All right, so as we round out this, you know, a lot of these things have been big concepts and this is kind of a lecture where it's a very specific, kind of a specific presentation. So it's, we'll go over the details of Shuman's kyphosis and we'll go over the, you know, some of the highlighted issues that are really the same issues we've been dealing with the whole time. So, kind of almost a specific case, almost like a case throughout the lecture, just one type of case. All right? And we'll talk about it because it does come up. Once again, disclosures irrelevant to this talk in most ways. So what is normal kyphosis? Again, you know, Bob made that comment about, what was the comment Bob, 30, 40, 50 or 40, 50, 60? That he had learned and he said, you know, and like we said, this is going to be largely derived from your pelvic incidence and the curves above that. But nonetheless, there's some idea about what a thoracic kyphosis should be and these are some of the numbers that one is thinking about. Shuman, or Shuman who basically described this back a long time ago, an orthopedic surgeon, Shuman's disease basically disabling back pain caused by a specific type of kyphosis in the juvenile, mostly male, in the upper or the mid thoracic spine. Okay? And basically he described this pathologically as a disease of the end plates that maybe caused this. So when we think about kyphosis in the kids, we can think about something like a general where you see some deformation of the vertebral body, whether it's a hemi or a partial formation of a vertebra. And this is a congenital deformity. I mean, these kids have very clear deformities, very early and progress very quickly because their bones aren't formed right. All right? Classic and general. Not an AIS, not idiopathic. Idiopathic obviously, they curve, we don't really understand that, but these are the ones who actually have a deformity from very early on. And then postural deformity is pretty much everybody in this room by the end of this morning, right? That's like everyone sitting here just like, you know, this. So a lot of people have this, and some people you sit there and say, you know, is this a postural deformity or is this a Schurman's or do I have a kyphosis? And the issue, as we'll get into, is really know if you can correct it and if you can do that dynamically while you're sitting there or while you're standing. So a postural is one that you can see, and then a Schurman's is one that when you stand forward you actually see it worse. All right? So maybe someone stands like this, and one of the ways you can tell is when they bend forward you really do get a focal kyphosis. So let's talk about postural kyphosis, which now everybody is standing straight up or sitting straight up. They do not want to be operated on for a Schurman's kyphosis. So usually, you know, you're looking at less than 60 degrees, the shoulders are what we call rounded, so you're actually getting some perceived kyphosis basically from the position of your shoulder girdles over your rib cage. You're kind of rounding your shoulders out as opposed to the actual spine itself. It's flexible, there's no wedging, so it's harmonious more than focal. And it's non-structural, as we said, because you can change it by bending backwards, okay? And here's kind of a normal versus a Schurman's, and you're seeing somewhat of a, I don't know if the lights are, if you can see that, but here you've got basically a harmonious non-focal, and what you'll see on the right is right in the thoracic apex, which usually around, in most people, around 7, 8, 8, 9, you're going to see a focal wedged bodies, and often usually some degeneration of those discs early on. Here's one way where you can really exacerbate this. So this lady on the left, maybe you say, oh she's got, I mean the lady on the right, maybe she's got some postural kyphosis, but when you make her bend forward, you really can see exaggerated focal kyphosis, okay? When you see these patients in clinic, they're pretty classic, and often what you'll often see as well is they'll have an increased lumbar hyperlordosis because their upper back is like this, and they end up kind of standing back like this, so they have like a little bit of this kind of, you know, a look, I don't know if I exaggerated that well. So these are some of the studies that have come out to really look at this. The prevalence is, in most studies, is greater than in men. There's some question whether it's autosomal dominant, but they do show that in twins that are identical twins, it's greater than fraternal twins, and the pathology is not clearly understood. It's only really been hypothesized, but the question is, is it a tension band issue where you have an anterior longitudinal ligament that's pulling it tighter, or do you have some kind of problem with the bones or the endochondral ossification center, so is it a problem of push or is it a problem of pull? Is it the bone issue that's not growing, or is it the ligament issue that's tethering too much? Nonetheless, it's all been hypothesized, mainly in orthopedic literature, to why this occurs, and there's no