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Kyphosis

  • If your child or teen has been diagnosed with kyphosis (also known as hyper-kyphosis), we know that you and your family are concerned. At Boston Children’s Hospital, we’ll approach your child’s treatment with sensitivity and support—for your child and your whole family.

    Whether your child’s condition is mild or more severe, you can have peace of mind knowing that the team in Boston Children’s Spinal Program has treated a large volume of spinal problems that few pediatric hospitals have ever seen—and we can provide expert diagnosis, treatment and care.

    What to know about kyphosis

    Some degree of kyphosis—a forward curve in the upper spine—is a normal shape. In fact, the normal spine can bend from 20 to 45 degrees of curvature in the upper back (thoracic) area—an acceptable range. 

    But if your child's curvature reaches 50 degrees or greater, it’s considered abnormal kyphosis—a forward curvature of the back bones (vertebrae) in the upper back area, giving your child an abnormally rounded or "humpback" appearance.

    Here are some additional facts about kyphosis:

    • Kyphosis is more common in girls than in boys.
    • Most cases of kyphosis are mild and require only close monitoring by a doctor until the child has stopped growing.
    • Kyphosis can be congenital (present at birth) or associated with other conditions, including:
      • metabolic disorders
      • neuromuscular conditions
      • congenital skeletal malformation
      • osteogenesis imperfecta (brittle bone disease)—a condition that causes bones to fracture with minimal force
      • spina bifida
      • Scheuermann's disease—a condition that causes the vertebrae to wedge together and curve forward in the upper back area. The cause of Scheuermann's disease is unknown and is commonly seen in early-adolescent boys.
    • A diagnosis of kyphosis is usually made by x-ray.
    •  Treatment can range from simple observation to bracing to surgery.
    • Severe cases can cause pain and, if left untreated, can cause impaired lung function, worsening deformity and pain.

    Boston Children's Hospital approach to kyphosis

    Boston Children’s Spinal Program is known for clinical innovation, research and leadership. We offer the most advanced diagnostics and treatments—several of which were pioneered and developed by our own researchers and clinicians. We have an experienced team of expert spinal physicians who can assess—and determine the best treatment for—your child’s kyphosis.

    One of the first comprehensive programs of its kind, Boston Children’s Orthopedic Center is the largest and busiest pediatric orthopedic surgery center in the United States, performing more than 6,000 surgical procedures each year. Our program, ranked #1 in the country by U.S.News & World Report, is the nation’s preeminent care center for children and young adults with developmental, congenital, neuromuscular and post-traumatic problems of the musculoskeletal system.

    Each year, our Spinal Program caregivers provide comprehensive evaluation, diagnosis, consultation, treatment and follow-up care for children during more than 6,000 outpatient visits. And every year, our orthopedic surgeons perform more than 300 spine procedures on babies, children, adolescents and young adults.

    Reviewed by M. Timothy Hresko, MD

    © Boston Children’s Hospital, 2012

    Contact Us

    Orthopedic Center
    Boston Children's Hospital

    300 Longwood Avenue
    Fegan 2
    Boston MA 02115
    617-355-6021



  • At Boston Children's Hospital, our team pioneers innovative spine treatments. And because our research informs our treatment, we’re known for our science-driven approach. We’re home to the world’s most extensive pediatric hospital research enterprise, and we partner with elite health care and biotech organizations around the globe. But as specialists in family-centered care, our doctors never forget that your child is precious, and not just a patient.

    In dealing with your child’s kyphosis, you may want to know the basics about how the spine works:

    What is the spine?

    Made up of many individual bones called vertebrae, the spine is joined together by muscles and ligaments. Flat, soft discs separate and cushion each vertebra from the next. Because the vertebrae are separate, the spine is flexible and can bend. Together the vertebrae, discs, muscles and ligaments make up the vertebral column or spine.

    Different regions of the spine are named differently. The cervical spine refers to the neck region, the thoracic spine to the chest region (where kyphosis occurs), and the lumbar and sacral spines to the lower back region.

    Spine illustration 

    Spine viewed from the front and side

    What are normal and abnormal front-to-back spine curves?

