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The way twelve-year-old Ked Eakins of Norton, Maine, sees it, his life has been stolen from him, piece by piece--first by kyphosis, a spinal abnormality which has made him a social outcast at school and a target for the school bully; by his friends who have recently abandoned him; by his mother, who left for the West Coast taking the insurance which might have saved him with her; and by his father, who's a gambling addict who has lost the rent money. But Ked is a builder, and using the school's Maker Space he intends to build his life back, and maybe make a few real friends, and save his father while he's at it.

SummaryA 6-month randomized controlled trial of spine-strengthening exercise and posture training reduced both radiographic and clinical measures of kyphosis. Participants receiving the intervention improved self-image and satisfaction with their appearance. Results suggest that spine-strengthening exercise and postural training may be an effective treatment option for older adults with hyperkyphosis.IntroductionThe purpose of the present study is to determine in a randomized controlled trial whether spine-strengthening exercises improve Cobb angle of kyphosis in community-dwelling older adults.MethodsWe recruited adults ≥60 years with kyphosis ≥40° and enrolled 99 participants (71 women, 28 men), mean age 70.6 ± 0.6 years, range 60–88, with baseline Cobb angle 57.4 ± 12.5°. The intervention included group spine-strengthening exercise and postural training, delivered by a physical therapist, 1-h, three times weekly for 6 months. Controls received four group health education meetings. The primary outcome was change in the gold standard Cobb angle of kyphosis measured from standing lateral spine radiographs. Secondary outcomes included change in kyphometer-measured kyphosis, physical function (modified Physical Performance Test, gait speed, Timed Up and Go, Timed Loaded Standing, 6-Min Walk), and health-related quality of life (HRQoL) (PROMIS global health and physical function indexes, SRS-30 self-image domain). ANCOVA was used to assess treatment effects on change from baseline to 6 months in all outcomes.ResultsThere was a −3.0° (95% CI −5.2, −0.8) between-group difference in change in Cobb angle, p = 0.009, favoring the intervention and approximating the magnitude of change from an incident vertebral fracture. Kyphometer-measured kyphosis (p = 0.03) and SRS-30 self-esteem (p < 0.001) showed favorable between-group differences in change, with no group differences in physical function or additional HRQoL outcomes, p > 0.05.ConclusionsSpine-strengthening exercise and posture training over 6 months reduced kyphosis compared to control. Our randomized controlled trial results suggest that a targeted kyphosis-specific exercise program may be an effective treatment option for older adults with hyperkyphosis.Trial registration number and name of trial registerClinicalTrials.gov; identifier NCT01751685

SummaryOur aim was to assess risk of vertebral fracture during high-intensity resistance and impact training (HiRIT) for postmenopausal women with low bone mass. HiRIT did not induce vertebral fracture, as evidenced by a reduction in kyphosis following 8 months of training and a lack of change in vertebral morphology.IntroductionThe LIFTMOR trial demonstrated a novel, HiRIT program notably improved bone mass in postmenopausal women with osteopenia and osteoporosis. While no clinical signs or symptoms of vertebral crush fracture were evident during the trial, anecdotal feedback suggests that concerns about safety of HiRIT in the osteoporosis demographic remain. The aim of the current work was to assess vertebral body morphology, Cobb angle, and clinical measures of thoracic kyphosis in participants in the LIFTMOR trial for evidence of vertebral fracture following 8 months of supervised HiRIT.MethodsParticipants were randomized to either 8 months of 30-min, twice-weekly, supervised HiRIT or unsupervised, low-intensity, home-based exercise (CON). Lateral thoracolumbar DXA scans (Medix DR, Medilink, France) were performed at baseline and follow-up. Cobb angle was determined, and vertebral fracture identification was performed using the semiquantitative Genant method. Clinical kyphosis measurements were performed in relaxed standing (neutral posture) and standing tall using an inclinometer and a flexicurve.ResultsThe HiRIT group exhibited a reduction in inclinometer-determined standing tall thoracic kyphosis compared to CON (− 6.7 ± 8.2° vs − 1.6 ± 8.1°, p = 0.031). Both the HiRIT and CON groups exhibited within-group improvement in kyphosis in relaxed standing as measured by both inclinometer and flexicurve (p < 0.05). There were no changes in vertebral fracture classification in the HiRIT group post-intervention. A single, new, wedge deformity was observed for CON.ConclusionsSupervised HiRIT was not associated with an increased risk of vertebral fracture in postmenopausal women with low bone mass. Indeed, a clinically relevant improvement in thoracic kyphosis was observed following 8 months of supervised HiRIT, further supporting its efficacy as an osteoporosis intervention for postmenopausal women with low to very low bone mass.

