Kyphosis correction by anterior instrumentation and fusion has been performed in some centers very recently. The aims are to save spinal segments and to avoid damage to the paraspinal muscles. There are, however, no reports yet on the out- come of this procedure. Posterior Approach The basic steps of the classical posterior procedure for Scheuermann’s kyphosis are: posterior release correction and internal fixation using posterior instrumentation posteriorfusionwithbonegraft Spinal cord monitoring and the possibility for a wake-up test are absolutely indis- pensable for a safe surgical correction of the kyphotic deformity. Posterior Release, Correction, and Fusion The goal is shortening of the posterior column to allow for extension of the spine. The posterior release encompasses the resection of: spinous processes ligamenta flava upper and lower margins of the laminae facet joints in the area of the deformity (usually four to six segments) ( Fig. 9b, c). Instrumentation includes the upper kyphosis end vertebra and the first lordotic segment Instrumentation and correction of the deformity follow the cantilever and poste- rior tension bend (compression) principle. The uppermost instrumented verte- bra is the upper end vertebra of the deformity. Distally, the first lordotic segment caudal to the apex should be included [39, 40, 41, 53, 56]. Claw constructs or pedicle screws areusedabovetheapexofthedeformity, pedicle screws in the lower part of the instrumentation. A two-rod construct ( Case Study 2) or a four-rod construct can be used for the correction maneuver ( Fig. 10a, b). Stiff rods should be chosen to minimize the risk of loss of correction. ab Figure 10. Cantilever technique Instrumentation/correction using cantilever and posterior tension band principle: a two-rod technique and b four-rod technique. Juvenile Kyphosis (Scheuermann’s Disease) Chapter 28 785 ab c de f g Case Study 2 A 16-year-old male student was admitted for assessment and treatment of thoracic hyperky- phosis. The patient had no earlier treatment or radiographs. The deformity had developed dur- ing 3 years. He complained about mild thoraco- lumbar pain after exercising and was dissatisfied with the cosmetic appearance of his back. Other- wise, he was healthy. Clinically, he exhibited the typical features of Scheuermann’s kyphosis in the lower thoracic spine ( a–c) . The deformity was pain free and corrected partially in extension. Bilateral hamstring tight- ness of 50 degrees was present, and there were no pathologic neurological signs. On the standing lateral radiograph, thoracic kyphosis measured 95 degrees ( d). It corrected to 54 degrees on the supine extension film (e). Around the apex (T8) there were five wedge vertebrae. The standing posteroanterior radiograph was normal ( f). MRI showed typical Scheuermann’s changes, and no cord compression or other pathology ( g). During the correction maneuver the area of the release should be watched very carefully to detect and avoid cord compression due to translation of the vertebrae or kinking of the laminae. The interlaminar gaps should not be fully closed at the end of the correction maneuver to allow for drainage of possible hematoma. After instrumentation the posterior elements of the area are decorticized with 786 Section Spinal Deformities and Malformations hi jk Case Study 2 (Cont.) As the deformity was relatively mobile, brace treatment was considered. It was, however, discarded because of the mini- mal remaining spinal growth left (Risser 4, skeletal age 18 years).Aposteriorrelease,UniversalSpineSystem(USS)instru- mentation/correction using the two-rod cantilever tension band principle, and a posterior fusion from T2 to L2 were per- formed. There were neither intraoperative nor postoperative complications. The cosmetic result looked very satisfactory ( h, i). On radiographs 6 months after operation, thoracic kyphosis measured 48 degrees (j, k). great care and packed with autogenous or allogenous bone graft to achieve a thick solid fusion mass. Spinal cord monitoring and/or wake-up test are manda- tory. Prophylactic antibiotics are recommended. Combined Anterior/Posterior Approach A combined anterior/poste- rior approach is indicated in very rigid kyphosis In very rigid severe deformities, especially in adult patients, a combined approach may be considered ( Fig. 9d). However, there are no scientifically based numeric data available informing the surgeon which cases need additional ante- rior release and which can be treated by posterior approach only. Halo-femoral traction, used by some authors during the