Scheuermann’s Kyphosis

Introduction

Scheuermann’s kyphosis is a rigid structural hyperkyphosis of the thoracic or thoracolumbar spine, first described by Holger Werfel Scheuermann in 1920 [1]. Radiographically, the condition is defined by anterior wedging of at least 5° in three or more contiguous vertebrae, accompanied by vertebral endplate irregularities, loss of disc space height and Schmorl’s nodes [2,3]. Sorensen later refined the diagnostic criteria in 1964, providing a radiographic standard that remains commonly used in clinical practice today.

Incidence

This condition typically presents during adolescence, most often between the ages of 12 and 17, coinciding with periods of rapid skeletal growth [4,5]. The reported incidence ranges from 0.4% to 8%, with males affected more frequently than females [4,5]. Although the exact etiology remains uncertain, several contributing factors have been proposed, including vertebral growth plate disturbances, biomechanical loading patterns, genetic influences, and changes in bone quality during development [6,7].

Presentation

Clinically, individuals with Scheuermann’s kyphosis typically present with a rigid thoracic or thoracolumbar hyperkyphosis that becomes more pronounced during forward bending [5,7]. This kyphosis does not correct with extension or when the patient is positioned supine or prone, distinguishing it from postural kyphosis. Additional clinical features may include compensatory cervical or lumbar hyperlordosis, hamstring tightness, and sometimes concurrent scoliosis. Patients often report activity-related back pain that tends to improve with rest [5,7].

Management

Management of Scheuermann’s kyphosis is typically nonoperative, focusing on pain relief, posture correction, and curve stabilization through physical therapy, bracing, and anti-inflammatory medications [5,6,7]. Surgical intervention is generally reserved for individuals with thoracic curves exceeding 70 degrees or thoracolumbar curves over 25 to 30 degrees, persistent or severe pain, neurologic involvement, cardiopulmonary compromise, or significant cosmetic concerns [6,7].

Radiological Assessment

Radiological assessment plays a crucial role in diagnosing and managing Scheuermann’s kyphosis, enabling clinicians to assess structural deformities, monitor progression, and plan treatment. The key imaging modalities include plain radiographs, MRI, CT, and EOS imaging, depending on clinical needs.

Both structural and non-structural misalignments can affect the sagittal balance of the spine [8,9] The thoracic spine in children and adolescents can be defined in a normal range as being between 20–40◦ degrees [10], and hyperkyphosis diagnosis is considered beyond 45◦ [11,12].

Standard Radiographs (X-rays)

The lateral standing X-ray is the cornerstone of diagnosis. It must include the full thoracic and lumbar spine in a neutral, weight-bearing position [13]. Inclusion of the proximal femur on the long upright lateral plain radiograph of the entire spine and identification of the relation between the femoral axis line and the center of C7 are important in evaluating sagittal imbalance. Hip and knee full extension is important to eliminate any compensatory flexion that may mask a severe deformity. The radiographic method most often used to assess sagittal imbalance involves using a standing lateral radiograph and measuring the horizontal distance between a C7 plumb line (SVA) and the posterosuperior aspect of the sacrum at the L5–S1 discs. Positive sagittal imbalance is defined as an anterior deviation of the C7 plumb line [14].

Key Parameters

Cobb Angle Measurement: Measured between the superior endplate of the most tilted upper vertebra and the inferior endplate of the lowest involved vertebra. A kyphosis angle >45°, with anterior wedging ≥5° in at least three adjacent vertebrae, confirms Scheuermann kyphosis [15,16].

Thoracic Kyphosis Angle (T3– T12) is measured using a modified Cobb method. The thoracic Cobb angle is measured from the T3 superior endplate to the T12 inferior endplate. The cervical lordosis (C2–C7) is measured from the C2 inferior endplate to the C7 inferior endplate. The lumbar lordosis (L1–S1) is measured from the L1 superior endplate to the S1 superior endplate. The transitional zone (T10–T12 and T12–L2) is measured using a modified Cobb method. The transitional zone angle was measured from the T10 superior endplate to the T12 inferior endplate and from the T12 superior endplate to the L2 inferior endplate [17].

Anterior Vertebral Wedging: Wedging of ≥5° in 3 or more contiguous vertebrae is diagnostic [15]. Scheuermann’s disease was initially described in 1920 by Scheuermann [15] as a rigid thoracic and thoracolumbar kyphosis associated with wedging of vertebral bodies occurring in late childhood. This definition has evolved over the years, and in 1964, Sorensen proposed a new definition using specific criteria of three or more adjacent apical vertebrae that are individually wedged by an angle of 5° or more. Conversely, other authors advocated diﬀerent criteria. In 1987, Ali et al. stated that two or more adjacent apical vertebrae were adequate for the diagnosis, whereas Sachs et al. reduced the requirement to at least one vertebra wedged at a minimum of 5° and a thoracic kyphosis angle >45° between T3 and T12 [17].

Endplate Irregularities: Flattened or irregular vertebral endplates are common [13,15]

Schmorl’s Nodes: Indicate disc material herniating into the vertebral body [16].

Disc Space Narrowing: Seen between affected vertebrae.

Sagittal Balance Parameters: Measured using the Sagittal Vertical Axis (SVA)

Pelvic Parameters: Pelvic tilt, sacral slope and pelvic incidence (PI) are especially relevant in surgical planning [18].

PI-LL is the difference between the PI angle and the lumbar lordosis (LL) angle, and quantifies the mismatch between pelvic morphology and the lumbar curve. The ideal PI-LL target should be <= 10 ° if satisfactory spinopelvic alignment is to be achieved. Scheuermann’s disease occurring in adolescent individuals may affect further pelvic development of the pelvis resulting in lower values of PI. In addition, higher values of TK or TLK may be sufficiently compensated by LL to maintain a neutral sagittal balance when PI has lower values [20]. Patients with thoracic hyperkyphosis or significant kyphosis in the thoracolumbar junction require greater lordotic correction (PI-LL < -10) [21].

MRI (Magnetic Resonance Imaging). While not routinely used for diagnosis, MRI is helpful to:

Assess spinal cord or nerve root compression.
Detect disc degeneration, Schmorl’s nodes, or Modic changes.
Investigate atypical kyphosis or neurological symptoms [22].

CT Scan (Computed Tomography). CT is occasionally used for:

Detailed evaluation of bony anatomy.
Ruling out infection, tumors, or fractures in differential diagnosis.
Preoperative planning in complex cases [23].

EOS Imaging (If available)

Low-radiation, full-body, weight-bearing imaging system providing 3D reconstructions.
Useful for evaluating global sagittal balance.
Preferred in pediatric or adolescent patients due to reduced radiation exposure [24]

Clinical Assessment

Scheuermann’s disease is the most common cause of hyperkyphosis of the thoracic and thoracolumbar spine during adolescence [25]. The clinical assessment of Scheuermann kyphosis involves a comprehensive evaluation including physical examination with imaging correlation along with comprehensive pain, function, and psychosocial assessment.

Clinical Examination

A thorough physical exam remains the cornerstone of initial assessment. Clinicians should evaluate posture, looking for excessive thoracic kyphosis and compensatory lumbar hyperlordosis [26]. Measuring procedures in posture can be widely utilized with a focus on sagittal balance assessment using non-radiographic methods.

Use Adam’s Forward Bend Test to distinguish structural kyphosis from postural deformity [27].
Palpate for spinal tenderness and rigidity, which are often present in the thoracic region.
Assess range of motion, particularly thoracic spine extension, which is typically limited in Scheuermann kyphosis [26].
Conduct a neurological exam to rule out spinal cord or nerve root involvement if symptoms such as numbness or weakness are present [28].

Plumb line is a device frequently used in routine clinical practice [29]. Plumb line distances (PDs) are well known and show good intra-rater reliability, a fair correlation to detect thoracic hyperkyphosis and lumbar lordosis. Even though PDs do not measure any angles, they describe deviations within the sagittal profile.

A wide array of instruments are available for other non-invasive thoracic kyphosis measurement.

Measuring Device	Description	Source
Debrunner Kyphometer	Protractor-like device: arms are placed at the top and bottom curve to measure kyphosis	[30]
Flexicurve Ruler	Plastic moldable device that captures curve shape. Kyphosis index >13 is hyperkyphotic	[30]
Digital Inclinometer	Instrument for measuring kyphosis angle	[31]
Rastereography	Photogrammetric technique to quantify 3D surface	[32]
IncliMed®	Pocket compass needle goniometer	[33]
Arcometer	Instrument used to measure surface angles	[34]
Flexible Electrogoniometer (FEG)	Measures angular changes in kyphosis	[35]
SpinalMouse®	Non-invasive computer assisted medical device	[36]
Photogrammetric measurements	Photographs with software analytics	[36]
Adams Forward Bend Test	To distinguish structural kyphosis from postural kyphosis	[27]
ROM Assessment	Perform active thoracic extension to attempt curve reduction	[26]
Neurologic Exam	Evaluating spinal cord or nerve root involvement	[28]

The Flexicurve index and the Debrunner kyphometer are the most commonly studied, in terms of both reliability and validity. The strongest level of evidence was in support of the high to very high levels of reliability of the Flexicurve index, Debrunner kyphometer and Spinal Mouse, which are simple, hand-held tools. The Flexicurve index and Arcometer have the strongest level of evidence in terms of validity. Flexicurve may be the most feasible as it is inexpensive, easy to use and has high levels of both reliability and validity [37].

Physical Therapy

Physiotherapy and structured exercise programs have demonstrated efficacy in the management of Scheuermann’s kyphosis [38,39]. The primary aim of these interventions is to halt the progression of kyphosis and to enhance functional outcomes. While evidence that physical therapy alone can alter the natural history of Scheuermann’s disease is limited, it is frequently considered a primary treatment option [40].

Indications

Indications for nonoperative treatment include thoracic kyphosis of 50° to 80°, or kyphosis greater than 45° with the presence of radiographic stigmata such as wedged vertebrae or Schmorl’s nodes [40]. For adolescent patients still in the growing phase with Scheuermann’s disease whose kyphosis exceeds 60°, a comprehensive approach integrating a full-time bracing program (exceeding 20 hours per day) with an exercise regimen is recommended. Prescribed exercises should encompass both stretching and strengthening modalities targeting the trunk, as well as addressing tightness in the hamstring and pectoral musculature [38].

Inpatient rehabilitation has demonstrated a beneficial impact on pain levels in individuals with Scheuermann’s disease. For adults diagnosed with Scheuermann’s disease, treatment is primarily indicated when patients experience pain [39].

Methodology

Specialized exercise programs are meticulously designed to optimize the relative alignment of the three sagittal plane curves through vertebral self-elongation, proprietary corrective breathing techniques, and neuromuscular re-education, aiming to enhance postural perception [41,42]. This therapeutic approach is fundamentally rooted in sensorimotor and kinesthetic principles. Patients are guided to strengthen the spinal musculature while maintaining the newly acquired and improved posture [38].

A crucial aspect of these specialized exercise programs is the enhancement of motor control learning. The therapeutic approach is designed to guide patients through the three distinct stages of motor learning: the cognitive, associative, and autonomous phases. In the cognitive phase, patients consciously understand the corrective movements and principles. Through consistent practice, particularly during daily home exercises, they transition to the associative phase, refining their movements and reducing errors. The ultimate goal is to achieve the autonomous phase, where corrected posture and movement patterns become automatic and integrated into daily activities.

While a universally defined protocol for exercise frequency and duration in Scheuermann’s kyphosis is not established, common practice, supported by various protocols, involves weekly supervised sessions at a clinic complemented by daily home exercises [38]. This treatment is typically maintained until the patient’s skeletal growth has ceased, aiming for sustained postural correction and prevention of further progression. The combination of regular clinic visits for expert feedback and intensive daily home practice is essential for facilitating this progression through the learning stages.