Summary Biomechanical analyses support the theory that thoracic spine hyperkyphosis may increase risk of new vertebral fractures. While greater kyphosis was associated with an increased rate of incident vertebral fractures, our analysis does not show an independent association of kyphosis on incident fracture, after adjustment for prevalent vertebral fracture. Excessive kyphosis may still be a clinical marker for prevalent vertebral fracture. Introduction Biomechanical analyses suggest hyperkyphosis may increase risk of incident vertebral fracture by increasing the load on vertebral bodies during daily activities. We propose to assess the association of kyphosis with incident radiographic vertebral fracture. Methods We used data from the Fracture Intervention Trial among 3038 women 55–81 years of age with low bone mineral density (BMD). Baseline kyphosis angle was measured using a Debrunner kyphometer. Vertebral fractures were assessed at baseline and follow-up from lateral radiographs of the thoracic and lumbar spine. We used Poisson models to estimate the independent association of kyphosis with incident fracture, controlling for age and femoral neck BMD. Results Mean baseline kyphosis was 48° (SD = 12) (range 7–83). At baseline, 962 (32 %) participants had a prevalent fracture. There were 221 incident fractures over a median of 4 years. At baseline, prevalent fracture was associated with 3.7° greater average kyphosis (95 % CI 2.8–4.6, p  < 0.0005), adjusting for age and femoral neck BMD. Before adjusting for prevalent fracture, each 10° greater kyphosis was associated with 22 % increase (95 % CI 8–38 %, p  = 0.001) in annualized rate of new radiographic vertebral fracture, adjusting for age and femoral neck BMD. After additional adjustment for prevalent fracture, estimated increased annualized rate was attenuated and no longer significant, 8 % per 10° kyphosis (95 % CI −4 to 22 %, p  = 0.18). Conclusions While greater kyphosis increased the rate of incident vertebral fractures, our analysis does not show an independent association of kyphosis on incident fracture, after adjustment for prevalent vertebral fracture. Excessive kyphosis may still be a clinical marker for prevalent vertebral fracture.

Purpose Thoracolumbar kyphosis (TLK) is frequently reported in children with achondroplasia. The combination of TLK and the narrow spinal canal in achondroplasia increases the risk of developing symptomatic spinal stenosis. However, there is no consensus on the optimal management of TLK. Methods This retrospective cohort study evaluated children under four years old with achondroplasia, monitoring TLK every six months. Pathologic TLK was defined as a Cobb angle of 20 degrees or more between T10 and L2. Management involved either a wait-and-see policy, which prohibited unsupported sitting, or bracing. Surgery was reserved for severe progressive TLK or spinal stenosis cases. TLK was evaluated over time. A receiver operating characteristic curve determined the baseline threshold where wait-and-see management failed to resolve TLK below 20 degrees. Multiple linear regression compared bracing versus wait-and-see management for cases exceeding 40 degrees. Results Sixty-two patients were included, with a median age of 10 months and a median follow-up of 31 months. TLK prevalence decreased from 85% at baseline to 42% at final follow-up. The mean Cobb angle decreased from 31 ± 11 degrees to 22 ± 16 degrees ( p  < 0.001). The threshold for ineffective wait-and-see management was identified as 33 degrees. Bracing resulted in significantly more TLK reduction than wait-and-see management for cases exceeding 40 degrees (15 degree difference, 95% CI 2–28, p  = 0.023). Three patients required surgery. Conclusion TLK is highly prevalent in achondroplasia, necessitating careful monitoring. A wait-and-see policy with restrictions on unsupported sitting is recommended initially, but early bracing should be considered for more severe cases.

Objective To determine optimal proximal fusion levels for instrumented spinal fusion for Scheuermann kyphosis. Methods We reviewed 86 patients (33 women) who underwent corrective instrumented spinal fusion for Scheuermann kyphosis. All patients had long-cassette upright lateral radiographs taken preoperatively, postoperatively, and at 2 years and the last follow-up. Demographic, radiographic, and surgical parameters were compared between patients with and without PJK. Results PJK occurred in 28 patients (32%). The mean maximum Cobb angle was 85.8° ± 11.7° preoperatively, 54.8° ± 14.2° postoperatively, and 59.7° ± 16.8° at the last follow-up. Age and sex did not differ between the PJK and non-PJK groups ( P  > 0.05). The preoperative curve characteristics, fusion levels, and corrective ratio were similar in both groups ( P  > 0.05). The maximal Cobb angle at 2 years and the last follow-up significantly differed between the 2 groups ( P  < 0.05). The proportion of patients with the uppermost instrumented vertebra (UIV) at or above the proximal end vertebra (PEV) was similar in both groups ( P  > 0.05). The proportion of patients with UIV at or above T2 was significantly greater in the non-PJK group (P < 0.05). PJK was significantly associated with a C7 plumb line (C7PL)-sacrum distance ≥ 50 mm ( P  < 0.05). Conclusion PJK is the main cause of postoperative correction loss. Proper fusion-level selection can reduce PJK occurrence. We recommend having the UIV at T2 or above, especially when the C7PL-sacrum distance ≥ 50 mm.

