Treatment approaches for Scheuermann kyphosis: a systematic review of historic and current management.

Abstract

Scheuermann kyphosis (SK) is an idiopathic kyphosis characterized by anterior wedging of ≥ 5° at 3 contiguous vertebrae managed with either nonoperative or operative treatment. Nonoperative treatment typically employs bracing, while operative treatment is performed with either a combined anterior-posterior fusion or posterior-only approach. Current evidence for these approaches has largely been derived from retrospective case series or focused reviews. Consequently, no consensus exists regarding optimal management strategies for patients afflicted with this condition. In this study, the authors systematically review the literature on SK with respect to indications for treatment, complications of treatment, differences in correction and loss of correction, and changes in treatment over time. Using PubMed, Embase, CINAHL, Web of Science, and the Cochrane Library, all full-text publications on the operative and nonoperative treatment for SK in the peer-reviewed English-language literature between 1950 and 2017 were screened. Inclusion criteria involved fully published, peer-reviewed, retrospective or prospective studies of the primary medical literature. Studies were excluded if they did not provide clinical outcomes and statistics specific to SK, described fewer than 2 patients, or discussed results in nonhuman models. Variables extracted included treatment indications and methodology, maximum pretreatment kyphosis, immediate posttreatment kyphosis, kyphosis at last follow-up, year of treatment, and complications of treatment. Of 659 unique studies, 45 met our inclusion criteria, covering 1829 unique patients. Indications for intervention were pain, deformity, failure of nonoperative treatment, and neural impairment. Among operatively treated patients, the most common complications were hardware failure and proximal or distal junctional kyphosis. Combined anterior-posterior procedures were additionally associated with neural, pulmonary, and cardiovascular complications. Posterior-only approaches offered superior correction compared to combined anterior-posterior fusion; both groups provided greater correction than bracing. Loss of correction was similar across operative approaches, and all were superior to bracing. Cross-sectional analysis suggested that surgeons have shifted from anterior-posterior to posterior-only approaches over the past two decades. The data indicate that for patients with SK, surgery affords superior correction and maintenance of correction relative to bracing. Posterior-only fusion may provide greater correction and similar loss of correction compared to anterior-posterior approaches along with a smaller complication profile. This posterior-only approach has concomitantly gained popularity over the combined anterior-posterior approach in recent years.