Objectives

The core objectives of these specialized exercises include mobilizing the thoracic kyphosis and reducing curve stiffness. Furthermore, these techniques aim to optimize the distribution of fluids within the intervertebral discs, thereby mitigating the deformation of these structures. Corrective breathing constitutes a core component of these methods. Its primary focus is to modify the patient’s breathing pattern to mitigate the risk of spinal deformity curve progression and to foster a more balanced posture. Specifically, these techniques aim to expand collapsed areas of the chest and improve rib motion [38]. These exercises are meticulously tailored to each patient’s unique needs. Primary treatment objectives include the passive mobilization and active reduction of the thoracic kyphosis, along with targeted stretching of the hamstring and pectoral muscles. Throughout therapy, patients actively engage corrective forces to achieve and maintain an upright posture. Subsequently, the sustained maintenance of this corrected posture during daily living activities is emphasized and ultimately contributes to a more optimized alignment. Furthermore, patient motivation, cooperation, and compliance are recognized as indispensable elements throughout the rehabilitation process. Detailed explanations of the method and each specific exercise are provided to patients to foster cooperation and enhance motivation. Clinical experience and research findings [43], corroborated by other reports, suggest that specific rehabilitation interventions are effective in preventing the deterioration of Scheuermann’s kyphosis and in decreasing the thoracic angle curve in affected patients.

Summary

Specific exercises for Scheuermann’s Kyphosis, like any other exercise, should be approached with caution in cases of severe pain, acute inflammatory conditions, new or worsening neurological symptoms, non-compliance, and severe cardiopulmonary conditions. These factors may necessitate reevaluation of the treatment plan or temporary cessation of exercises. Trained healthcare professionals must assess each patient individually to ensure PSSE is appropriate and safe for their specific condition.

Bracing Treatment

Introduction

Scheuermann’s Kyphosis (SK) is a structural hyperkyphosis characterized by anterior vertebral wedging and endplate irregularities. Non-operative management remains the first-line approach for most adolescents, with bracing and physiotherapy forming the cornerstone of treatment. Recent studies confirm that early bracing during growth, combined with exercise, can stabilize and partially correct kyphosis, while adult bracing primarily offers symptomatic relief [44,45].

Thoracic kyphosis in healthy adolescents typically measures between 20° and 40° [44]. Scheuermann’s Kyphosis is defined by rigid deformity with anterior vertebral wedging of at least 5° in three consecutive vertebrae, often accompanied by disc space narrowing and Schmorl nodes [44]. The condition affects approximately 0.4–8% of adolescents, with a male predominance and onset commonly during the growth spurt [44]. Diagnosis relies on standing lateral radiographs, and hyperextension views help assess flexibility [46]. Structural kyphosis differs from postural hyperkyphosis, which is flexible and corrects with extension [46].

Indications for Bracing

Bracing is most effective in skeletally immature adolescents, typically those with Risser grades 0–2, who present with thoracic kyphosis between 50° and 80° [44,45]. The literature supports initiating bracing when curves exceed 50° and show progression or cause pain or cosmetic concern [44,47]. Modern consensus suggests that bracing should begin as early as possible during growth to maximize vertebral remodeling potential [45]. While most authors agree on these thresholds, there is no universal consensus on exact criteria, reflecting variability in clinical practice [46]. Milwaukee braces are traditionally recommended for curves with an apex at or above T8, while thoracolumbosacral orthoses (TLSO) are preferred for lower apices [47]. Recent studies emphasize the role of CAD/CAM-designed kyphosis-specific braces for improved comfort and correction [48].

Goals of Bracing

Unlike adolescent idiopathic scoliosis, where bracing primarily aims to halt progression, the goal in Scheuermann’s Kyphosis is both stabilization and partial correction of the deformity [44,45]. Hyperextension forces applied by the brace can restore anterior vertebral height during growth, leading to structural improvement [45]. Long-term studies report an average correction of 7° to 15° when bracing is initiated early and compliance is high [45,49]. These improvements are often maintained years after brace discontinuation, highlighting the durability of conservative treatment when properly applied [49].

Contraindications

Bracing is less effective in skeletally mature patients with rigid curves and significant vertebral wedging, typically beyond 65° [46]. In these cases, structural correction is unlikely, and bracing serves primarily for pain relief and postural support [50]. Severe kyphosis exceeding 75° to 80°, especially when associated with refractory pain or neurological compromise, is generally considered a surgical indication [46,50]. Poor compliance and inability to tolerate brace wear are practical contraindications that may necessitate alternative strategies [50].

Optimal Bracing Dosage

Current protocols recommend full-time wear, typically 16 to 23 hours per day, sustained until near skeletal maturity [45,49]. Gradual weaning is advised as growth slows, often transitioning to night-only wear before discontinuation [49]. Studies consistently show that higher compliance and longer daily wear correlate with better outcomes [45]. Objective monitoring using temperature or force sensors has revealed that self-reported wear times often overestimate actual compliance, underscoring the importance of adherence strategies [51].

Timing of Initiation

Early initiation during the growth spurt is critical for optimizing results [44,45]. Bracing should begin when kyphosis reaches approximately 50° to 55°, before the curve exceeds 70°, to maximize the potential for vertebral remodeling [45,47]. Delayed treatment reduces the likelihood of structural correction and may limit outcomes to stabilization alone [46].

Bracing in Adults

In adults, bracing rarely achieves structural correction due to skeletal maturity [50]. Instead, it is used for symptomatic relief, postural support, and functional improvement [50]. Recent randomized trials in older adults with thoracic hyperkyphosis have demonstrated that semi-rigid orthoses can improve balance, gait, and reduce kyphosis angle when combined with exercise [52,53]. These findings suggest a role for bracing beyond adolescence, albeit with different therapeutic goals [52,53].

Compliance Monitoring

Advances in sensor technology have improved the ability to monitor brace wear objectively [51]. Integrated temperature and force sensors provide accurate data on adherence, enabling clinicians to tailor interventions and improve outcomes [51]. These systems are increasingly incorporated into clinical practice, though widespread adoption remains limited [51].

Conclusion

Bracing remains a cornerstone of conservative management for Scheuermann’s Kyphosis in adolescents [44,45]. When initiated early, worn consistently, and combined with physiotherapy, it can stabilize and partially correct deformity with durable results [45,49]. In adults, bracing serves primarily as a supportive measure for pain and posture [50,52]. Future research should focus on standardized protocols, comparative trials of modern brace designs, and strategies to enhance compliance [46,51].

