What Causes Kyphosis?

Patient Presentation
A 10-year-old male came to clinic as his aunt had noticed that he seemed to have a more prominent spine around his shoulders when he was swimming and mentioned it to his mother. He and his mother denied any mobility problems and neurological issues. His mother had noticed it before, but he “looks just like his father’s family,” she said. She denied any significant progression of it. The family history was positive for a grandfather with prominent kyphosis but without any functional problems. The review of systems was negative for any systemic problems.

The pertinent physical exam showed normal vital signs including blood pressure. He was obese with a muscular build. His physical examination was negative including no significant skin changes. He was pre-pubertal. His spine was straight in all positions including with flexion. He had full range of motion without any pain, numbness or tingling. There was a more noticeable rounded kyphosis in the thoracic area that did not appear to change much with position. He had well-developed trapezius muscles that appeared to accentuate the kyphosis on inspection. There was no specific mass or increased tissue in the area noted. Neurological examination was normal.

The diagnosis of kyphosis was made. The patient was referred to orthopaedics who felt this was a developmental kyphosis but was not significant enough at this time to warrant additional treatment. Monitoring at intervals was planned.

There are 3 planes to view and describe spinal deformities from:

  • Coronal or frontal plane – the view is from front or back of the patient
  • Sagittal plane – is the view from the side of the patient
  • Transverse or horizontal plane – is the view from the top or bottom of the patient

Normally the spine is straight when viewed from the frontal or coronal plane. Normally the spine also has a small kyphosis in the thoracic region (20-45%) and lordosis in the sacral region when viewed laterally in the sagittal plane.

Scoliosis or abnormal deviation of the spinal laterally is the most common spinal deformity. It is best viewed from the frontal or coronal plane.
A review can be found here

Kyphosis is the second most common spinal deformity. It is an abnormal deviation of the spine posteriorly and is best viewed from the sagittal plane. Kyphosis is located in the thoracic or thoracolumbar spinal area and defined as having more than a 40 degree Cobb angle deviation as determined on radiographs. In a study of normally development children (ages 5-16 years) serial measurements were made and found that kyphosis increased for both males and females as they aged. Kyphosis usually does not cause significant functional issues, but is associated with a modest risk of back pain and may have an increased risk for negative body image.

There are two major kyphosis groupings: round and angular. Round is a smooth, large radius curve to the back that usually involves a large number of vertebrae. It is usually more stable, flexible and reducible in childhood, but can become rigid. Angular kyphosis has a sharp angle to the curve as fewer vertebrae are involved. It can be stable but is more likely to be unstable than round kyphosis.

Evaluation includes inspection and palpation of the spine in all angles and Adam’s forward bend test should also be performed. Flexibility, changing curvature, pain and provocation of neurological symptoms should be noted. Patients are often evaluated with radiographs as it can be more difficult to ascertain the extent of kyphosis.
Treatment is usually monitoring and physical therapy and bracing, plus potentially surgical correction.

Learning Point
Causes of kyphosis include:

  • Postural – most common, this improves with patient in proper posture, usually round
  • Developmental kyphosis <ul
  • Scheuermann’s disease is the most common form affecting 4-8% of patients especially boys. Usually round. Usually presents in late childhood with wedged vertebral bodies and cause is unknown but possibly genetic.
  • Congenital malformations usually due to vertebral segmentation and formation problem, often angular
  • Vertebral dysplasia – round or angular
    • Bone fragility problems such as osteogenesis imperfecta, osteoporosis, metabolic diseases, degenerative
    • Soft tissue diseases – Ehler-Danlos syndrome
    • Bone dystrophy
  • Iatrogenic including radiation
  • Infection – tuberculosis is the classic example
  • Paralysis or muscular problems
  • Trauma – often angular
  • TumorQuestions for Further Discussion
    1. How do you perform the Adams Forward Bend Test? A review can be found here
    2. What causes lordosis?
    3. How common is idiopathic scoliosis?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Spine Injuries and Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Campos MA, Weinstein SL. Pediatric scoliosis and kyphosis. Neurosurg Clin N Am. 2007;18(3):515-529. doi:10.1016/j.nec.2007.04.007

    Oskouian RJ, Sansur CA, Shaffrey CI. Congenital abnormalities of the thoracic and lumbar spine. Neurosurg Clin N Am. 2007;18(3):479-498. doi:10.1016/j.nec.2007.04.004

    Miladi L. Round and angular kyphosis in paediatric patients. Orthop Traumatol Surg Res. 2013;99(1 Suppl):S140-149. doi:10.1016/j.otsr.2012.12.004

    Gardner A, Berryman F, Pynsent P. The Development of Kyphosis and Lordosis in the Growing Spine. Spine (Phila Pa 1976). 2018;43(19):E1109-E1115. doi:10.1097/BRS.0000000000002654

    Sheehan DD, Grayhack J. Pediatric Scoliosis and Kyphosis: An Overview of Diagnosis, Management, and Surgical Treatment. Pediatr Ann. 2017;46(12):e472-e480. doi:10.3928/19382359-20171113-01

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa