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Summary In 27 centres across Europe, the prevalence of deforming spinal Scheuermann’s disease in age-stratified population-based samples of over 10,000 men and women aged 50+ averaged 8 % in each sex, but was highly variable between centres. Low DXA BMD was un-associated with Scheuermann’s, helping the differential diagnosis from osteoporosis. Introduction This study aims to assess the prevalence of Scheuermann’s disease of the spine across Europe in men and women over 50 years of age, to quantitate its association with bone mineral density (BMD) and to assess its role as a confounder for the radiographic diagnosis of osteoporotic fracture. Methods In 27 centres participating in the population-based European Vertebral Osteoporosis Study (EVOS), standardised lateral radiographs of the lumbar and of the thoracic spine from T4 to L4 were assessed in all those of adequate quality. The presence of Scheuermann’s disease, a confounder for prevalent fracture in later life, was defined by the presence of at least one Schmorl’s node or irregular endplate together with kyphosis (sagittal Cobb angle >40° between T4 and T12) or a wedged-shaped vertebral body. Alternatively, the (rare) Edgren-Vaino sign was taken as diagnostic. The 6-point-per-vertebral-body (13 vertebrae) method was used to assess osteoporotic vertebral shape and fracture caseness. DXA BMD of the L2–L4 and femoral neck regions was measured in subsets. We also assessed the presence of Scheuermann’s by alternative published algorithms when these used the radiographic signs we assessed. Results Vertebral radiographic images from 4486 men and 5655 women passed all quality checks. Prevalence of Scheuermann’s varied considerably between centres, and based on random effect modelling, the overall European prevalence using our method was 8 % with no significant difference between sexes. The highest prevalences were seen in Germany, Sweden, the UK and France and low prevalences were seen in Hungary, Poland and Slovakia. Centre-level prevalences in men and women were highly correlated. Scheuermann’s was not associated with BMD of the spine or hip. Conclusions Since most of the variation in population impact of Scheuermann’s was unaccounted for by the radiological and anthropometric data, the search for new genetic and environmental determinants of this disease is encouraged.

Background Scheuermann’s disease always occurs in adolescent, and it is uncommon for elderly individuals. The aim of this research is to investigate the different potential pathogenic mechanisms and clinical characteristics of thoracolumbar disc herniation (TLDH) in Scheuermann’s disease between elderly and adolescent patients. Methods We retrospectively analyzed data from patients with Scheuermann’s disease who underwent surgical treatment for TLDH from a single center between June 2013 and June 2023. Patients were divided into two groups: elderly (≥ 65 years) and adolescent (≤ 20 years), with 24 patients in each group. Data, including medical records and imaging parameters, were independently collected and analyzed by two doctors. Results The elderly group exhibited significantly lower preoperative modified Japanese Orthopaedic Association (mJOA) scores (5.58 ± 2.38 vs. 7.25 ± 2.19, P  = 0.009) and longer symptom duration (48.29 ± 62.32 vs. 8.37 ± 13.19 months, P  < 0.001) compared to the adolescent group. The elderly group also had a higher prevalence of diabetes mellitus (6/24 vs. 0/24, P  = 0.029), fewer Schmorl’s nodes, more severe intervertebral disc degeneration, and a higher frequency of intervertebral disc vacuum phenomena. Additionally, elderly patients exhibited more frequent localized ossification or hypertrophy of the ligamentum flavum in the thoracolumbar region. Conclusion The later onset of TLDH in Scheuermann’s disease among elderly patients is likely due to a combination of genetically determined higher endplate strength and age-related degenerative factors. Elderly patients also commonly show localized ossification or hypertrophy of the ligamentum flavum, which may contribute to more severe symptoms.