Surgery

Surgical Indications and Patient Selection

While the natural history of Scheuermann’s Kyphosis (SK) is generally benign, surgical intervention is reserved for severe cases where conservative management fails. Current literature typically recommends surgery for thoracic kyphosis with Cobb angles exceeding 70–75 degrees. However, there is significant variability in clinical practice, with reported indications ranging from 50 to 80 degrees [54].

Additional indications include persistent intractable pain, documented curve progression, neurological deficits (rare), or significant dissatisfaction with cosmetic appearance [55]. Patients opting for surgical correction are predominantly male and average 20 years of age [56].

The “Limit of Compensation”

A novel, biomechanically based surgical indication has been proposed by Haselhuhn et al. (2024) regarding the patient’s “compensatory reserve.” SK patients compensate for thoracic hyperkyphosis by increasing lumbar lordosis [55].

● Assessment: Compare Standing Lumbar Lordosis (LL) vs. Supine Hyperextension LL.

● Critical Finding: If the standing LL is greater than or equal to the supine extension LL, the patient has reached their maximal limit of compensation. Further progression of kyphosis will result in immediate anterior sagittal decompensation, serving as a strong indication for surgery to prevent long-term degenerative sequelae [55].

Surgical Technique: Trends and Osteotomies

Historical approaches utilizing combined Anterior-Posterior (AP) fusion have largely been supplanted by Posterior-Only (PO) techniques. The PO approach has trended as the preferred technique in recent decades due to the advent of stronger pedicle screw instrumentation and aggressive posterior column shortening osteotomies [56].

● Efficacy: Comparative studies demonstrate that PO approaches offer superior correction, better maintenance of spinal alignment, fewer complications (e.g., pulmonary issues), and shorter hospital stays compared to combined AP surgeries [56-57].

● Instrumentation: Constructs typically involve high-density pedicle screw fixation spanning four or more levels per osteotomy site to maximize corrective power [58].

● Osteotomies: The “workhorse” for correction is the Ponte Osteotomy (Grade 2). This involves the complete resection of the spinous processes, supraspinous/interspinous ligaments, and wide bilateral facetectomies at the apical segments (typically T6-T9). This release allows for posterior shortening and “opening” of the anterior column without the need for anterior disc release [54].

Sagittal Plane Analysis and Alignment Goals

Successful SK surgery is defined not by the degree of kyphosis reduction, but by the restoration of a harmonious Global Sagittal Balance aligned with the patient’s pelvic morphology. Goals for correction must account for patient-specific biomechanics rather than targeting a generic Cobb angle [56].

Modern Alignment Parameters

Current surgical planning integrates advanced metrics beyond simple plumb lines:

● Roussouly Morphotypes: Most SK patients present with a Type 1 or Type 2 spine (Low Pelvic Incidence < 45°). The surgical goal is to restore a “flat” lumbar lordosis profile compatible with this low PI, rather than inducing iatrogenic hyperlordosis (Type 3/4), which leads to mechanical failure.

● GAP Score (Global Alignment and Proportion): Utilized to predict mechanical complications by ensuring the distribution of lordosis matches the pelvic version.

● T4-L1-Hip Axis (New Standard): Recent literature (Hills et al.) emphasizes the harmonic relationship between the thoracic and lumbar apices [60].

○ The Axis: In a balanced spine, the T4-Pelvic Angle (T4PA) and L1-Pelvic Angle (L1PA) should be nearly identical.

○ Surgical Target: Surgeons should aim for a T4-L1PA mismatch between -3° and +1°. Deviations outside this “safe zone” are strongly predictive of proximal junctional failure and mechanical complications [59,60].

Distal Fusion Level Selection (LIV)

Selecting the Lowest Instrumented Vertebra (LIV) is critical to preventing Distal Junctional Kyphosis (DJK).

● SSV vs. FLV: Historically, fusion often stopped at the First Lordotic Vertebra (FLV). However, recent systematic reviews suggest a significant benefit to instrumenting down to the Stable Sagittal Vertebra (SSV)—defined as the proximal-most vertebra touched by the Posterior Sacral Vertical Line (PSVL) [61].

● Evidence: Extending fusion to the SSV significantly reduces the incidence of DJK and revision surgery compared to stopping at the FLV, providing a stable “landing zone” within the cone of economy [61].

^{Figure 1. A 16-year-old female patient with progressive severe Scheuermann kyphosis treated with posterior column osteotomy + long-segment instrumentation. Preoperative whole-spine standing radiographs (lateral and AP) showing 75° thoracic kyphosis (T5–T12), loss of physiological lumbar lordosis, and sagittal imbalance. Immediate postoperative standing radiographs demonstrating correction of thoracic kyphosis and restoration of global sagittal alignment. All angular measurements were performed using Surgimap® software. The patient met Sørensen criteria for Scheuermann kyphosis (≥3 contiguous vertebrae with ≥5° anterior wedging). SSV: Sagittal Stable Vertebra.}

Management of Concomitant Coronal Deformities (Scoliosis)

Approximately 15–30% of SK patients present with a concomitant mild-to-moderate scoliosis [62]. Management of this coronal component requires a distinct strategy:

● Incidental Correction: The scoliosis in SK is typically non-progressive and secondary to the sagittal deformity. Primary correction of the kyphosis via posterior shortening (cantilever maneuver) usually results in spontaneous improvement of the coronal curve.

● Derotation Caution: Unlike in Adolescent Idiopathic Scoliosis (AIS), aggressive vertebral derotation is contraindicated or should be used with extreme caution. Forceful derotation can “lock” the facet joints, hindering the necessary posterior closing required to correct the kyphosis [62].

● Fusion Extent: If the scoliotic curve extends distal to the kyphotic deformity, the LIV may need to be extended to include the stable vertebra of the scoliosis to prevent “adding-on.”

Outcomes and Complications

Surgical correction typically achieves a kyphosis reduction of 33–35 degrees, with minimal loss at follow-up, alongside significant improvements in pain, self-image, and functional capacity [56].