interval between staged anterior and posterior surgery, does not seem to improve final results [12, 29]. Through an anterior approach the rib heads, the anterior longitudinal liga- ment, the intervertebral discs down to the posterior longitudinal ligament, and the cartilaginous vertebral endplates in the area of the deformity are resected. The disc spaces are distracted and filled with bone graft (morcellized rib). Tradi- tionally, this has been performed through a thoracotomy as an open procedure. The literature has shown that thoracoscopic anterior release is effective in Juvenile Kyphosis (Scheuermann’s Disease) Chapter 28 787 Scheuermann’s kyphosis [1]. Its definitive advantages over classic open thoracot- omies are cosmesis and less morbidity. It does, however, have a considerable learning curve [45]. Results of Operative Treatment Surgery provides a favorable outcome in selected cases Outcome data after operative treatment of Scheuermann’s kyphosis comprise mainly retrospective short-term or mid-term follow-up reports. Results are ana- lyzed usually according to the two major indications for which the surgery was carried out: pain and deformity. As far as pain is concerned, all series report an improvement in the amount of back pain of between 60% and 100% [12, 15, 29, 31, 60]. Hosman et al. showed a marked improvement concerning back pain in 31 out of 33 patients after a mean follow-up of 4.5 years. However, neck pain did not seem to have improved after surgery. Interestingly, no relationship between the amount of correction and the amount of residual back pain was found. As far as patients’ satisfaction is concerned, most series report a very high satisfaction rate of up to 96% [31]. As no cosmetic scale has been available for the assessment of juvenile kypho- sis, one has to judge the cosmetic correction on plain radiographs, which repre- sent an extrapolation of the cosmetic results. The rate of correction given in the different surgical series is 21–51%. Loss of correction in the instrumented area is minimal at present due to the rigidity of instrumentation systems used ( Table 8). Ideally, the result of correction of juvenile kyphosis should be assessed according to patient satisfaction and improvement of perceived self-image and independent judgement of clinical photographs before and after the surgery by non-medical observers. The literature definitively lacks such information. The resultsofcorrectivesurgeryshouldnotbebasedonCobbanglecorrectionalone but rather on outcome instruments such as the SRS 24, the sagittal balance of the patient, and the assessment of spinal mobility and function. So far, only Poolman et al. have used the SRS questionnaire instrument, which includes assessment of the cosmetic situation [56]. Table 8. Surgical treatment of juvenile kyphosis Author N Technique Follow-up time (months) Kyphosis (degrees) Outcome/complications Conclusions Bradford et al. (1974) 22 post Harrington compression 35 (5 –92) pre 72 (50– 128) pain relief 100%, cosmesis improved 100 % complications frequent cast for 9.8 months follow-up 47 (29–88) pseudarthrosis 3, infection 1, thromboembolia 1, neurologi- cal 1 indication restricted to patients with severe pain correction: 35% need for combined approach to avoid loss of correction loss >10 in 15/22 patients Taylor et al. (1979) 27 post Harrington compression 26.6 (6 –72) Pre 72 (55 –93) pain relief 100%, cosmesis improved 100 % instrument/fusion too short leading to loss of correction cast for 5 months follow-up 46 (23–63) new neck/shoulder pain 9/27 patients recommendation to fuse whole curve correction: 36% intraoperative lamina fracture 1, pneumothorax 1, donor-site hematoma 3, transient paresthesia 1, gastrointestinal obstruction 1 loss of correction: in fusion: 7 outside: 12 788 Section Spinal Deformities and Malformations Table 8. (Cont.) Author N Technique Follow-up time (months) Kyphosis (degrees) Outcome/complications Conclusions Bradford et al. (1980) 24 anterior release 24– 68 pre 77 (54– 110) hook site pain 2, fusion extended forpain1,pulmonaryembolus/ deep femoral thrombosis 2, deep infection 1, vascular obstruction of duodenum 1, hematothorax 1, pericardial effusion 1, pseudar- throsis 1, intercostal neuroma 1, discomfort at lower hook 3 (2 removed) correction after com- bined approach supe- rior to anterior only but greater morbidity Halo traction 2 weeks follow-up 47 (30–67) post Harrington compression correction: 39% Risser cast 9–12 months loss of correc- tion: mean 6 outside fusion: 13–25 in 5 patients Herndon et al. (1981) 13 anterior release 29 (12 –66) pre 