Proper posture is essential for healthy living. Maintaining an ideal upright posture is one of the most critical indicators of the health of the musculoskeletal and movement systems. The current study compared the effectiveness of 6 weeks of NASM-based exercise training and eccentric-based exercise programs on body image and upper-quarter posture in schoolgirls with hyperkyphosis. In this randomized, controlled study, two intervention groups that received 6 weeks of NASM and eccentric-based exercise were compared with a control group that did nothing but continue their daily activities. For the purpose of conducting the experiment, 14 subjects were assigned to two groups (eccentric-based and control), and 12 subjects were assigned to the NASM group by using a simple blocked randomization method. The body esteem scale questionnaire was used to assess participants’ body image in the groups. Likewise, the photogrammetric technique and Kyphometer were used to gather data from all groups before and after six weeks of targeted corrective exercises. Differences in responses to workouts across groups were investigated using analysis of variance-covariance (ANCOVA) followed by post hoc Bonferroni tests. The results from the ANCOVA analysis indicated significant differences between the experimental and control groups regarding the effects of time*group on kyphosis ( P  < 0.001), shoulder angle ( P  < 0.001), and forward head posture ( P  < 0.001). Nonetheless, there was no significant difference between the considered groups regarding body image ( P  = 0.617). Based on the Bonferroni test, we found a significant difference between the control and eccentric-based groups for postural parameters measured during the study ( P  < 0.001). Similarly, both the control and NASM groups demonstrated significant differences for all variables( P  < 0.001), except the body image. However, we could not find any statistical difference between the NASM training group and the eccentric-based exercise group concerning the upper quarter postural variables that were mentioned before. This study demonstrates that compared with a control group, schoolgirls with hyper-kyphosis who received a six-week intervention of eccentric-based and NASM- based exercises had significantly improved postural parameters but not body image. Despite these advantages, the improved kyphosis, shoulder angle, and forward head posture did not differ significantly between the NASM-based and eccentric-based exercise groups.

Introduction Junctional spinal disorders have become one of the greatest challenges in spinal deformity surgery. They can occur at any age but are mostly seen in adult deformity surgery and are most often observed as the patient gets older. Definitions Different forms can be individualized according to their types and location: one can observe simple segmental degeneration above or below instrumentation with or without spinal stenosis. Or the situation may be more complex with proximal junctional kyphosis, distal junctional kyphosis and intercalary junctional kyphosis where the junctional kyphosis occurs between two instrumented segments of the spine. Junctional scoliosis may also be observed as a new curve that did not exist after the index surgery. Pathophysiology Many different factors have been described being associated or the cause of junctional problems: old age, increased BMI, osteoporosis, etc. The role of pre-existing and postoperative sagittal imbalance plays a definitive role in their pathogenesis. As well the weakened posterior elements and or fatty degeneration of the posterior muscles are key factors in the occurrence of these problems. Multiple different radiologic parameters to describe and achieve perfect sagittal balance have been described knowing that the pelvic incidence of the patients is the key element that governs lumbar lordosis of the patient and hence the sagittal balance. Away from the spine one has to integrate the issues of the knees and the hips in the presentation of these junctional problems whether they are the cause or one of the consequences of the sagittal malalignment. Likewise the non-instrumented part of the spine (thoracic and or cervical spine) will also play a role in the pathogenesis or prevention of these junctional problems if they are stiff and or autofused along with their respective deformity. Treatment To prevent the occurrence of such junctional problems some basic surgical rules must be observed, but still lots remain unknown such as how much restoration of lordosis is really necessary, how to create a smoother transition between the instrumented and non-instrumented spine, which metal and where to use it, which implants to use as our widely used pedicle screw system may be one of the causes of these problems. Clinically these junctional problems can be asymptomatic and require only observation, or require revision surgery. Revision will require in most cases decompression of the neural elements, extension of the instrumentation and spinal osteotomies. Conclusion Definitively the issue of junctional spinal disorder after deformity surgery will require further extensive research to minimize this problem especially in our aging population.