    The normal spine is strong and mobile. While it varies in size and shape from person to person, the healthy spine has natural front-to-back curves that enable us to walk, balance, sit, stand and twist—all of which are complex interactive movements. When these natural front-to-back curves become too large, they can present problems:

    • When the forward curve in the thoracic spine is too great, the condition is called kyphosis (hyper-kyphosis, thoracic hyper-kyphosis, “round back”).
    • When the inward curve in the lower back is too great, the condition is called hyper-lordosis (“swayback”). '

    When do normal spine curves develop?

    • in utero: During fetal development, the primary curves develop (thoracic and sacral).
    • as babies: All infants start life with a C-shaped spine. Their secondary curves (cervical and lumbar) develop as they become:
      • able to lift the head (cervical)
      • able to sit up (cervical)
      • able to crawl, stand and walk (lumbar)
    • as children: As children grow, their natural spinal curves continue to develop into a normal spine.

    Pain down the legs and changes in bowel and bladder habits aren’t symptoms commonly associated with kyphosis. If your child is experiencing these types of symptoms, you should seek further medical evaluation by a physician.

    The symptoms of kyphosis may resemble other spinal conditions or deformities, or may be a result of an injury or infection. Always consult your child's doctor for a diagnosis.

    Are there different categories of kyphosis?

    The major types of kyphosis are:

    • postural kyphosis: the most common type, normally attributed to slouching; can be treated by correcting imbalances in the musculature of the back, usually with exercise or bracing
    • Scheuermann (juvenile) kyphosis: usually more severe, more rigid and more cosmetically deforming; typically occurs in early-adolescent boys; can run in families; often requires brace or surgery
    • congenital kyphosis: present at birth if a child’s spinal column did not develop normally in the womb; often requires surgery

    Causes

    Kyphosis can be:

    • postural (attributed to slouching)
    • congenital (present at birth due to abnormal development of the spine in utero)
    • neuromuscular (associated with a neuromuscular condition such as cerebral palsy or spina bifida)
    • related to metabolic conditions (internal body chemistry)
    • related to an infection or tumor
    • related to an untreated or poorly healed fracture
    • hereditary (sometimes runs in families)

    Symptoms

    • The following are common symptoms of kyphosis:
    • excessive rounding of shoulders
    • head bending forward compared to the rest of the body
    • shoulder height difference
    • difference in shoulder blade height or position
    • height of the upper back appears higher than normal when bending forward
    • tight hamstring (back thigh) muscles

    When to seek medical advice

    Congenital kyphosis is present at birth, but may not be apparent until later. Consult your pediatrician if your child is developing a rounded upper back, and/or if your family has a history of spinal problems.


    Who’s at risk

    Risk factors for developing kyphosis vary. Common risk factors and predispositions can include:

    • a family history of spine problems
    • other birth defects
    • neuromuscular conditions
    • metabolic conditions that affect bones
    • syndromes that affect neurologic function
    • other genetic syndromes                                                                                

    Complications

    • Untreated kyphosis can become progressively worse and can become painful and deforming, and can result in lung problems, worsening deformity and pain.
    • If surgery is needed, there is a very slight chance of complications from the surgery, such as bleeding, infection or nerve damage.
    • A very small percentage of patients who have had surgery will need an additional procedure, usually for cosmetic reasons.
    • Older children and teens can have body image issues as a result of their kyphosis.

    Long-term outlook

    When treated successfully, kyphosis curves can be corrected, and children can go on to lead normal, active, unrestricted lives.

    If your child needs surgery, she should be able to walk around in a day or two, and return home in about a week.

    She can go back to school within a month or so, and resume most activities within three to four months.

    Complete fusion takes about one year.

    For teens

    If you’re a teen with kyphosis, you have a lot to cope with. Besides the typical issues any teenager faces—from social acceptance to body image and more—you’ll also have to deal with medical appointments and procedures, some delay of your natural wish for independence, feeling different and assuming a big personal responsibility for maintaining your own good health.