78 (61–95) pain relief in 8/13 patients, cos- mesis improved 100% significant risk of severe complications Halo traction 2 weeks follow-up 45 (30–73) mortality 1, instrumentation problems 2, transient neurology 1, pressure sore 1, urinary reten- tion 1, deep thrombosis 1, psy- chological problems in halo 1 no advantage from preoperative halo; deformities over 70° need combined approach post Harrington compression correction: 51% Risser cast 6 months Lowe (1987) 24 anterior release 32 (19 –48) pre 84 (72– 105) pain relief in 18/24 patients, cosmesis improved 100% longer follow-up neces- sary Halo gravity 1 week follow-up 49 (30–65) transient hyperesthesia of trunk and lower extremity 4, rod removal for bursa 4, fusion too short distally 2, rod migration 1 hyperesthesia worri- some posterior Luque double rod correction: 43% good patient accep- tance no external sup- port loss of correc- tion: mean 5 Lowe and Kasten (1994) 32 anterior release +posterior Cotrel-Dubous- set instrumen- tation in 28 patients 42 (24 –74) pre 85 (75– 105) preoperative back pain 27/28 patients, at follow-up 18/28 mild back discomfort with vig- orous activities indication for surgery symptomatic kyphosis >75° 4patientspost C-D only follow-up 47 (24–65) cosmetically satisfied 26/28 patients negative sagittal bal- ance in Scheuermann’s correction: 45% proximal junctional kyphosis 26° (12°–49°) in 10/28 patients due to overcorrection (> 50%) or short fusion avoid overcorrection to avoid junctional kypho- sis loss of correc- tion: 4 (0– 19) distal junctional kyphosis 17° (10°–30°) in 9/28 patients due to short fusion include proximal end vertebra and first lor- dotic segment distally sagittal balance: pre –5.3 cm follow-up –6.6 cm Otsuka et al. (1990) 10 posterior heavy Harrington compression 27 (18 –33) pre 71 (63–90) pain relief 100 %, cosmesis improved 100 % good cosmesis improvement and pain relief Brace 6–9months follow-up 39 (28–57) rod breakage after motor vehi- cle accident 1, intraoperative lamina fracture 1 in flexible kyphosis (bending to <50°) pos- terior surgery only is sufficient correction 45% lung problems in patient with preoperative congenital obstructive lung disease 1 loss of correc- tion: 8 Fusion too short 3 in 3/10 patients loss >10 Juvenile Kyphosis (Scheuermann’s Disease) Chapter 28 789 Table 8. (Cont.) Author N Technique Follow-up time (months) Kyphosis (degrees) Outcome/complications Conclusions Reinhardt and Bassett (1990) 14 post Harrington compression 32 (12 –65) pre 71 (54 –101) clinical outcome and complica- tions not mentioned to avoid junctional kyphosis, fusion beyond the end verte- bra to a non-wedged (“square”) vertebra nec- essary anterior release in 6/14 patients follow-up 37 (15–54) distal junctional kyphosis 23° (15°–31°) in 5/14 patients cast or brace for 6 months correction: 48% proximal junctional kyphosis 34° in one patient loss of correc- tion: 8 (4– 14) Poolman et al. (2002) 23 anterior release 75 (25 –126) pre 70 (62–78) SRS outcome instrument at fol- low-up: total score 83 (55– 106), 7patients<72 outcome relatively fair post Cotrel- Dubousset 13/23 follow-up 55 (36–65) back pain increased 4, back pain improved 10, self-image improved 10, self-image wors- ened 3, would have the proce- dure again 16, no correlation SRS score vs. radiography loss of correction after implant removal Moss-Miami 10/23 correction: 21% aorta + thoracic duct lesion 1, proximal junctional kyphosis 3, screw breakage 3, painful hard- ware 6 indication for surgery questioned loss of correc- tion: mean 15° in 8 patients after rod removal Hosman et al. (2002, 2003) 33 posterior H- frame instru- mentation A. Post only 50 (25 –93) A+BPre79 (70–103) Oswestry Disability Index Pre 21.3 (0 –72), follow-up 6.6 (0–52) good radiographic and clinical results. No bene- fit from anterior release. Excessive correction should be avoided to minimize risk for postop- erative sagittal malalign- ment. anterior release in 17/33 patients, B. Combined 55 (24 –98) follow-up 52 (32–81) no difference if compared pos- terior only versus combined sur- gery orthosis 3 months correction: 34% cosmesis improved 100% loss of correc- tion: mean 1.4° infection 3, instrumentation removal for prominence or irri- tation 4, loss of distal fixation (reop.) 1, rod breakage 1, proxi- mal junctional kyphosis 1 patients with ham- string tightness have significantly higher risk for postoperative sagit- tal imbalance no difference A vs. B Complications Operative kyphosis correction carries the risk of major complications Surgery on juvenile kyphosis is not benign and complications can