current understanding of the pathology enough to reverse it in any medical way. So what happens is these patients present, you know, the idea is that the rectangular vertebrae now become wedge-shaped, and when you see this, sometimes you'll get an x-ray and the radiologist will say this, they'll actually say, at least at our center, three contiguous vertebral bodies look wedged, please consider Shuberman's kyphosis, clinical correlation advised, you know the line. But that's basically what they're saying, they'll often see it, and they have criteria for which they do this. And as we've known from the rest of this weekend, they have symptoms similar to other types of kyphosis. Severe back pain, and often these patients will say when they wear a backpack, it bothers them, those are the ones that talk to me about it. Severe back pain with sports, a rigid curve that gets worse, difficulty standing erect, chest pain, decreased lung function, very rare, and you have to have severe upper kyphos, you know, kyphoscoliosis to have that, so that's not really an issue. Maybe tight hamstrings and forward posture of the head and neck, which can lead to issues with their neck pain, right, if they're leaning forward and they're doing things like this. The apex as always in most patients is going to be between T7 and T9 in all of us, okay, so anyone stands up, we hit the most dorsal aspect of their spine, it's going to be around T7, T8, or T9, usually around T8. Same thing on these patients, just exaggerated. And as I said before, in order to accommodate that being pushed forward, they often sometimes become hyper lordotic, and sometimes they become actually negatively sagittal balanced in some way, their plumb line falls a little bit posterior. So the Sorensen criterion is basically greater than 5 degrees of wedging, at least 3 bodies, that's it. And that's what the radiologists will say when they see it, but often what they'll also make comments on is you have these relatively young patients who have some degeneration at those disc levels, and they'll say early degeneration or what have you, and that's kind of the whole presentation. In general, it's a benign course, and people will often make some cutoffs, that being said, this has to be looked at in the setting of the patient, right, so some guidelines have been if it's less than 75 degrees of maturity, there's no long-term difficulties, if it becomes 175 or 70, then you're thinking about maybe trying to do something to help them because they are going to be more symptomatic long-term. There are, as always, and every time you'll be asked a question on your neurosurgical oral boards, there are going to be both non-operative and operative options, okay, and so there's no difference here as well, and the non-operative or anything from really do nothing to do bracing or operative, which can be through the three flavors of spine surgery, front, back, or front back, those are the three flavors of spine surgery, right, so no matter how many modificated ways you can do it, those are really the ways you're going to approach somebody, and as Pete discussed briefly on bracing, the real goal of bracing is to prevent someone who's skeletal immature from progressing during their growth, but once someone becomes fully skeletal mature, bracing really does nothing for a curve progression in AIS or in Shumans as well. So basically you can watch the patients who are asymptomatic, non-progressive, and a relatively small curve. You can do postural exercise where they work with PT and they really try to do this on their own and work with extension exercises, in fact, my wife's a PT, she tells me that you can do that for your problems with slouching if you need it, or actually you can do rhomboid exercises and try to have your shoulders not rounded, but I don't know if anyone really works on that, but the fact of the matter is there's PT exercises for both this and for Shumans. Skeletal casting is for the rigid and larger curves, and obviously you have to do this before the patients are skeletal mature. The bracing prerequisites, therefore, adequate curve flexibility, sufficient growth remaining, and patient compliance. Pete made a comment about 20 hours a day, which is hard to do in an adolescent, it's hard to do in an adult, but in someone who has a significant body image identity issue, wearing a brace in high school 20 hours a day can be a big deal, and when they stop wearing the brace, they all go back, alright, they all go back to some degree. Because of the higher level of these curves, sometimes you have to extend the brace to cover those, like Joe said with the three point bending, if you're going to brace around a curve, you actually have to brace around the curve. So a lot of people will say, you know, for traumas, if you have a trauma at the lumbosacral junction, TLSO braces really do nothing, you'd have to have a hip spica cast to really help the brace, right, because you're not over that curve. So just like this, if you want to cover the curve, you really have to cover the upper thoracic spine, and sometimes that means extending it to very high and even to