However, the procedure carries notable risks that must be discussed during consent:

● Hardware Failure: Reported in up to 25% of cases (e.g., screw pullout, rod breakage) due to the high biomechanical forces [56].

● Junctional Kyphosis:

○ Proximal Junctional Kyphosis (PJK): Occurs in ~14% of patients. Risk is higher in cases of PI-TK mismatch or overcorrection [55].

○ Distal Junctional Kyphosis (DJK): Occurs in ~14% of patients, often linked to short distal fusion levels (stopping above SSV) [56].

● Revision Rate: Approximately 10% of patients require re-operation for infection, mechanical failure, or junctional deformity [56].

Health Related Quality of Life (HRQOL or QOL) Measures

Health-related quality of life (QOL) assessments help to measure one’s overall health and well-being and include physical, mental, social, and emotional health domains [63]. Adolescents with Scheuermann’s kyphosis tend to be more symptomatic than normal controls and those with larger kyphosis magnitudes may experience increased pain, lower self-image, and decreased function and activity [64].

Assessment of QOL can be measured using the following standardized assessments.

Pain and Functional Outcome Measures

Multiple standardized tools are used to evaluate pain severity and functional limitations:

Visual Analog Scale (VAS) or Numeric Rating Scale (NRS): These are quick and validated measures for quantifying pain intensity [65].
Oswestry Disability Index (ODI): Though originally designed for lumbar spine conditions, ODI is widely used to measure disability in spinal deformities, including kyphosis [66].
Scoliosis Research Society Questionnaire (SRS-22): A validated instrument used in both scoliosis and kyphosis that evaluates pain, self-image, function, mental health, and satisfaction with treatment [67].
SF-36 (Short Form Health Survey): A general quality-of-life tool useful for measuring physical and emotional wellbeing in patients with spinal deformity [68].
PROMIS (Patient Reported Outcome Measurement Information System): Measures to evaluate pain interference, mobility, and anxiety [69].

Psychosocial and Appearance-Based Assessment

Psychosocial well-being is important, particularly in adolescents with kyphosis due to cosmetic concerns:

Spinal Appearance Questionnaire (SAQ): Originally designed for idiopathic scoliosis, this tool is also applicable for Scheuermann patients to assess body image perception [70].
Kyphosis-Specific Spinal Appearance Questionnaire (K-SAQ): A K-SAQ was developed from a modified SAQ to measure kyphosis-specific aspects of appearance. The K-SAQ has only 1 illustration, in response to reading and comprehension problems reported in SAQ illustrations.The images farthest to the right in both questionnaires indicate the worst deformity. The remaining nine questions were truncated and modified from the SAQ to address common kyphosis-specific appearance concerns such as a chin thrust, rounded shoulders, barrel chest and a panniculus [69].
Screening for anxiety, depression, or social withdrawal may be indicated, especially in those reporting significant distress related to posture or self-image [68].

There is very limited research on the impact of Scheuermann’s kyphosis on the quality of life in the adolescent population. A few studies found that Scheuermann’s kyphosis significantly impacts pain and self-image domains and greater kyphotic angles are also often correlated with poorer QOL. Several studies measuring QOL pre and post operatively demonstrated marked improvements in pain, self-image, and function after posterior spinal fusion, with pain and activity scores reaching levels comparable to healthy controls, though some self-image and functional limitations were often found to persist [71, 72].

Psychosocial Needs

Psychological research on Scheuermann’s disease remains limited overall. However, considering Mental health studies, hyperkyphosis has been consistently associated with depression, while no significant findings have emerged regarding anxiety. In adolescent patients with Scheuermann’s disease, vitamin D deficiency has been linked to higher rates of depression and suicide attempts, suggesting a potential biological factor contributing to mental health risks in this population [73]. Among elderly individuals with hyperkyphosis, there is a significant association with increased depressive symptoms and reduced quality of life, conditions that are further exacerbated by chronic pain [74]. Additionally, patients with recurrent major depressive disorder exhibit greater thoracic kyphosis and forward head posture, with the severity of kyphosis correlating to the intensity of depressive symptoms [75].

Pain and body image are closely intertwined in patients with hyperkyphosis, impacting both physical function and psychosocial well-being. Children with hyperkyphosis report significantly greater back pain disability and lower PROMIS scores compared to those with idiopathic scoliosis, highlighting a more severe physical and psychosocial burden that calls for comprehensive care [76]. In adolescents treated with posterior spinal fusion for Scheuermann’s kyphosis, health-related quality of life improves notably over two years, with significant benefits observed in both pain reduction and self-image [77]. Furthermore, intensive multidisciplinary rehabilitation programs that combine physical therapy, postural education, and psychological support have been shown to effectively reduce pain levels in Scheuermann’s patients, emphasizing the importance of holistic treatment approaches [78].

References

Intro:

1.Scheuermann H: Kyfosis dorsalis juvenilis. Ugeskr Laeger 1920;82:385-393.

2.Schmol G: Die pathologenese der juvenile kyphose. Fortschr Ger Roentgen 1930;41:359-383.

3.Sorensen K: Scheuermann’s Juvenile Kyphosis: Clinical Appearances, Radiography, Aetiology, and Prognosis. Copenhagen, Denmark, Munksgaard, 1964.

4.Yaman O, Dalbayrak S. Kyphosis and review of the literature. Turk Neurosurg. 2014;24(4):455-65. doi: 10.5137/1019-5149.JTN.8940-13.0. PMID: 25050667.

5.Mansfield JT, Bennett M. Scheuermann Disease. 2023 Jul 31. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 29763141.

6.Sardar ZM, Ames RJ, Lenke L. Scheuermann’s Kyphosis: Diagnosis, Management, and Selecting Fusion Levels. J Am Acad Orthop Surg. 2019 May 15;27(10):e462-e472. doi: 10.5435/JAAOS-D-17-00748. PMID: 30407981.

7.Kaur S, Lalam R. Scheuermann’s Disease. Semin Musculoskelet Radiol. 2023 Oct;27(5):522-528. doi: 10.1055/s-0043-1771334. Epub 2023 Oct 10. PMID: 37816360.