occur. Neu- rological complications due to spinal cord compression can arise during the correction maneuver because of a rare but preoperatively undetected intraspi- nal problem, or due to a surgical technique failure. The exact rate of neurologi- cal complications is not known in surgery of juvenile kyphosis. Probably, it is higher than for idiopathic scoliosis operations. Possible complications such as death, dura lesion, vascular lesion, lamina fracture, Brown-S´equard syndrome, pulmonary problems, venous thrombosis, gastrointestinal ob- struction, infection, instrument failure, and pseudarthrosis have been described as in any major corrective procedure for spinal deformities [2, 4, 12, 15, 29, 39, 53, 56]. Postoperative sagittal imbalance must be avoided Proximal junctional kyphosis due to overcorrection occurs in 20–30% of cases according to Lowe and Kasten [41]. Distal junctional kyphosis due to short fusion causing lossof correction (“adding on”)outside the instrumented area has been reported by several authors [12, 26, 29, 41, 58, 67]. Reinhardt and Bassett 790 Section Spinal Deformities and Malformations saw distal junctional kyphosis if fusion was carried out to a wedged caudal end vertebra of the kyphosis. They recommend including the next “square” vertebra to allow smooth transition into lumbar lordosis [58]. Lowe postulates three pos- sible mechanisms: firstly, fusion that is too short, distally stopping above the first lordotic disc, results in distal junctional kyphosis; secondly, fusion that is too short proximally and does not include the whole kyphosis on the top may cause proximal junctional kyphosis and a goose neck appearance. Finally, overcorrec- tion seems to be a factor and one should not correct the kyphosis to more than 50% of its initial value [40]. In the case of overcorrection, possibly the remaining mobile segments below the fusion are unable to adapt to the alignment changes caused by excessive kyphosis correction. As a result this leads to permanent increased flexion stress on the segment adjacent to the fusion, finally causing its breakdown. This view is supported by Hosman et al. [30], who stressed the importance of tight hamstrings for surgical correction. According to Poolman et al., significant loss of correction occurs after removal of the instrumentation even if the fusion is healed [56]. Therefore, the metal should not be removed if it is not imperative to do so, e.g. in the case of infection. The benign natural history must be weighed against therisksofthesurgery Overall, surgery in Scheuermann’s kyphosis bears the risk of serious complica- tions, a risk the surgeon should be aware of. The benign nature of the deformity should be kept in mind, and the risks and benefits of an operation should be weighed up carefully. Recapitulation The sagittal alignment of the human spine devel- opsduringgrowthandshowsgreatindividualvari- ability. The range of thoracic kyphosis in healthy people ranges from 10 to 60 degrees. There are no evidence-based “normal values”. Definition and epidemiology. “Classic” juvenile ky- phosis (Type I)isarigid thoracic or thoracolumbar hyperkyphosis due to wedge vertebrae develop- ing during adolescence. The incidence is 1–8% ac- cording to the literature. Atypical juvenile kyphosis (Type II, “lumbar” Scheuermann’s kyphosis) affects mainly the lumbar spine, is characterized by end- plate changes of the vertebral bodies without sig- nificant wedging, and leads to loss of lumbar lordo- sis (flat back). Pathogenesis. The exact etiology is unknown.Ge- netic, hormonal, and mechanical factors have been discussed. A disturbance of the enchondral ossifica- tion of the vertebral bodies leads to wedge verte- bra formation, causing increased kyphosis. Type II is frequently seen in athletes as a sequela of axial overloading. Clinical presentation. A rigid thoracic hyperkypho- sis with or without pain is the reason for consulta- tion. Hamstring tightness is common. Abnormal neurological signs are rare. In Type II, the lumbar spine is stiff and pain symptoms are more promi- nent. Diagnostic work-up. Diagnosis is based on typical changes seen on lateral standing plain radiographs: hyperkyphosis, irregularity of the endplates, wedged vertebrae, increased sagittal length on the vertebral bodies, and narrowed disc spaces. Schmorl’s nodes may be present but they are not pathognomonic. MRI is taken if abnormal neuro- logical signs are observed or in connection with preoperative work-up. Non-operative treatment. The general objectives of treatment are to prevent progression of the kyphosis, to correct the