the neck. At least the 16-24 hours a day, and like I said, it's similar to the scoliosis in terms of wearing the brace. Apex as we said, here we go. Even for adults, but especially adolescents, they find the bracing difficult, uncomfortable, it's hot, it's rigid, it's unattractive, they're self-conscious, and I would feel the same way as an adult, much less being a teenager. But you can expect to have some correction, so the idea is here that if you hold that person in extension, and you get a little bit better, so you put the x-ray up and you see them slouched like this, and then you see an extension orthosis like this, that the goal is that those bones will grow as this child is growing, and fill in the wedges to some degree, and you'll get something. Now, what you'll often see, and I'll show a slide later, is that this is where they are pre-brace, this is where they are in-brace, and this is where they are after, somewhere in between. So you're going to get at least, probably 15 degrees loss of correction 18 months after you stop, at least shown by Sachs, and poor success based on the magnitude, alright? Generally not indicated for skeletal maturity, so here's an example of that, a 2005, here's a 64 degree with the brace, you can see how extended they are, and you can see one year later that they're, you know, they've lost some of their correction, so they're somewhere between 64, and probably what this is, which is maybe even 34, and they're down to 44, so they lose some degrees, but that patient on the right is significantly better than they were on the left, with a brace, granted. Indications for surgery, if a brace fails, obviously, if you don't think you can obtain the prerequisites for bracing, right? Curves that are greater than 75 are rapidly progressing, and then this alter respiratory function, which comes up all the time in my clinic, and really the data on that is very, you have to look at severe, severe curves, whether it's kyphoscoliosis of the thoracic spine, where people say, I'm worried about my scoliosis, I think I'm going to stop breathing, my organs are going to get crushed, that has not been shown, unless patients have severe, usually the congenital kyphoscoliosis, where there's an issue with pulmonary function, that they can actually document, and may not be symptomatic, but can be documented, alright? In general, it's clinical deformity, as well, or cosmetic, depending on how you term it, alright? So the goals for operative treatment would obviously be to reduce this hyperkyphosis, in the setting of maintaining sagittal balance, and that's obvious to everyone in this room, I know, at the end of this, that global sagittal balance still reigns king, in no matter what you do. And the options are the three flavors, right, anterior, posterior, combined, and they can all be modified, right? Whether it's some type of hybrid in the back, where you're softening the top, whether it's an anterior release, whether it's a thoracoscopic anterior release, or what have you, alright? So here, when you think about anterior releases, this is the kind of thing you're thinking about in anterior alone, where you're doing multiple inner bodies, and multiple anchors, and you're reducing that kyphosis in the front, mainly through the inner body work, alright? Because usually going anterior can sometimes kyphosis patients if you just attack the disc. So you're really doing it through inner body work, and there's been a number of studies, here's a study by Gaines Group, looking at these patients, minimum two-year follow-up, pre-op, 88 degrees, post-op, 47. The goal of some people, this is to say, reduce their kyphosis by 50%, other surgeons don't say, don't make it a percentage, like Harry Shufflebarger in Miami, in Florida, will say, it's not, I'm not shooting for 50%, although a lot of us will say shoot for 50%, he'll say, I like to shoot for 40 degrees or less, or in that range. So really, you're shooting for that goal, whatever that goal may be, in terms of percentage, or at least an absolute. And when you look at these patients, post-surgery, kind of to echo what Pete said, it mirrors the implants that we've had. So originally, there was a lot of loss of correction, because you were doing segmental members that weren't that strong, with hooks or cables. And as we got better, we got more powerful systems, you saw better correction, okay? Then people, then ponte, as we all know, SPOs we call them, but if ponte is in the room when you say SPO, and the patient does have ankylosing spinal lice, like Charlie said, he may raise his hand and tell you that that's not the way it is, it's described as a ponte, or ponte. So when this started happening, this allowed us more bony resections to become more common, multi-levels. HARMS introduced significant rigid pedicle screws, and then Lankey, kind of the combination of the two. So, at least in terms of publications. So this became more adopted, and here you can see a patient with a 78 degree to a 50 degree or 55. Posterior loam, obviously you want to be able to say that the patient can correct to some degree, because you're not releasing the