Radiological Assessment:

8.Le Huec, J. C., Thompson, W., Mohsinaly, Y., Barrey, C., & Faundez, A. (2019). Sagittal balance of the spine. European Spine Journal, 28(9), 1889–1905. https://doi.org/10.1007/s00586-019-06083-1

9.Roussouly, P., & Nnadi, C. (2010). Sagittal plane deformity: An overview of interpretation and management. European Spine Journal, 19(11), 1824–1836. https://doi.org/10.1007/s00586-010-1476-9

10.Feng, Q., Wang, M., Zhang, Y., & Zhou, Y. (2018). The effect of a corrective functional exercise program on postural thoracic kyphosis in teenagers: A randomized controlled trial. Clinical Rehabilitation, 32(1), 48–56. https://doi.org/10.1177/0269215517723052

11.Tribus, C. B. (1998). Scheuermann’s kyphosis in adolescents and adults: Diagnosis and management. Journal of the American Academy of Orthopaedic Surgeons, 6(1), 36–43. https://doi.org/10.5435/00124635-199801000-00004

12.Lowe, T. G. (2007). Scheuermann’s kyphosis. Neurosurgical Clinics of North America, 18(2), 305–315. https://doi.org/10.1016/j.nec.2007.01.003

13.Sørensen, K. H. (1964). Scheuermann’s juvenile kyphosis: Clinical appearances, radiography, aetiology, and prognosis. Copenhagen: Munksgaard.

14.Elgafy, H., Bransford, R., Semaan, H., & Wagner, T. (2011). Clinical and radiographic evaluation of sagittal imbalance: A new radiographic assessment. American Journal of Orthopedics, 40(3), E30–E34.

15.Bezalel, T., Carmeli, E., & Kalichman, L. (2015). Scheuermann’s disease: Current diagnosis and management. Current Orthopaedic Practice, 26(1), 58–62. https://doi.org/10.1097/BCO.0000000000000213

16.Blumenthal, S. L., Roach, J., & Herring, J. A. (1987). Lumbar Scheuermann’s: A clinical series and classification. Spine, 12(9), 929–932. https://doi.org/10.1097/00007632-198710000-00014

17.Bezalel, T., Carmeli, E., & Kalichman, L. (2019). Scheuermann’s disease: Radiographic pathomorphology and association with clinical features. Asian Spine Journal, 13(1), 86–95. https://doi.org/10.31616/asj.2018.0025

18.Mac-Thiong, J. M., & Labelle, H. (2006). The sagittal balance of the spine: An overview of normal and pathological conditions. European Spine Journal, 15(Suppl 1), 75–84. https://doi.org/10.1007/s00586-006-1064-x

19.Tyrakowski, M., Janusz, P., Mardjetko, S., et al. (2015). Comparison of radiographic sagittal spinopelvic alignment between skeletally immature and skeletally mature individuals with Scheuermann’s disease. European Spine Journal, 24, 1237–1243. https://doi.org/10.1007/s00586-014-3595-1

20.Tyrakowski, M., Mardjetko, S., & Siemionow, K. (2014). Radiographic spinopelvic parameters in skeletally mature patients with Scheuermann disease. Spine, 39(18), E1080–E1085. https://doi.org/10.1097/BRS.0000000000000460

21.Diebo, B. G., Henry, J., Lafage, V., & Berjano, P. (2015). Sagittal deformities of the spine: Factors influencing the outcomes and complications. European Spine Journal, 24(Suppl 1), S3–S15. https://doi.org/10.1007/s00586-014-3653-8

22.Modic, M. T., & Ross, J. S. (2007). Lumbar degenerative disk disease. Radiology, 245(1), 43–61. https://doi.org/10.1148/radiol.2451051706

23.Wenger, D. R., & Frick, S. L. (1999). Scheuermann kyphosis. Spine, 24(24), 2630–2639. https://doi.org/10.1097/00007632-199912150-00013

24.Ilharreborde, B., Even, J., et al. (2013). EOS imaging: Applications in pediatric orthopaedics. Orthopaedics & Traumatology: Surgery & Research, 99(1 Suppl), S147–S152. https://doi.org/10.1016/j.otsr.2012.11.002

Clinical Assessment:

25.Bezalel, T., Carmeli, E., Been, E., & Kalichman, L. (2014). Scheuermann’s disease: Current diagnosis and treatment approach. Journal of Back and Musculoskeletal Rehabilitation, 27(4), 383–390. https://doi.org/10.3233/BMR-140483

26.Sørensen, K. H. (1964). Scheuermann’s juvenile kyphosis: Clinical appearances, radiography, aetiology, and prognosis. Copenhagen: Munksgaard.

27.Bezalel, T., Carmeli, E., & Kalichman, L. (2015). Scheuermann’s disease: Current diagnosis and management. Current Orthopaedic Practice, 26(1), 58–62

28.Glassman, S. D., Bridwell, K., et al. (2005). The impact of positive sagittal balance in adult spinal deformity. Spine, 30(18), 2024–2029.

29.Stagnara, P., & Dove, J. (n.d.). Spinal deformity. London: Butterworth-Heinemann. https://www.abebooks.com/9780407004276/Spinal-Deformity-P-Stagnara-J-0407004270/plp Stagnara, P. (1985). Les déformations du rachis. Paris: Masson Ed.

30.Katzman, W. B., Wanek, L., Shepherd, J. A., & Sellmeyer, D. E. (2010). Age-related hyperkyphosis: Its causes, consequences, and management. Journal of Orthopaedic & Sports Physical Therapy, 40(6), 352–360.

31.Azadinia, F., Kamyab, M., Behtash, H., Ganjavian, M. S., & Javaheri, M. R. M. (n.d.). The validity and reliability of noninvasive methods for measuring kyphosis. [Journal unspecified].