Purpose The aim was to assess the clinical outcomes after posterior spinal fusion (PSF) in patients with Scheuermann’s disease (SD). Methods SD undergoing PSF were retrospectively analyzed. Clinical outcome was determined using SRS-22- and Eq. 5D-questionaires preop and after 3, 12, 24 months after surgery. Whole spine x-rays were analyzed (preop, postop, after 6, 12, 24 months): sagittal and coronary Cobb angles, and pelvic parameters were evaluated; ideal lumbar lordosis (LL) was calculated using formula of le Huec (LL = 0.54*PI + 27.6). Surgical time, complications and blood loss were compared. Postop appearance of proximal (PJF) and distal junction failure (DJF) were calculated. Values were given as mean. Comparison with significance α = 0.05. Results 73 patients were included. SRS-22 total score and EQ5D showed significant increase from preop to two-year FU (each p  < 0.001). Preop Thoracic kyphosis (TK) was 75.1° with significant correction to 48.5° ( p  < 0.001). LL showed mean correction from 68.2° to 46.7° ( p  < 0.001). Difference between ideal and measured LL showed improvement from − 17.2° preop to -3.3° 6 month postop, good spontaneous correction of hyperlordosis. 63% had < 10° deviation from ideal LL 6 month postoperatively, whereas only 21.4% were in this range preoperatively. No significant changes for spinopelvic parameters during FU. Complications occurred in 13,7% of cases. A low revision rate for PJF (2,7%) was necessary. Subscore mental health showed a correlation to preop TK ( p  < 0.05). Conclusion Physiological reconstruction of sagittal alignment could be achieved in most cases (63%). Clinical FU results were convincing with significant improvement of patient’s satisfaction. Complication rate was moderate and risk of PJF after PSF low.

Scheuermann’s kyphosis (SK) is a rigid dorsal kyphosis of unclear pathophysiological origin. The aim of this review is to summarise current theories and both clinical and experimental findings regarding the underlying mechanisms of SK. Emerging evidence highlights the significant role of excessive mechanical loading as a major contributor to defective growth of the cartilaginous vertebral endplate. This is associated with the formation of Schmorl’s nodes, disruption of the ring apophysis, and compromised intervertebral disc integrity—ultimately resulting in vertebral body wedging and thickening of the anterior longitudinal ligament. In addition, numerous studies have investigated the genetic contribution and underlying molecular mechanisms involved in the pathogenesis of SK. Recent in vivo findings suggest an association between asymmetric mechanosensory activation of cerebrospinal fluid (CSF), contacting neurons, and defective Reissner fibre signalling, which may contribute to abnormal spinal morphogenesis in the sagittal thoracic plane. These findings indicate a potential link between altered CSF dynamics and the development of SK. Taken together, the evidence supports a multifactorial aetiology, with both genetic and biomechanical factors playing central roles in the development of Scheuermann’s kyphosis. The interpretation of the underlying pathophysiological mechanism could result in the early detection of the subjects that may have genetical predisposition for SK appearance and the development of target molecular treatments in order to counter the progression of the deformity.

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.

Thoracolumbar kyphosis (TLK) secondary to Scheuermann’s disease often leads to low back pain, which may be related to altered biomechanical properties of the spine. However, There is a lack of biomechanical studies in the literature that comprehensively evaluate tissue-level stresses and strains in the thoracolumbar spine affected by Scheuermann’s kyphosis, particularly during functional motions such as forward flexion. This study analyzed biomechanical changes during forward flexion in TLK patients using musculoskeletal dynamics and finite element modeling. Twenty TLK patients and twenty healthy individuals were recruited. Kinematic data (joint angles), kinetic data (joint reaction forces and moments), and electromyographic (EMG) data were collected at different bending angles using Vicon 3D motion capture and surface electromyography. Physiologic motions captured from in vivo experiment was simulated using OpenSim, with inverse dynamics and optimization used to calculate vertebral joint angles, muscle forces, and intervertebral reaction forces, serving as boundary conditions for ANSYS finite element models. Subject-specific finite element models for both groups were constructed in ANSYS using computed tomography (CT) DICOM files. The CT-based finite element models were used to compute von Mises stress distributions—a mechanical parameter indicating combined tissue stress and potential risk of overload—in the vertebral body, intervertebral discs, and articular cartilage at different forward flexion angles under the applied loadig conditions. At different forward bending angles, TLK patients exhibited high stress distribution in the L1-S1 segment vertebral articular processes. Compared with healthy individuals, the stress distribution in the S1 segment was uneven, with peak stress reaching up to to 2.8 times higher (180% increase) than that of healthy individuals. TLK patients exhibit stress concentration in the annulus fibrosus region of the intervertebral disc, while the stress distribution in the nucleus pulposus region is relatively uniform. The peak stress in the intervertebral disc during different movements can be up to 2.33 times higher (133% increase) than in healthy individuals. In TLK patients, stress concentration was observed in the articular cartilage of all segments except for the L5/S1 segment. The peak stress in the articular cartilage during different movements was up to 12.02 times higher (1,102% increase) than in healthy individuals. These results suggest that TLK patients experience elevated and uneven spinal tissue stress during forward flexion, which may contribute to increased risk of degeneration and back pain.