    The good news is that with successful treatment and your own compliance with bracing or other therapies, your kyphosis has a great chance of being corrected in the near future. But for now, if you feel self-conscious, depressed or anxious, speak to your doctor, nurse, parents or counselor—they’re all on your team, and they all want to help.

    Prevention

    Most spinal problems have no definite cause and/or no known method of prevention. Some are genetic in origin. Proper nutrition, prenatal care and vitamin consumption (especially folic acid) are always important if you’re pregnant, or if pregnancy is a possibility. If your family has a history of birth defects, consult a geneticist.

    Kyphosis glossary

    • brace, bracing (spinal orthosis): If your growing child’s curve shows significant worsening or is already greater than 45 degrees, your physician may recommend a program in which a brace is designed specifically for your child’s particular curve. The brace holds your child’s spine in a straighter position while she’s growing in order to partly correct the curve or prevent it from increasing.

    There are many types of brace, including the Boston Brace developed at Children’s. A bracing program may help avoid surgery.

    • congenital kyphosis:The spine forms and develops between three and six weeks after conception. Congenital kyphosis results from abnormal in utero spinal development, such as a partial or missing formation or a lack of separation of the vertebrae.
    • (hyper-) kyphosis: A spine affected by kyphosis shows evidence of excessive backward curvature of the back bones (vertebrae) in the upper back area, giving the child an abnormally rounded or “humpback” appearance. Abnormal (hyper-) kyphosis is a type of spinal deformity and should not be confused with poor posture.
    • neuromuscular: affecting, or characteristic of, both neural (nerve) and muscular tissue
    •  orthopedics: the medical specialty concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments

    •  orthopedic surgeon, orthopedist: a physician specializing in surgical and non-surgical treatment of the spine, skeletal system and associated muscles, joins and ligaments
    • orthotics: the science of designing and fitting of devices such as braces to treat orthopedic conditions
    • physical therapy: a rehabilitative health specialty that uses therapeutic exercises and equipment to help patients improve or regain muscle strength, mobility and other physical capabilities
    • progression, curve progression: worsening of a spinal curve
    • >spina bifida (myelodysplasia): a condition in which there is abnormal development of the back bones, spinal cord, surrounding nerves and the fluid-filled sac that surrounds the spinal cord. This neurological condition can cause a portion of the spinal cord and the surrounding structures to develop abnormally. The defect can occur anywhere along the spine. Kyphosis can be an associated condition.
    • spinal cord: a nerve bundle within the vertebral column that extends down from the brain stem; it conducts signals in both directions between the brain and extremities, and allows for bodily motion and sensation
    • spinal abnormality: a condition in which the spine develops abnormally. Some abnormalities are present at birth, such as congenital kyphosisor congenital scoliosis. Some are the result of nerve or muscle (neuromuscular) diseases, injuries or illnesses—for example, cerebral palsy or spina bifida. In some cases, there’s no definite cause (idiopathic) or means of prevention for the spine’s failure to develop normally.
    • spinal fusion: usually a solid fusion (solidification) of the curved part of the spine, achieved by operating on the spine, adding bone chips and allowing the vertebral bones and bone chips to slowly heal together to form a solid mass of bone called a fusion
    • spine (spinal column, vertebral column): the series of vertebrae that move and form the axis of the skeleton and protecting the spinal cord

    • spine curves, normal and abnormal: front-to-back and sideways curves of the spine

    • All spines have normal front-to-back curves. Abnormal front-to-back curves can indicate “round back” (hyper-kyphosis) or “swayback” (hyper-lordosis).

    • Normal spines do not have much sideways curvature. An abnormal sideways “S” or “C” curve can indicate scoliosis.

    •  vertebra, vertebrae: the individual spine bones that form the spinal column

    • x-rays: a diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film

  • At Boston Children's Hospital, we know that the first step in treating your child is forming an accurate and complete diagnosis.

    Most cases of kyphosis are detected by a child’s parents or pediatrician, or by school screenings. Once kyphosis is detected, doctors use medical and family histories, physical exams (including measurement of the curve) and diagnostic tests to determine the nature and extent of your child’s condition.