32.Coneys, U., Tabard-Fougère, A., Gavira, N., & Dayer, R. (2025). Validating rasterstereography to evaluate thoracic kyphosis in patients with Scheuermann’s disease. European Spine Journal, 34(3), 831–836. https://doi.org/10.1007/s00586-024-08610-1

33.Gravina, A., Ferraro, C., Poli, P., Barazzuol, M., Del Felice, A., & Masiero, S. (2017). Goniometric evaluation of the spinal sagittal curves in children and adolescents: A reliability study. Journal of Back and Musculoskeletal Rehabilitation, 30(2), 325–331. https://doi.org/10.3233/BMR-160541

34.D’Osualdo, F., Schierano, S., & Iannis, M. (1997). Validation of clinical measurement of kyphosis with a simple instrument, the arcometer. Spine, 22(4), 408–413. https://doi.org/10.1097/00007632-199702150-00011

35.Perriman, D. M., Scarvell, J. M., Hughes, A. R., Ashman, B., Lueck, C. J., & Smith, P. N. (2010). Validation of the flexible electrogoniometer for measuring thoracic kyphosis. Spine, 35(14), E633–E640. https://doi.org/10.1097/BRS.0b013e3181d13039

36.Belli, G., Toselli, S., Mauro, M., Maietta Latessa, P., & Russo, L. (2023). Relation between photogrammetry and Spinal Mouse for sagittal imbalance assessment in adolescents with thoracic kyphosis. Journal of Functional Morphology and Kinesiology, 8(2), 68. https://doi.org/10.3390/jfmk8020068

37.Barrett, E., McCreesh, K., & Lewis, J. (2014). Reliability and validity of non-radiographic methods of thoracic kyphosis measurement: A systematic review. Manual Therapy, 19(1), 10–17. https://doi.org/10.1016/j.math.2013.09.003

Physical Therapy:

38.Bezalel, T., Carmeli, E., Levi, D., & Kalichman, L. (2019). The Effect of Schroth Therapy on Thoracic Kyphotic Curve and Quality of Life in Scheuermann’s Patients: A Randomized Controlled Trial. Asian Spine J., 13(3), 490-499. doi: 10.31616/asj.2018.0097.

39.Weiss, H. R., Dieckmann, J., & Gerner, H. J. (2002). Outcome of in-patient rehabilitation in patients with M. Scheuermann evaluated by surface topography. Stud Health Technol Inform., 88, 246-249. PMID: 15456043.

40.O’Donnell, J. M., Wu, W., Youn, A., & et al. (2023). Scheuermann Kyphosis: Current Concepts and Management. Curr Rev Musculoskelet Med., 16, 521–530. doi: 10.1007/s12178-023-09861-z.

41.Lehnert-Schroth, C. (1992). Introduction to the Three-dimensional Scoliosis Treatment According to Schroth. Physiotherapy, 78(11), 810-815. doi: 10.1016/S0031-9406(10)60451-8.

42.Weiss, H. R. (2011). The method of Katharina Schroth – history, principles and current development. Scoliosis, 6, 17. doi: 10.1186/1748-7161-6-17.

43.Bezalel, T., & Kalichman, L. (2015). Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment. J Bodyw Mov Ther., 19(2), 232-237.

Bracing:

44.O’Donnell JM, Wu W, Youn A, Mann A, Swarup I. Scheuermann Kyphosis: Current Concepts and Management. Curr Rev Musculoskelet Med. 2023;16:521–530.

45.Aulisa AG, Marsiolo M, Calogero V, Giordano M, Falciglia F. Long-term outcome after brace treatment of Scheuermann’s kyphosis: an observational controlled cohort study. Eur J Phys Rehabil Med. 2023;59(4):529–534.

46.Huq S, Ehresman J, Cottrill E, et al. Treatment approaches for Scheuermann kyphosis: a systematic review of historic and current management. J Neurosurg Spine. 2020;32(2):235–247.

47.Sebaaly A, et al. Scheuermann’s kyphosis: pathophysiology and surgical treatment update. EFORT Open Rev. 2022;7:782–791.

48.Weiss HR, Turnbull D, Bohr S. Brace treatment for patients with Scheuermann’s disease – a review of the literature and first experiences with a new brace design. Scoliosis. 2009;4:22.

49.Aulisa AM, Calogero V, Giordano M, Falciglia F. Long-term brace outcomes in adolescents with Scheuermann’s kyphosis. Eur J Phys Rehabil Med. 2023;59(4):529–534.

50.AO Spine Surgery Reference. Nonoperative procedure for Scheuermann’s kyphosis. AO Foundation; 2020. (Consensus guideline; no newer multicenter trials available)

51.Zou Y, Zhou L, Wang J, Lou E, Wong M-S. Integrated force and temperature sensors improve orthosis compliance monitoring. Sensors. 2025;25(3):686.

52.Hosseinabadi M, Kamyab M, Azadinia F, Sarrafzadeh J. Spinomed orthosis improves balance and kyphosis angle in elderly hyperkyphosis: randomized controlled trial. Prosthet Orthot Int. 2020;44(4):234–244.

53.Eldemir K, Eldemir S, Ozkul C, Guclu-Gunduz A. Immediate efficacy of Spinomed orthosis and biofeedback posture orthosis on balance and gait in older people with thoracic hyperkyphosis. Gait & Posture. 2024;111:136–142.

Surgery:

54.Skaggs, K., Kato, K., Illingworth, K., et al. (2021). Master’s surgical technique: Operative treatment of Scheuermann’s kyphosis. Journal of the Pediatric Orthopaedic Society of North America, 3(1), 222. https://doi.org/10.55275/JPOSNA-2021-222

55.Haselhuhn, J. J., Odland, K., Soriano, P. B. O., Jones, K. E., & Polly, D. W. Jr. (2024). A novel surgical indication for Scheuermann’s kyphosis. JAAOS Global Research & Reviews, 8(3), e23.00187. https://doi.org/10.5435/JAAOSGlobal-D-23-001871

56.Huq, S., Ehresman, J., Cottrill, E., et al. (2019). Treatment approaches for Scheuermann kyphosis: A systematic review of historic and current management. Journal of Neurosurgery: Spine, 32(2), 235–247. https://doi.org/10.3171/2019.8.SPINE19500

57.Jain, A., Sponseller, P., Kebaish, K., et al. (2015). National trends in spinal fusion surgery for Scheuermann kyphosis. Spine Deformity, 3(1), 52–56. https://doi.org/10.1016/j.jspd.2014.06.009

58.Horn, S. R., Poorman, G. W., Tishelman, J. C., et al. (2019). Trends in treatment of Scheuermann kyphosis: A study of 1,070 cases from 2003 to 2012. Spine Deformity, 7(1), 100–106. https://doi.org/10.1016/j.jspd.2018.06.004

59.Hills, J. M., Mundis, G. M., Klineberg, E. O., et al. (2022). The T4–L1–hip axis: Sagittal spinal realignment targets in long-construct adult spinal deformity surgery. Spine, 47(23), 1638–1646.