anterior tension band, so you want to be able to see some bolstered or supine images, like Tyler talked about, and seeing if this patient can bend out, because you're going to be able to say, wow, on an extension table, they're going to be pretty good if I can bend them out either over a bolster or a supine film. Potential posterior complications, the same that we know for everything. So people say, oh, you have a posterior, maybe the infection in your anterior is not, but then you deal with the lungs in the front. So there really is, in terms of infections, in terms of complications for that matter, we know those. And really one of the basic rules for this is you want to go to the, you want to cover the cob, right, the kyphotic cob, you want to cover that. Usually that means going to an upper level of kyphosis all the way up to 1 or 2, as opposed to the other surgeries we've been looking at today where you'll stop at T3, T4 if you're going all the way up from the pelvis up in an adult issue or an AIS, unless the proximal thoracic curve is involved. In general, the Schuermann's, you're going to go T1, T2, and you're going to keep going until you get to one of the first lordotic segments, and that kind of deals with Joe's comments on biomechanic plumb lines, because as you'll see, if you don't go to the first lordotic segment, you're really not, your plumb line will be dorsal, I'm sorry, your implants will be dorsal to your interventational rotation, you'll have a chance to failure and usually distal failure. And the basic construct can be a number of different ways. Here's the double rod, which is basically the old way you'd put two rods and then you'd do it literally a cantilever, so you'd take someone who's like this, you'd put two rods and you'd bend them and then lock them together, right, that's a classic cantilever construct. Still used in trauma at times, but not as common where we have all these little instruments that we can dial in cases. But this is one way that things can be done. Here's a patient with really, you're looking at about a 115 degree curve, and you're going all the way up from the top down to the first lordotic segment. And what I was trying to say is if you were to just cover, say this, what happens is that as you drop your plumb line, this construct is going to see more force at the very bottom and it's going to fail here, versus if the construct covers the instantaneous exertation. It's the same idea with long iliac screws, that you want it to go through the McCord point or you want it to go through the inflection point, so that the screw is on both sides of the instantaneous exertation. So these way, if you come all the way to the first lordotic segment, you're covering, your construct's going into your plumb line, and that therefore means an ergonomic way of displacing those forces, as Joe talked about in his talk this morning. And this is classic what we'll do, we'll put in screws, or the way that I do, I always put my screws, the holes in first, and then I'll do my osteotomies, and then I'll put the screws in after so I don't box myself out. But then classic what we'll do is we'll put the rods in the top and they'll be sticking out just like this, and then you'll reduce, reduce, reduce with a number of instruments. You can push down with a rod pusher in combination with some of the catching devices that we have for reduction, and then at the end of that you're going to compress segmentally on those, and these patients don't have usually a coronal abnormality, so you symmetrically compress on these areas. So here are the ponties, and here you can see a patient with, and this is the classic one, is a male who comes in kind of like with this look, and then you just kind of say, you know, he's kind of chilling, he's kind of, you know, and then you sit there and say like stand up, like take your shirt off, and sometimes these patients even have a little bit what looks like a pectus excavatum where their chest actually almost looks sunken in as a result of their thoracic ribcage kind of being under, underrepresented compared to their shoulders leaning forward, and this is what you see, and then you can obtain something like this postoperatively. A combined technique, a number of studies where you're basically doing a release or inner bodies, you guys get this at this point, you can try to increase length, try to increase the release, and this has been shown in at least a study by Lim et al., kyphosis of 83 down to 46, and over time maybe lost a little correction, but that's expected in many deforming operations we do, but they did follow it up for a while. If you want to combine this with a thoroscope, that's fantastic if you know that technique. If you don't, you need a thoracic surgeon to help you with that technique, and the idea being you're going to release, and then you're going to do something in the back to lock it in. Once again, this group put out 84 down to 43, and long-term follow-up after two years was 45 degrees, and the idea being you might want to pull this out if you think on those extension films you're not getting as much extension and it's