    Diagnosing kyphosis is usually done by x-rays that measure and evaluate the degree of spinal curvature. A determination for treatment can often be made based on this measurement.

    Less often, diagnostic testing can include:

    • MRI (magnetic resonance imaging): uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body. This test is done to rule out any associated abnormalities of the spinal cord and nerves.

    • CT or CAT scan (computerized tomography scan): uses a combination of x-rays and computer technology to produce cross-sectional images (“slices”), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

    • bone scan: evaluates any degenerative and/or arthritic changes in the joints; detects bone diseases and tumors; determines the cause of bone pain or inflammation; rules out infection or fractures

    • blood tests (not standard—blood tests are used to look for associated metabolic conditions)

    • pulmonary function tests (only needed if breathing is affected)

    In addition, routine school screenings will sometimes detect kyphosis in children, even if they have no symptoms (this is called being “asymptomatic”). Detecting kyphosis early is important for successful treatment.


  • How we'll treat your child's kyphosis depends on the complexity and severity of her condition. Boston Children's Hospital's Spinal Program provides comprehensive treatment—including evaluation, diagnosis, consultation and follow-up care.

    The goals of treatment for kyphosis are:

    • to stop the progression of your child's curve
    • to prevent deformity

    Your child's doctor will determine her treatment plan and follow-up based on her x-rays and physical exams. Her treatment will be individualized depending on her age, the degree of curvature and the amount of growing she has yet to do (skeletal growth).

    As recommended by the Scoliosis Research Society, your child's treatment may include:

    • simple observation and monitoring: Once a kyphosis curve has been detected, it's important to monitor the curve as your child grows. The progression of the curve depends upon the amount of skeletal growth your child has remaining. In many cases, her condition may require only close monitoring during skeletal growth. The progression of the curve slows or stops after your child reaches puberty.
    • physical therapy: Children's physical therapists work closely with specialists in our Spinal Program to provide exercise regimens and therapies to address the muscular imbalance associated with kyphosis. Exercises involve strengthening the child's core and the musculature of her upper back, shoulder and around the shoulder blades (scapulae).
    • bracing: For children with moderate to severe curves and significant growth remaining, doctors may prescribe a brace:
      • Bracing helps positioning and function.
      • Bracing can help control or correct curves. The brace holds your child's spine in a straighter position while she is growing in order to partly correct the curve or prevent it from increasing. A bracing program may help avoid surgery.

    Your child's doctor will determine the type of brace and the amount of time spent in the brace. The success of a bracing program depends on complying with the custom regimen that your child's doctor develops for her. Typical braces are the Boston Kyphosis brace, which was developed here at Children's, and the Milwaukee brace, which is often worn at night.

    • surgery: Surgery may become necessary if:
      • your child's curve measures 75 degrees or more
      • bracing proves unsuccessful at slowing or stopping the curve from progressing
      • the kyphosis is congenital, involving skeletal malformation (surgery may be needed at an early age)
      • the kyphosis is caused by an infection or tumor

    If surgery is needed, our orthopedic surgeons use the most advanced techniques, such as:

    • spinal fusion: the most common surgical procedure for treating more severe cases of kyphosis. Usually, a fusion and instrumentation are combined to correct and solidify (fuse) the curve.

    Long-term outlook

    When treated successfully, kyphosis curves can be corrected, and children can go on to lead normal, active, unrestricted lives. If your child needs surgery, she should be able to walk around in a few days, and return home in about a week. She can go back to school within a month or so, and resume most activities within three to four months. Complete fusion takes about one year.

    Your child's doctor will examine your child often to monitor the curve as she grows and develops. Early detection is important. If left untreated, kyphosis can lead to impaired lung function, worsening deformity and pain.