60.Hills, J. M., et al. (2024). The T4–L1–hip axis objectifies the Roussouly classification using continuous measures. Journal of Bone and Joint Surgery – American Volume.

61.Verma, A., Baishya, R., Kumar, A., et al. (2025). Comparison between stable sagittal vertebra (SSV) and first lordotic vertebra (FLV) instrumentation for prevention of distal junctional kyphosis in Scheuermann disease: An updated systematic review. Spine Deformity. Advance online publication. https://doi.org/10.1007/s43390-025-01210-z

62.Lonner, B. S., Newton, P., Betz, R., et al. (2007). Operative management of Scheuermann’s kyphosis in 78 patients: Radiographic outcomes, complications, and technique. Spine, 32(24), 2644–2652.

QOL:

63.Audat ZA, Kheirallah KA, Ababneh BF, et al. Assessment of Quality of Life for Scheuermann’s Kyphosis Patients with Cobb’s Angle 50°-65° Treated Conservatively or Surgically in North Jordan: A Prospective Comparative Study. Clin Orthop Surg. 2022;14(2):244-252. doi:10.4055/cios20219 https://pmc.ncbi.nlm.nih.gov/articles/PMC9152904/

64.Petcharaporn M, Pawelek J, Bastrom T, Lonner B, Newton PO. The relationship between thoracic hyperkyphosis and the Scoliosis Research Society outcomes instrument. Spine (Phila Pa 1976). 2007;32(20):2226-2231. doi:10.1097/BRS.0b013e31814b1bef

65.Jensen, M. P., et al. (2003). The validity of the numeric rating scale as an outcome measure in chronic pain trials. Clinical Journal of Pain, 19(5), 345–350.

66.Fairbank, J. C. T., & Pynsent, P. B. (2000). The Oswestry Disability Index. Spine, 25(22), 2940–2953.

67.Hägg, O., et al. (2003). The reliability and validity of the SRS-22 patient questionnaire for idiopathic scoliosis. Spine, 28(1), 63–69.

68.Ware, J. E., & Sherbourne, C. D. (1992). The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Medical Care, 30(6), 473–483.

69.Zapata, K. A., Jo, C., Carreon, L. Y., et al. (2021). Reliability and validity of a kyphosis-specific spinal appearance questionnaire. Spine Deformity, 9, 933–939. https://doi.org/10.1007/s43390-021-00292-91.

70.Sanders, J. O., et al. (2007). The spinal appearance questionnaire: A valid and reliable instrument to evaluate body image in idiopathic scoliosis. Journal of Bone and Joint Surgery – American Volume, 89(3), 356–363.

71.Lonner B, Yoo A, Terran JS, et al. Effect of spinal deformity on adolescent quality of life: comparison of operative scheuermann kyphosis, adolescent idiopathic scoliosis, and normal controls. Spine (Phila Pa 1976). 2013;38(12):1049-1055. doi:10.1097/BRS.0b013e3182893c01 https://pubmed.ncbi.nlm.nih.gov/23370683/

72.Suominen EN, Saarinen AJ, Syvänen J, et al. Health-related quality of life outcomes in adolescent Scheuermann’s kyphosis patients treated with posterior spinal fusion: A comparison with age- and sex-matched controls. Journal of Children’s Orthopaedics. 2022;16(4):290-296. doi:10.1177/18632521221106384 https://journals.sagepub.com/doi/abs/10.1177/18632521221106384

Psychosocial:

73.Chokshi SN, Mudiganty S, Clement RC 3rd, Accousti W. Vitamin D deficiency in Scheuermann’s disease is associated with increased adverse outcomes. SICOT J. 2024;10:13. doi:10.1051/sicotj/2024010. https://pubmed.ncbi.nlm.nih.gov/38568088/

74.Braithwaite D, Chicaiza A, Lopez K, et al. Clinician and patient perspectives on screening mammography among women age 75 and older: A pilot study of a novel decision aid. PEC Innov. 2023;2:100132. doi:10.1016/j.pecinn.2023.100132 https://pubmed.ncbi.nlm.nih.gov/37124453/

75.Canales JZ, Fiquer JT, Campos RN, Soeiro-de-Souza MG, Moreno RA. Investigation of associations between recurrence of major depressive disorder and spinal posture alignment. J Affect Disord. 2016 Sep 15;201:235-241. doi:10.1016/j.jad.2016.05.044. PMID: 27987469. Accessed May 18, 2025. https://pubmed.ncbi.nlm.nih.gov/27987469/

76.Zapata KA, Nadolny C, Lovrich E, Ma Y, Ramo BA. Back pain disability and PROMIS scores in children with hyperkyphosis are worse than children with idiopathic scoliosis. Spine Deform. 2025;13(3):801-809. doi:10.1007/s43390-024-01028-1https://pubmed.ncbi.nlm.nih.gov/39804532/

77.Suominen EN, Saarinen AJ, Syvänen J, et al. Health-related quality of life outcomes in adolescent Scheuermann’s kyphosis patients treated with posterior spinal fusion: A comparison with age- and sex-matched controls. J Child Orthop. 2022;16(4):290-296. doi:10.1177/18632521221106384. https://pmc.ncbi.nlm.nih.gov/articles/PMC9382711/

78.Weiss HR, Dieckmann J, Gerner HJ. Effect of intensive rehabilitation on pain in patients with Scheuermann’s disease. Stud Health Technol Inform. 2002;88:254-257. https://pubmed.ncbi.nlm.nih.gov/15456045/