Scheuermann's disease
| Classification according to ICD-10 | |
|---|---|
| M42.0- | Juvenile osteochondrosis of the spine including M. Scheuermann |
| ICD-10 online (WHO version 2019) | |
The Scheuermann's disease , also Scheuermann, Adoleszentenkyphose or juvenile kyphosis (medical nomenclature: Osteochondritis deformans juvenilis dorsi ), is a growth disorder of the juvenile spine, which may lead to a painful malposition. Contrary to previous assumptions that it is an aseptic osteochondrosis (cartilage-bone disease without the involvement of germs), the more recent view consists in a weakening of the cartilaginous ring apophyses (the growth zones) of the basal and cover plates of the vertebral bodies. Male adolescents are 4 to 5 times more likely to be affected than female ones. The transition between poor posture and the norm variant is fluid.
It was named after the person who first described it, the Danish radiologist Holger Werfel Scheuermann .
Pathogenesis
During the adolescent growth spurt between the ages of 11 and 15 in girls and between the ages of 12 and 17 in boys, the spine is particularly prone to undesirable development. With increased bending load, e.g. B. by sitting bent over for a long time (therefore also called "tailor's hump" or "apprentice's hump" in the vernacular ) and at the same time weak back muscles (lack of counter- tension ), the vertebral bodies in the lower thoracic spine are usually disproportionately stressed on the concave anterior front edges , and damage to the cartilage-bone connections of the top and bottom plates of the vertebral bodies occurs. The growth zone at the edges of the vertebral bodies is damaged, causing the vertebral bodies to grow more slowly and in a wedge-shaped manner. In the jagged top and bottom plates, small lenticular to pea-sized caverns are created, which are filled with intervertebral disc material and are known as Schmorl cartilage nodules . In serious cases, the cover plate breaks. Most of the time, the distance between the vertebral bodies is greatly reduced in relation to the normal spine. This causes the spine to become defective. Due to the wedge shape of several vertebral bodies, there is a rounded back or hump formation, i. H. for increased kyphosis of the spine. Often a reinforced hollow back ( hyperlordosis ) with the formation of barrel vertebrae (elevation of the vertebral bodies) arises to compensate for this in the lumbar spine . It may also for lysis in the vertebral arches with consecutive spondylolisthesis come.
There is also an atypical form of M. Scheuermann, type II, which mainly affects the lumbar spine. Instead of a natural lordosis (forward curvature of the spine), a flat back or even kyphosis of the lumbar spine occurs there. The long-term pain prognosis of M. Scheuermann II is less favorable than that of M. Scheuermann of the thoracic spine . It is assumed that in the thoracic M. Scheuermann part of the loss of stability caused by the mass defect in the intervertebral spaces is absorbed by the surrounding thorax. If the same changes occur in the lumbar spine, this compensation effect has no effect.
course
Once the growth is complete, there is no further progression of the disease, so it is self-limiting. Overall, the prognosis for classic thoracic Scheuermann's disease is good (see e.g. Kayer / Weber 2007, 135, Ristolainen et al. 2012, Hefti 2015, 123). Often those affected have no or only a few symptoms despite clearly visible kyphosis. Hefti differentiates between fixed, thoracic kyphosis below 50 degrees, in which back pain is neither more frequent nor more intense in adulthood than in normal persons, and fixed, thoracic kyphosis above 50 degrees, which in adults does not suggest more, but stronger back pain (cf. Hefti 2015 , 123). The stated findings are supported by long-term empirical studies from the USA and Finland. The result of a long-term study by Murray et al. (1993), who compared Scheuermann patients with a control group over 32 years of age, found that those affected complain more of back pain, but that there were no significant differences between those affected and the control group in terms of increased days of absence from work, occupational disability, impairments in the everyday life, increased consumption of painkillers or the general quality of life. Ristolainen, et al. (2012) replicated these findings in their long-term study, in which they compared untreated Scheuermann patients with a control group over 37 years of age. The prognosis for lumbar manifestations is somewhat worse (see e.g. Kayser / Weber 2007, 135, Hefti 2015 2015, 123). In severe forms, osteochondrosis , further degeneration that is too early , and deterioration of the Cobb angle can occur as late effects of M. Scheuermann in adulthood. One then speaks of a "condition according to M. Scheuermann" or post-Scheuermann syndrome. The complaints mentioned do not necessarily have to occur, however, and are strongly related to the general state of health, the extent of (back-friendly) sporting activity, overweight and the condition of the back and abdominal muscles.
diagnosis
The diagnosis is first given by the typical clinical findings. The corresponding x-ray findings in the side view, often back pain and the appropriate age confirm the diagnosis. M. Scheuermann is often diagnosed as an incidental finding in chest x-rays.