    Coping and support

    At Children's, we understand that a hospital visit can be difficult, and sometimes overwhelming. So we offer many amenities to make your child's—and your own—hospital experience as pleasant as possible. Visit Children's Center for Familiesfor details on:

    • getting to Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family

    In particular, we understand that you may have a lot of questions when your child is diagnosed with kyphosis: Will my child need surgery? Will kyphosis affect my child long term? What do we do next? We can help you connect with a number of resources to help you and your family through this difficult time, including:

    • patient education: From the office visit to physical therapy and recovery, our nurses and physical therapists will be on hand to walk you through your child's treatment and help answer any questions you may have—How long will my child's recovery take? How should we manage home exercises and therapy? We will help you coordinate and continue the care and support you received while at Children's.
    • parent-to-parent: Want to talk with someone whose child has been treated for kyphosis? We can often put you in touch with other families who've been through the same procedure or process that you and your child are facing, and who will share their experiences.
    • faith-based support: If you feel a need for spiritual support, we'll connect you with the Children's chaplaincy. Our program includes nearly a dozen clergy—representing Protestant, Jewish, Muslim, Catholic and other faith traditions—who will listen to you, pray with you and help you observe your own faith practices during your hospital experience.
    • social work: Our social workers and mental health clinicians have helped many other families in your situation. We can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to coping with illness and dealing with financial issues.

    A long line of orthopedic firsts

    With a long history of excellence and innovation and a team of clinicians and researchers at the forefront of orthopedic research and care, Boston Children's is home to many treatment breakthroughs:

    • advanced techniques and microsurgery care for complex fractures and soft tissue injuries to the hand and upper extremity
    • advances in our Spinal Program, such as video-assisted thorascopic surgery
    • the oldest and largest comprehensive center for the care of spina bifida
    • a Hip Program that has performed over 1,2,00 periacetabular osteotomies
    • one of the first scoliosis clinics in the nation
    • one of the first and only sports medicine clinics in the nation
    • one of the first centers in the nation to use adjuvant chemotherapy and perform limb salvage surgery for patients with osteosarcoma
  • For more than a century, orthopedic surgeons and investigators at Children’s Hospital Boston have played a vital role in the field of musculoskeletal research—pioneering treatment approaches and major advances in the care and treatment of conditions such as scoliosis and other spine problems, polio, tuberculosis, hip dysplasias and traumas to the hand and upper extremities.

    Our pioneering research helps answer the most pressing questions in pediatric orthopedics today—so that we can provide children with the most innovative care available.

    At Boston Children’s Orthopedic Center, we take great pride in our basic science and clinical research leaders, who are recognized throughout the world for their respective achievements. Our orthopedic research team includes:

    •  five full-time basic scientists
    • 28 clinical investigators
    • a team of research coordinators and statisticians

    Our ongoing clinical trials will help pave the way for ever better kyphosis treatments. They include trials that examine the effectiveness and long-term outcomes of surgical treatment for kyphosis patients.

    National study of surgical outcomes
    Boston Children's Hospital is one of a select group of hospitals involved in a prospective national study to determine the surgical outcomes of patients with complex spinal deformities including kyphosis, idiopathic scoliosis, early onset infantile scoliosis and spondylolisthesis. The Division of Spinal Surgery is actively involved in the development of non-operative, minimally invasive and non-fusion techniques for treatment of spinal deformity.

    Spinal program

    Physicians in the CERC Spinal Program are active in several areas of ongoing basic and clinical research based at Children’s and the Harvard Orthopaedics Biomechanics Laboratory. Research topics include:

    • congenital scoliosis and idiopathic scoliosis
    • spondylolisthesis and spondylolysis
    • bone density studies of braced patients
    • in vitromechanical testing of lumbosacral fixation devices
    • computer-assisted strength analysis of vertebral metastases

    Pediatric and Adolescent Kyphosis Study

    Our ongoing clinical studies includea prospective pediatric and adolescent kyphosis study. The main objective of this prospective multi-center, observational study is to assess outcome measures in pediatric and adolescent kyphosis patients who are being treated non-operatively or operatively with current surgical techniques. Secondarily, we are collecting data on currently available surgical approaches to treat pediatric kyphosis in the thoracic and/or thoracolumbar spine.

    Orthopedic basic science laboratories

    Some of the leading musculoskeletal researchers in the nation are working in our labs, including:

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