Purpose Evaluate the validity of rasterstereography compared to low-dose, biplanar spine radiography for assessing thoracic kyphosis (TK) angles in Scheuermann’s disease patients. Methods This prospective study included all the Scheuermann’s disease patients consulting our clinic from 2016 to 2018. Recruited patients underwent two-dimensional low-dose biplanar anteroposterior full-length spine radiography and rasterstereography on the same day. Relationships between the TK angles measured were evaluated using Pearson correlation coefficients. Agreement between radiographic and rasterstereographic TK angles was evaluated using two-way intraclass correlation coefficients (ICCs) and Bland–Altman plots. Proportional biases were assessed using the slope regression lines fitted to Bland–Altman plots. Results The mean demographic and radiological characteristics of the 52 patients (20 girls; 39%) included were: age 13.1 ± 2 years; BMI 17.3 ± 2.8; and TK max. 50.4° ± 10°. Rasterstereographic TK angles were strongly correlated with radiographic TK angles evaluated from T2–T12 (r = 0.677) and from C7–Max (r = 0.704), with ‘good’ agreement (ICC > 0.75). A proportional bias was revealed in the slope regression line fitted to the Bland–Altman plot from the C7–Max radiography and the rasterstereography measurements ( p  = 0.034) but not from the T2–T12 and rasterstereographic TK angles ( p  = 0.997). Conclusion Rasterstereography is a reliable means of quantifying TK angles in Scheuermann’s disease patients. It could directly reduce the number of radiographic scans patients need over time, minimising their radiation exposure.

Purpose The present prospective cohort study was intended to present the minimum 3 years’ results of flexible posterior vertebral tethering (PVT) applied to 10 skeletally immature patients with SK to question, if it could be an alternative to fusion. Methods Ten skeletally immature patients with radiographically confirmed SK, who had flexible (minimum 35%) kyphotic curves (T2–T12), were included. A decision to proceed with PVT was based on curve progression within the brace, and/or persistent pain, and/or unacceptable cosmetic concerns of the patient/caregivers, and/or non-compliance within the brace. Results Patients had an average age of 13.1 (range 11–15) and an average follow-up duration of 47.6 months (range 36–60). Posterior vertebral tethering (PVT) was undertaken to all patients by utilizing Wiltse approach and placing monoaxial pedicle screws intermittently. At the final follow-up: mean pre-operative thoracic kyphosis and lumbar lordosis improved from 73.6°–45.7° to 34.7°–32.1°. Mean sagittal vertical axis, vertebral wedge angle and total SRS-22 scores improved significantly. A fulcrum lateral X-ray obtained at the latest follow-up, showed that the tethered levels remained mobile. Conclusion This study, for the first time in the literature, concluded, that as a result of growth modulation applied to skeletally immature patients with SK, flexible PVT was detected to yield gradual correction of the thoracic kyphosis by reverting the pathological vertebral wedging process, while keeping the mobility of the tethered segments in addition to successful clinical–functional results. The successful results of the present study answered the role of the PVT as a viable alternative to fusion in skeletally immature patients with SK. Level of evidence IV.

