or a “hunchback” appearance is observed. Pain can arise within hyper-kyphotic vertebral region. Hyper-kyphosis of the thoracic spine, irregular vertebral endplates, occurrence of Schmorl’s nodes and decimated height of intervertebral disc space, discernible on sagittal imaging, are commonly encountered [3,4].
Implicated adolescents manifest a cosmetic or postural deformity and subacute pain within the thoracic region which worsens upon activity and ameliorates with rest. Typically deformity of spine appears within early to mid-teens [3,4].
Subjects depict physical disability with inability to exercise,
work and complete daily activities on account of pain or
accompanying physical deformity. Cutaneous pigmentation
upon the greatest curvature of hyper-kyphosis can appear due
to friction with chairs or seating manifestos. Individuals with
Scheuermann’s disease are well muscled [3,4]. Subjects with
Scheuermann’s disease demonstrate an enhanced possibility
of chronic back pain. Typically, pain within the affected region
ameliorates following skeletal maturity [3,4]. Severe instances
are exceptionally associated with impaired cardiac and pulmonary
function along with serious neurological symptoms [3,4].
On microscopy, aberrant cartilage of the vertebral endplate,
foci of irregular bony mineralization, altered endochondral
ossification, reduced collagen to proteoglycan ratio with enhanced
proteoglycan values are discerned  (Figures 1-6).
Scheuermann’s disease necessitates a segregation from
conditions such as postural kyphosis with flexible postural
deformity hyper-kyphosis contingent to secondary disease
postsurgical kyphosis ankylosing spondylitis scoliosis [5,6].
Upon physical examination, a rigid curve of hyper-kyphosis
is observed which accentuates upon forward bending. Hyperkyphosis
is unrelieved upon extension, prone or supine position
thereby implying a “rigid” deformity. Additionally, cervical,
or lumbar lordosis, scoliosis and contracted hamstrings are
observed. Although neurologic symptoms are infrequent, a
competent neurologic examination is mandated [6,7]. Physical
examination of Scheuermann’s disease is comprised of postural
assessment with anterior, posterior, and lateral view along
with neurological screening to exclude impending paraplegia
with clonus and hyperreflexia. Associated scoliosis can be
assessed with Adam’s forward- bend test. Evaluation of muscle
length, especially of pectorals, hamstrings, sub-occipitals, and
flexors of hip joint along with possible contractures of anterior
shoulder and hip is necessitated. Evaluation of muscle strength
of abdominal, core, gluteal muscles and extensors of trunk is
Evaluation of spinal range of motion is necessitated with
assessment of planes such as flexion/extension, right/left lateral
bending and right/left spinal rotation. Percentage of hyperkyphosis
requires assessment upon serial imaging to evaluate
degree of disease progression. Investigating the functional range
of motion along with degree of deformity aids in appropriate
therapeutic intervention and assaying prognostic outcomes [7,8].
Plain radiographs such as antero-posterior or lateral
radiographs are essential to evaluate Scheuermann’s disease.
Lateral radiographs can appropriately categorize diagnostic
criteria such as rigid hyper-kyphosis exceeding 400 and anterior
wedging ≥ 5⁰ in three or more adjacent vertebral bodies[7,8].
Additionally, antero-posterior, or lateral radiographs
display irregular vertebral endplates, Schmorl’s nodes, lack of
height of intervertebral disc space, scoliosis, spondylolysis or
spondylolisthesis and herniation of intervertebral disc [7,8].
Magnetic resonance imaging (MRI) can evaluate anatomic
alterations or be employed for pre-operative planning.
Computerized tomography (CT) is usually unnecessary as are
non-diagnostic haematological or biochemical parameters or
cogent histological features [7,8].
Scheuermann’s disease can be appropriately managed with
non-operative techniques such as stretching, lifestyle modification,
physical therapy, and administration of non-steroidal antiinflammatory
drugs (NSAIDs). Anti-inflammatory agents are
employed for a short duration in young individuals and extended
duration in adult subjects with continuous pain [6,8]. Noninvasive
therapy is advantageous in asymptomatic individuals or
subjects with kyphosis<60⁰ [6,8]. Extension bracing is adopted
for kyphosis between 60⁰ to 80⁰ and symptomatic individuals. It
is typically required for a period of 12 months to 24 months and
delays progression of kyphosis. Skeletally immature individuals are benefitted, and bracing is efficaciously adopted prior to
skeletal maturity at around 14 years. Ideally, a brace is applied
at puberty for approximately 2 years and removed at skeletal
maturity [7,8]. Diverse categories of braces such as Milwaukee
brace, kyphologic brace and thoraco-lumbosacral orthosisstyle
Boston brace can be employed. Treatment with brace is
advantageous in kyphosis between 55⁰ and 80⁰, especially in
skeletally immature subjects [7,8].
Adjuvant physiotherapy is recommended in combination
with bracing. Physiotherapy is preferably adopted to assist
with pain, appropriate spinal posturing, assessment and
therapy of muscular imbalance which affects mechanical pull
upon the spine [7,8]. Surgical methodologies such as spinal
fusion are indicated when kyphosis exceeding > 75⁰ engenders an
unacceptable deformity, neurologic deficit, spinal cord compression
and severe refractory pain. Symptomatic amelioration as well as
melioration of curve deformity is delineated [7,8]. Conservative
management is optimal for majority of incriminated subjects.
Pain within implicated region ameliorates with emergence of
skeletal maturity. However, an enhanced possible occurrence of
chronic back pain is observed. Skeletally mature subjects with
a kyphotic curve <60⁰ are devoid of long-term sequelae [7,8].
Scheuermann’s disease is associated with complications such as
progressive cosmetic deformity, chronic back pain, neurological
deficits, and spinal cord compression. Additionally, postoperative
complications such as pseudo-arthrosis and persistent pain may
Extension-based stretching, stretching of hamstrings, muscle
strengthening, adequate body posture and body mechanic
techniques are advantageous for treating Scheuermann’s disease.
Appropriate employment and handling of braces is recommended.
Bracing can be adopted for pain relief in adults where surgical
treatment is not recommended [7,8]. Neurologic deficits require
an exclusion while treating hyper-kyphosis unresponsive to
conservative management. Subjects may depict compromised
pulmonary function tests on account of kyphosis [7,8].