Introduction Standing in an erect position is a human property. The pelvis anatomy and position, defined by the pelvis incidence, interact with the spinal organization in shape and position to regulate the sagittal balance between both the spine and pelvis. Sagittal balance of the human body may be defined by a setting of different parameters such as (a) pelvic parameters: pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS); (b) C7 positioning: spino-pelvic angle (SSA) and C7 plumb line; (c) shape of the spine: lumbar lordosis. Biomechanical adaptation of the spine in pathology In case of pathological kyphosis, different mechanical compensations may be activated. When the spine remains flexible, the hyperextension of the spine below or above compensates the kyphosis. When the spine is rigid, the only way is rotating backward the pelvis (retroversion). This mechanism is limited by the value of PI. Hip extension is a limitation factor of big retroversion when PI is high. Flexion of the knees may occur when hip extension is overpassed. The quantity of global kyphosis may be calculated by the SSA. The more SSA decreases, the more the severity of kyphosis increases. We used Roussouly’s classification of lumbar lordosis into four types to define the shape of the spine. The forces acting on a spinal unit are combined in a contact force (CF). CF is the addition of gravity and muscle forces. In case of unbalance, CF is tremendously increased. Distribution of CF depends on the vertebral plate orientation. In an average tilt (45°), the two resultants, parallel to the plate (sliding force) or perpendicular (pressure), are equivalent. If the tilt increases, the sliding force is predominant. On the contrary, with a horizontal plate, the pressure increases. Importance of curvature is another factor of CF distribution. In a flat or kyphosis spine, CF acts more on the vertebral bodies and disc. In the case of important extension curvature, it is on the posterior elements that CF acts more. According to the shape of the spine, we may expect different degenerative evolution: (a) Type 1 is a long thoraco-lumbar kyphosis and a short hyperlordosis: discopathies in the TL area and arthritis of the posterior facets in the distal lumbar spine. In younger patients, L4 S1 hyperextension may induce a nutcracker L5 spondylolysis. (b) Type 2 is a flat lordosis: Stress is at its maximum on the discs with a high risk of early disc herniation than later with multilevel discopathies. (c) Type 3 has an average shape without characteristics for a specific degeneration of the spine. (d) Type 4 is a long and curved lumbar spine: this is the spine for L5 isthmic lysis by shear forces. When the patient keeps the lordosis curvature, a posterior arthritis may occur and later a degenerative L4 L5 spondylolisthesis. Older patients may lose the lordosis curvature, SSA decreases and pelvis tilt increases. A widely retroverted pelvis with a high pelvic incidence is certainly a previous Type 4 and a restoration of a big lordosis is needed in case of arthrodesis. Conclusion The genuine shape of the spine is probably one of the main mechanical factors of degenerative evolution. This shape is oriented by a shape pelvis parameter, the pelvis incidence. In case of pathology, this constant parameter is the only signature to determine the original spine shape we have to restore the balance of the patient.

Background Proximal junctional kyphosis (PJK) is a common complication following corrective surgery for adolescent idiopathic scoliosis (AIS) with a Lenke 5 curve. Previous studies have suggested that PJK may be associated with osteopenia, which is prevalent in AIS patients. MRI-based vertebral bone quality (VBQ) scores have been proposed as a valuable tool to assess preoperative bone quality. However, accurately measuring VBQ scores in Lenke 5 AIS patients with a structural lumbar curve can be challenging. Recently, a simplified S1 VBQ score has been proposed as an alternative method when the traditional VBQ score is not applicable. This study aims to evaluate the predictive value of the simplified S1 VBQ score in predicting the occurrence of PJK after corrective surgery for Lenke 5 AIS. Methods We conducted a retrospective analysis of patient data to assess the predictive utility of the S1 VBQ score for PJK in Lenke 5 AIS patients. Demographic, radiographic, and surgical data were collected, and S1 VBQ scores were calculated based on preoperative T1-weighted MRI images. Univariate analysis, linear regression, and multivariate logistic regression were performed to identify potential risk factors for PJK and to assess the correlation between other variables and the S1 VBQ score. Receiver operating characteristic analysis and area under the curve values were used to evaluate the predictive efficiency of the S1 VBQ score for PJK. Results A total of 105 patients (aged 15.50 ± 2.36 years) were included in the analysis, of whom 24 (22.9%) developed PJK. S1 VBQ scores were significantly higher in the PJK group compared to the non-PJK group (2.83 ± 0.44 vs. 2.48 ± 0.30, P  < 0.001), and there was a significant positive correlation between the S1 VBQ score and proximal junctional angle (PJA) ( r  = 0.46, P  < 0.0001). Multivariate analysis revealed that the S1 VBQ scores and preoperative thoracic kyphosis (TK) were significant predictors of PJK. Conclusion This study provided evidence that higher S1 VBQ scores were independently associated with PJK occurrence following corrective surgery for Lenke 5 AIS. Preoperative measurement of the S1 VBQ score on MRI may serve as a valuable tool in planning surgical correction for Lenke 5 AIS.