For a careful diagnosis of Scheuermann's disease, a full lateral spine image is required, in which the kyphosis and lordosis angle is measured according to COBB. In the case of kyphosis of the thoracic spine that goes beyond the norm, a compensatory hyperlordosis of the lumbar spine occurs; the clinical findings here show a hollow back position. The affected wedge vertebrae should also be named and their wedge angle measured. Vertebral bodies with deviations from the norm should be named and described (eg "Schmorl's knot, 7 mm diameter, in the cover plate WK Th 5 wedge 15 °, ventral edge notches"). The fixation or residual mobility of the spine is to be documented by measuring according to Schober and Ott . The erection of the kyphosis in slip hold and deep slip hold are reference values for the conservatively achievable therapy results. Without careful diagnosis and documentation of the measured values, the observation and prognosis of the progression (deterioration tendency) is not possible.
In adults with a condition according to M. Scheuermann and pain problems, ankylosing spondylitis disease and similar rheumatic diseases as well as osteoporosis should be excluded from the differential diagnosis .
The differential diagnosis can lead to confusion with notochord come -Rückbildungsstörungen. This clinically harmless standard variant shows itself as flat arched hollows in the dorsal vertebral body end plates, which have no influence on the statics of the spine and no disease value, but can be mistaken for Schmorl's nodules on the X-ray.
The Edgren - Vainio sign is a radiological sign, which is an increased bone growth in the cover plate of a vertebral body opposite a Schmorl body. The Edgren-Vainio sign can be helpful in differentiating between Scheuermann's disease and spondylitic effects.
treatment
Physiotherapy and sports
In a physiotherapeutic treatment concept, the avoidance of incorrect strain (e.g. sitting bent over for hours) is crucial. Not every sport is suitable for Scheuermann patients. Some sports can aggravate the symptoms in the acute phase in adolescents, especially sports in which the spine is exposed to considerable compression and torsional loads from jumps, jumps, blows, falls, etc. (martial arts (judo, wrestling), indoor ball sports , Apparatus and floor exercise, cycling in racing bike position, running sports on hard floors with insufficient damping, etc.). Weight training (without lifting and pressing loads), swimming, gymnastics, walking, etc. are suitable. It is important to ensure that no inclining exercises that reinforce kyphosis are performed. In the non-florid phase, Scheuermann's disease is usually not painful. Most of the sporting activities can then be resumed. Since Scheuermann's signs increasingly appear in performance rowers in adolescence, this activity is not recommended under performance conditions.
The therapeutic goal is the reclination , straightening and stretching, stretching of shortened structures and muscle chains that pull into the hunched back, strengthening the static autochthonous back muscles and training a more upright posture. This can be supported by simple physiotherapeutic measures, with exercises that, in addition to straightening the trunk, also stretch the chest muscles, which are often shortened.
Orthotics
In the case of partially fixed kyphosis in the growing age with a Cobb angle of over 40 ° in the thoracic spine area, where complete self- straightening is not possible, a reclining trunk orthosis (straightening corset) can show good results if the corset uses the kyphosis angle as a primary correction of at least 40 % corrected (or over 15 °) and the corset is worn with sufficient compliance together with daily physiotherapy at the start of treatment for at least 20 hours per day. A strongly reclining orthosis can also reduce pain and improve posture in adult pain patients.
Known reclining orthoses are z. B. the Munster kyphosis orthosis according to Chêneau , the Tübingen kyphosis orthosis according to Zielke and Nusser , the Balgrist kyphosis orthosis according to Böni (University Hospital Zurich) or the anti-kyphosis orthosis according to Rahmouni. A new CAD variant for which it is no longer necessary to make a plaster cast is the kyphologic brace after Weiss .
In any case, corsets and orthotics are therapeutically effective if they correct at least 40% of the Cobb angle, which goes beyond the standard variant as incorrect statics of the spine:
Example:
- Standard variant BWS kyphosis angle 15 to 25 years about 30 ° Cobb
- Patient without corset: 70 ° Cobb.
- Patient in corset: 50 ° Cobb. = 50% correction
- Patient in corset: 30 ° Cobb = 100% correction
- Patient in corset: 20 ° Cobb = 10 ° overcorrection
There are different curvature patterns or different spinal sections that can be affected by Scheuermann signs: A distinction is made between the thoracic (thoracic spine), the thoracolumbar (transition between thoracic and lumbar spine) and the lumbar (lumbar spine) curvature pattern. These different curvature patterns are treated both physiotherapy and with corsets with different targets.
Achieving an overcorrection in the corset makes sense because after taking off the corset, the spine can be expected to “spring back”. It depends on the length of time it is worn, the intensity of self-straightening and the level of training of the autochthonous back muscles, how much or how little the patient sinks back into the kyphosis statics after taking off the corset. With good compliance, good straightening and healing successes can be achieved. Then the prognosis for M. Scheuermann is positive. With the CAD / CAM corsets used today, the stiffening can be reduced, and with good cooperation it can even be completely eliminated. Most patients achieve the treatment goal with these types of braces even if they are worn for 16 hours a day.
surgery
Surgical straightening of the spine was previously only considered in extreme exceptional cases above 70 ° kyphosis angle and in severe pain that was resistant to treatment with conservative methods, because some scientists found no evidence that surgery can eliminate the health-related signs and symptoms of kyphosis, and believed it was more of a cosmetic indication for surgery.
