The goal of treatment is to prevent progression and loss of crepancy. Thus, it is important to distinguish between a strucfunction. Nonambulatory patients are more comfortable and tural and compensatory spinal deformity.
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Kyphosis refers to a roundback deformity or to increased angulation of the thoracic or thoracolumbar spine in the sagittal plane. Kyphosis can be postural, structural (Scheuermann kyphosis), or congenital.
Postural kyphosis is secondary to poor posture. It is voluntarily corrected in the standing and prone positions. The patient may also have increased lumbar lordosis. Radiographs are usually unnecessary if the kyphosis fully corrects. If not, radiographs will reveal no vertebral abnormalities. Treatment, if needed, is aimed at improving the child’s posture.
Scheuermann disease is the second most common cause of pediatric spinal deformity. It occurs equally in males and females. The etiology is unknown, but there may be hereditary factors. Scheuermann kyphosis is differentiated from postural roundback on physical examination and by radiographs.
A patient with Scheuermann disease cannot correct thekyphosis with standing or lying prone. When viewed fromthe side in the forward flexed position, patients with Scheuermann disease will have an abrupt angulation in the mid tolower thoracic region (Fig. 202-4), and patients with posturalroundback show a smooth, symmetrical contour. In bothconditions, lumbar lordosis is increased. However, half of patients with Scheuermann disease will have atypical backpain, especially with thoracolumbar kyphosis. The classic radiologic findings of Scheuermann kyphosis include the following:Narrowing of disk spaceLoss of anterior height of the involved vertebrae producing wedging of 5° or more in at least three consecutive vertebrae Irregularities of the vertebral endplatesSchmorl nodes
Treatment of Scheuermann kyphosis is similar to idiopathic scoliosis. It is dependent on the degree of deformity, skeletal maturity, and the presence or absence of pain. Nonoperative treatment begins with bracing. Surgical fusion is done for patients who have completed growth, have a severe deformity, or have intractable pain.
Congenital kyphosis is a failure of the formation of all or part of the vertebral body (with preservation of posterior elements) or failure of anterior segmentation of the spine, or both. Severe deformities are found at birth and tend to rapidly progress. Progression will not cease until the end of skeletal growth. A progressive spine deformity may result in neurologic deficit. Treatment of congenital kyphosis is often surgical.
Figure 202-4 Note the sharp break in the contour of a child with kyphosis. (From Behrman RE: Nelson Textbook of Pediatrics, ed 14, Philadelphia, 1992, WB Saunders.)
Torticollis is usually first identified in newborns because of a head tilt. Torticollis is usually secondary to a shortened sternocleidomastoid muscle (muscular torticollis). This may result from in utero positioning or birth trauma. Acquired torticollis may be related to upper cervical spine abnormalities or central nervous system pathology (mass lesion). It can also occur in older children during a respiratory infection (potentially secondary to lymphadenitis) or local head or neck infection, and it may herald psychiatric diagnoses.
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Infants with muscular torticollis have the ear tilted toward the clavicle on the ipsilateral side. The face will look upward toward the contralateral side. There may be a palpable swelling or fibrosis in the body of the sternocleidomastoid shortly after birth, which is often the precursor of a contracture. Congenital muscular torticollis is associated with skull and facial asymmetry (plagiocephaly) and developmental dysplasia of the hip.