deformity, and to relieve pain. The choice of treatment must consider the natural history, which is benign in the majority of cases. In Type I, back pain is common but usu- ally mild. Type II and kyphosis of greater than 70 de- grees causes more clinical symptoms. Pulmonary compromise occurs only in severe deformities (>100 degrees). Bracing and casting are effective in mobile deformities of between 45 and 60 degrees if at least 1 year of growth is left. Juvenile Kyphosis (Scheuermann’s Disease) Chapter 28 791 Operative treatment. Theonlyabsoluteindication for surgery is a neurological compromise (spastic paraparesis). Kyphosis greater than 75 degrees, pain, and severe cosmetic impairment are relative indications. The benign natural history should be kept in mind and overtreatment must be avoided. Posterior correction, instrumentation and fusion are sufficient in the majority of cases. In very severe rigiddeformitiesacombinedapproachwithaddi- tional anterior release can be considered. The oper- ative results are good in most cases concerning pain relief and cosmesis. Severe intra- and postop- erative complications have been described. The risks and benefits of operative treatment must be weighed carefully against the benign natural his- tory. Key Articles Arlet V (2000) Anterior tho racoscopic spine release in deformity surgery: a meta-analy- sis and review. Eur Spine J 9 Suppl 1:S17 – 23 This is a meta-analysis of all the literature available on thoracoscopic spine release done for scoliosis or kyphosis. Thoracoscopic release has been effective in kyphosis for curves with an average of 78 degrees that were corrected after video-assisted thoracoscopic release and posterior surgery to 44 degrees. No report of the surgical outcome (balance, rate of fusion, rib hump correction, cosmetic correction, pain, and patient satisfaction) was available for any series. Bernhardt M, Bridwell KH (1989) Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction. Spine 14:717 –21 This is a review of the normal sagittal alignment of the spine segment by segment in 102 healthy individuals, indicating that there is a wide range of normal sagittal alignment of the thoracic and lumbar spines. The thoracolumbar junction is for all practical purposes straight; lumbar lordosis usually starts at L1–2 and gradually increases at each level cau- dally to the sacrum. Hosman AJ , de Kleuver M, Anderson PG, van Limbeek J, Langeloo DD, Veth RP, Slot GH (2003) Scheuermann kyphosis: the importance of tight hamstrings in the surgical cor- rection. Spine 19:2252 – 9 The author reviewed 33 patients with juvenile kyphosis who underwent surgical correc- tion. Sixteen patients had tight hamstrings, and 17 patients had non-tight hamstrings. Hamstrings were considered tight if the popliteal angle was >30 degrees. Patients with tight hamstrings had a significantly greater risk of postoperative imbalance (p<0.05). Tight hamstring patients can be classified as “lumbar compensators” and as such are prone to overcorrection and imbalance. HosmanAJ,LangelooDD,deKleuverM,AndersonPG,VethRP,SlotGH(2002)Analysis of the sag ittal plane after surg ical management for Scheuermann’s disease: a view on over correction and the use of an anterior release. Spine 2:167 –75 A cohort of 33 patients who had undergone surgery for their Scheuermann’s kypho- sis were reviewed: Group A: posterior technique (n=16); Group B: anteroposterior technique (n=17). At follow-up evaluation (4.5±2 years) there was no difference in curve morphometry, correction, sagittal balance, average age, and follow-up period between Groups A and B. In reducing postoperative sagittal malalignment, the authors believe that surgical management should aim at a correction within the high normal kyphosis range of 40–50 degrees, consequently providing good results and, particularly in flexible adolescents and young adults, minimizing the necessity for an anterior release. MurrayPM,WeinsteinSL,SprattKF(1993) The natural history and long-term follow-up of Scheuermann kyphosis. J Bone Joint Surg Am 75A:236 –48 Sixty-seven patients who had a diagnosis of Scheuermann kyphosis and a mean angle of kyphosis of 71 degrees were evaluated after an average follow-up of 32 years. The results were compared with those in a control group of 34 subjects who were matched for age and sex: The patients who had juvenile kyphosis had more intense back pain, jobs that tended to have lower requirements for activity, less range of motion of extension of the trunk and 792 Section Spinal Deformities and Malformations less-strong extension of the trunk, and different