Even pronounced findings on the x-ray can remain symptom-free and do not necessarily limit resilience. In contrast, less pronounced findings can lead to considerable pain and posture problems: There is no connection between pain and the severity of the M. Scheuermann finding (similar to scoliosis ), so the decision for or against a surgical intervention is always an individual decision. concerning the individual case. A spinal specialist for weighting the kyphosis angle:
“Increasing or recyphosing is difficult or impossible to compensate muscularly, especially in TLÜ, and even at low Cobb angles (<15–20 °) lead to static loads on the sections of the spine above or below the deformity. These [...] misalignments thus represent an indication for revision surgery "
The operation ( spondylodesis ) is carried out by removing the worn intervertebral discs anteriorly , inserting bone segments from the iliac crest or the ribs instead of the intervertebral discs, straightening up by removing dorsal bone wedges ( osteotomy ) and fixation with rod implants ( internal fixator ) made of titanium or stainless steel , which with Pedicle screws are anchored in the vertebral bodies.
literature
- Hefti, F. (2015): Pediatric orthopedics in practice. 3. Edition. Springer publishing house. Berlin, Heidelberg. Pp. 120-127.
- Kayser, R. / Weber, U (2007): Scheuermann's disease. In: Orthopedics and trauma surgery up2date 2007; 2 (2): 125-140 doi: 10.1055 / s-2007-966423 Georg Thieme Verlag KG Stuttgart · New York.
- Murray, PM et al. (1993): The natural history an long-term follwo-up of Scheuermann kyphosis. J Bone Joint Surg Am 75 (2): 236-248.
- Ristolainen, L. et al. (2012): Untreated Scheuermann's disease: a 37-year follow-up study. Eur Spine J 21: 819-824.
- Holger Werfel Scheuermann : Kyphosis dorsalis juvenilis. In: Journal of orthopedic surgery including therapeutic gymnastics and massage. Vol. 41, 1921, ZDB -ID 201105-0 , pp. 305-317.
Individual evidence
- ↑ M. Aufdermauer: Juvenile Kyphosis (Scheuermann's disease) Radiography, histology and pathogenesis. In: Clinical Orthopedics and Related Research . Vol. 154, 1981, ISSN 0009-921X , pp. 166-174.
- ^ Maximilian Reiser : Radiology. = Dual Row Radiology (= Dual Row. ). Thieme, Stuttgart 2004, ISBN 3-13-125321-5 .
- ↑ Christa Lehnert-Schroth, Hans-Rudolf Weiss: Physiotherapy treatment for Scheuermann's disease. In: Hans-Rudolf Weiss (Hrsg.): Corset care, physiotherapy scoliosis treatment, physiotherapy treatment and M. Scheuermann (= spinal deformities. Vol. 2). G. Fischer Stuttgart et al. 1992, ISBN 3-437-11473-5 , pp. 103-113.
- ↑ Christa Lehnert-Schroth: Three-dimensional scoliosis treatment. Respiratory orthopedic system Schroth . 7th, revised and supplemented edition. Urban & Fischer, Elsevier, Munich et al. 2007, ISBN 978-3-437-44025-0 .
- ↑ a b c d e Hans-Rudolf Weiss, Deborah Turnbull: Kyphosis (Physical and technical rehabilitation of patients with Scheuermann's disease and kyphosis) . In: John H. Stone, Maurice Blouin (Eds.): International Encyclopedia of Rehabilitation. 2012, online at CIRRIE .
- ↑ Hans-Rudolf Weiss: A new model in bracing of the thoracic kyphosis [A new model in bracing of the thoracic kyphosis]. In: Medical-orthopedic technology. MOT. Vol. 125, 2005, ISSN 0340-5508 , pp. 65-71.
- ^ Hans-Rudolf Weiss, Deborah Turnbull, Silvia Bohr: Brace treatment for patients with Scheuermann's disease - a review of the literature and first experiences with a new brace design. In: Scoliosis. Vol. 4, No. 22, ISSN 1748-7161 , doi: 10.1186 / 1748-7161-4-22 .
- ^ Martha Hawes: Developmental Neurorehabilitation. In: Impact of spine surgery on signs and symptoms of spinal deformity. Vol. 9, No. 4, ISSN 1751-8423 , pp. 318-339, doi: 10.1080 / 13638490500402264 .
- ^ Martha C. Hawes, Joseph P. O'Brien: A century of spine surgery: What can patients expect? In: Disability and Rehabilitation. Vol. 30, No. 10, 2008, ISSN 0963-8288 , pp. 808-917, doi: 10.1080 / 09638280801889972 .
- ↑ K. Röhl, F. Röhrich: Operative treatment of complications after spinal surgery. In: Trauma occupational disease. Vol. 7, No. 1 Supplement, 2005, ISSN 1436-6274 , pp. S187-S193, doi: 10.1007 / s10039-004-0896-3 .