too rigid, then you try to release it. Posterior versus anterior-posterior combined, basically two big studies that compared the Johnson group and the Lee group, and really if you look here, there really was no difference in what they got, so these were good surgeons who could get what they wanted to get, so they saw really no significant difference in the sagittal plane, and no difference in the correction in the post-op. Lee basically said posterior only achieved and maintained better outcomes and had less complications likely because they did less surgery. That's usually the line, is that sometimes AP can get more done, but it comes at some cost in terms of complications. That's true of most surgeries, no matter what it is for. This is a paper out of the SRS M&M Committee report in 2005, and you can see some of the issues. You're going to deal with neurologic and death extremely rarely, and wound infections at a reasonable rate compared to the national average, but when you look at posterior only versus AP, they're about the same, and most of what you're dealing with is what the circle has is a DJK, a distal junctional failure in these patients. You're locking them in thoracal, lumbar, and the only part that's mobile is really the bottom. If you've gone too short or if your patient's going to move a lot, they're not going to fail at the top as much as they're going to fail at the bottom in these patients. Junctional kyphosis, post-op your distal pump was reduced by including the first lordotic segment. That was first really written about most in the literature by Crawford, and most of us feel that, and we want to save as many motion segments as possible, like Pete said, in kids, but you do not want to go too short because if they do fail, you're looking at adding a couple more levels potentially. There has been more recent studies about linking this to pelvic incidence, which is not surprising. This was one of the early studies showing that if patients had high PI, it may impact on their failure, and then the risk was, at least by Sun et al, showing that at five years it was really not related to the curve progression, so basically you're looking at patients, no matter how big the curve is, having about the similar type of outcomes. Natural history, what if you don't do anything? Well there are studies, there's actually a great study that was a very longitudinal study, look at this, 67 patients with 32 years follow-up, I mean like, are you kidding me? This is insane, alright, and you know, the study is not the same follow-up, it's not a prospective follow-up, it's really a retrospective, looking at some prospective patients retrospectively, but nonetheless they found no difference in pain, ADLs, fatigue or self-esteem, or employment or sick leave, or back pain, or sciatica, or psychiatric compared to controls. Sounds pretty insane. However, the site of the intensity of the pain were different, they had jobs with less physical requirement compared to controls and had less extension. So in this study, hey, you know, so one guy becomes a jackhammer specialist, one person becomes a desk jockey, I don't know, but in general this study said no big difference. This was not as rigorous as the studies we do for outcomes now, so there may be a little bit of author bias in saying, in my last 32 years, I didn't really see a difference, you know, I asked these guys and they didn't really report any difference, so this is probably not as rigorous, so look at it for what you will. Kyphosis, once again, being big, really doesn't affect it. Another more recent study, really long-term follow-up patients treated with really no difference between the observation, bracing, and the surgery in the domains that they looked at. They saw that the kyphosis may have increased in the surgical group, but final follow-up meaning they lost some. And 94% of all patients, regardless of treatment regime, worked without restriction. So this is, you know, in terms of Pete's terms, this is a clinical deformity, but patients can have pain. So the issue is that you have to counsel them, and if they say, what if I don't do anything? You can say, you might still have some back pain, that may change what you do, but you're not really going to be forced to tell these patients that they have to do something done for pulmonary function unless it's extremely severe. In terms of the surgical controversy, posterior, anterior, like Pete said, I completely agree with him, and like a lot of people said, we really do most things in the back, and this technically is a pretty straightforward approach from us going from the back. People have compared with Lenke Group and Newton, and I think Lenke's in most of these studies, loss of correction was less with anterior-posterior, and what have you. So this is really, I don't think this is as controversial as it used to be, because I think most of us are looking, unless we feel we cannot open a very large, very stiff curve, we're probably pretty much going to go from the back. And so that's it.

Shuman's kyphosis

disabling back pain

end plates

postural kyphosis

operative treatment

surgery