localization of the pain. No significant differences between the patients and the control subjects were demonstrated for level of education, number of days absent from work because of low-back pain, extent that the pain interfered with activities of daily living, presence of numbness in the lower extremi- ties, self-consciousness, self-esteem, social limitations, use of medication for back pain, or level of recreational activities. Poolman RW, Been HD, Ubags LH (2002) Clinical outcome and radiographic results after operative treatment of Scheuermann’s disease. Eur Spine J 11: 561 –9 This paper is a prospective study to evaluate radiographic findings, patient satisfaction and clinical outcome, and to report complications and instrumentation failure after operative treatment of Scheuermann’s kyphosis using a combined anterior and poste- rior spondylodesis. Significant correction was maintained at 1 and 2 years follow-up but recurrence of the deformity was observed at the final follow-up. The late deterioration of correction in the sagittal plane was mainly caused by removal of the posterior instru- mentation, and occurred despite radiographs, bone scans and thorough intraoperative explorations demonstrating solid fusions. There was no significant correlation between the radiographic outcome and the SRS score. Therefore, the indication for surgery in patients with Scheuermann’s disease can be questioned and surgery should be limited to patients with kyphosis greater than 75 degrees in whom conservative treatment has failed. Soo CL, Noble PC, Esses SI (2002) Scheuermann kyphosis: long-term follow-up. Spine J 2:49 – 56 Sixty-three patients were evaluated a mean of 14 years after treatment (10–28 years) using a specially designed questionnaire. The patients had been treated using three dif- ferent treatment modalities: exercise and observation, Milwaukee bracing, and surgical fusion using the Harrington compression system. At the time of follow-up evaluation, there were no differences in marital status, general health, education level, work status, degree of pain and functional capacity between the various curve types, treatment modality and degree of curve. Patients treated by bracing or surgery did have improved self-image. Patients with kyphotic curves exceeding 70 degrees at follow-up had an infe- rior functional result. StagnaraP,DeMauroyJC,DranG,GononGP,CostanzoG,DimnetJ,PasquetA(1982) Reciprocal angulation of vertebral bodies in a sagittal plane: Approach to references for theevaluationofkyphosisandlordosis.Spine7:335 – 342 This report establishes a table of references for kyphosis and lordosis in a sample of 100 healthy adults (43 females, 57 males, age 20–29 years) from France. Segmental measurements were carried out from standing lateral radiographs of the whole spine. Mean thoracic kyphosis was 37 degrees (range 7–63); mean lumbar lordosis was 50 degrees (range 32–84). The majority of individuals had a thoracic kyphosis of between 30 and 50 degrees. There was a correlation between sacral slope and lumbar lordosis and thoracic kyphosis. The considerable variability is stressed. As the distri- bution was found to be irregular, the authors consider it unreasonable to speak of nor- mal kyphotic or lordotic curves. They state that average values are only indicative not normative. References 1. 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Lang G, Kehr P, Aebi J, Paternotte H (1983) Die Behandlung der regulären Kyphose beim Jugendlichen. Z Orthop 121:368 36. Legaye J, Duval-Beaupere G, Hecquet J, Marty C (1998) Pelvic incidence: a fundamental pel- vic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J 7: 99–103 37. Lindemann K (1933) Die lumbale Kyphose im Adoleszentenalter. Z Orthop 58:54–65 38. Lonstein JE, Winter RB, Moe JH, Bradford DS, Chou SN, Pinto WC (1980) Neurologic deficit secondary to spinal deformity. A review of the literature and report of 43 cases. Spine 5: 331–55 794 Section Spinal Deformities and Malformations . activity, less range of motion of extension of the trunk and 792 Section Spinal Deformities and Malformations less-strong extension of the trunk, and different localization of the pain. No significant differences. history and long-term follow-up of Scheuermann kyphosis. J Bone Joint Surg Am 75A:236 –48 Sixty-seven patients who had a diagnosis of Scheuermann kyphosis and a mean angle of kyphosis of 71 degrees. work-up. Non-operative treatment. The general objectives of treatment are to prevent progression of the kyphosis, to correct the deformity, and to relieve pain. The choice of treatment must consider