Purpose Distal junctional kyphosis (DJK) is a major instrumentation-related complication after the surgical correction of Scheuermann kyphosis (SK). The exact criteria to avoid DJK have been controversial. It has been recommended to include the SSV into the fusion by some authors, while others suggest that fusion to FLV is sufficient. The purpose of this study was to investigate the occurrence of DJK in relation to distal fusion level selection in SK surgery by investigating the relationship between the sagittal stable vertebra (SSV), first lordotic vertebra (FLV), and the lowest instrumented vertebra (LIV). Methods 54 patients (mean age: 21.2 years, range 12–43; male/female: 20/34) with SK who were treated by posterior segmental instrumentation and fusion were prospectively evaluated. Patients were allocated into 3 groups according to distal fusion level. In group 1, SSV was chosen as LIV ( n  = 20), and in group 2, LIV was the FLV ( n  = 16). Third group consisted of 18 patients in whom SSV and FLV was the same vertebra. Distal junctional angle, sagittal plane analysis, and clinical outcomes according to SF-36 were evaluated. Results Mean preoperative kyphosis angles were 77.2°, 73.4°, and 76.7° in groups 1, 2, and 3, respectively ( p  = 0.281), which decreased to 38.1°, 37.3°, and 37.8° postoperatively at final follow-up ( p  = 0.988). Mean follow-up time was 28.3 months. Correction amounts were similar between the groups ( p  = 0.409). 3 patients in SSV group, 5 patients in FLV group, and 3 patients in SSV-FLV group developed DJK, which was statistically insignificant. The C7 sagittal plumbline, lumbar lordosis, and pelvic parameters were not significantly different before or after surgery between the groups. Preoperative and postoperative results of SF-36 questionnaire were similar in all the groups. None of the patients who had DJK required revision surgery during the follow-up time. Conclusion Proper selection of distal fusion level is important in order to prevent DJK after SK surgery. According to this study, it is not necessary to extend the fusion down to the SSV. Fusion to FLV is sufficient and saves a level.

Purpose To analyse pre-operative and post-operative changes of cervical sagittal alignment (CSA) in Scheuermann’s kyphosis (SK) patients. Methods 64 SK and 33 control patients were retrospectively reviewed. Whole spine X-rays obtained at pre-op, 3 months post-op and at latest follow-up were reviewed and ten separate CSA radiological parameters were measured. Patients were divided in three groups: thoracic SK (TK group, apex T6–T9, n  = 40), thoracolumbar SK (TLK group, apex T10–T12, n  = 24), and controls. Results Pre-operative C2–C7 lordosis was 21.1° ± 8.1°(TK), 6.1° ± 5.0°(TLK), and 11.4° ± 8.3° in control group and correlated significantly with T1 slope in both SK groups ( r  = 0.640, r  = 0.772). Pre-operative T1 slope was dependent on deformity type, thoracic kyphosis (TK, β  = 0.445), and lumbar lordosis (LL, β  = −0.354). At final follow-up C2–C7 lordosis decreased to 15.7° ± 5.5° in TK, and increased to 12.1° ± 4.1° in TLK group. C2–C7 lordosis changes linearly correlated with T1 slope changes post-operatively ( r  = 0.721). Post-operative T1 slope showed linear correlation with post-operative changes in TK ( β  = 0.728) and pelvic tilt (PT, β  = 0.539) in TK, and LL ( β  = −0.669), thoracolumbar kyphosis (TLK, β  = −0.434), and PT ( β  = 0.760) in TLK group. Conclusions Our study suggests that SK is not a homogenous group of patients. Two patterns of pre- and post-operative CSA are demonstrated in TK and TLK groups. T1 slope is the most important parameter in determining pre-operative CSA and correlates with other regional anatomical parameters (TK and LL). Post-operative CSA adaptations also correlate with T1 slope post-operative changes. However, post-surgical T1 slope correlates with different parameters in the two SK groups (TK and PT in TK group; TLK, LL, and PT in TLK group).