Diagnosing
Similar imaging guidelines exist as described for scoliosis. With the patient erect, radiographs are taken to show side-to-side alignment. Spinal radiographs are sometimes taken with the patient erect and supine are helpful to document flexibility of a rigid deformity. Specialized imaging studies (CT scan, MRI, bone scan) are used as required.

Clinical
Pertinent historical points include those previously mentioned for scoliosis assessment. Examination includes the forward bend test and the patient is viewed from the side to see if the normal spine contours are present (Fig.19). Prominence of the patient's thoracic kyphosis or failure to reverse their lumbar lordosis with bend requires further investigation.

Figure 19. Clinical photo of kyphotic deformity
in a 13yr-old boy with Scheuermann's disease

Postural "Round Back"
Postural "round back" is defined as an increase in thoracic kyphosis while standing. Curve flexibility is seen when the patient "stands tall" or, when prone or supine, the "deformity" resolves. This non-progressive condition is commonly seen in middle school children, especially girls, and almost always resolves by itself and requires no specific treatment. Parental "nagging" should be avoided.

Scheuermann's Disease
Scheuermann's disease is a condition of unknown cause which produces an increased thoracic kyphosis (>40° ) with true structural changes within the thoracic vertebra with 5° of wedging in each of three adjacent vertebrae measured on side-view radiographs (Fig.21). This localized deformity is usually painless. Treatment is dependent upon the magnitude of the deformity, pain complaints and patient maturity. Observation is done for deformity of less than 60° and brace treatment for curves between 60° and 80° if the patient is skeletally immature. Surgery is rarely required. A subtype of Scheuermann's disease occurs in the lumbar spine, usually in male patients during late adolescence who are involved in heavy lifting tasks. The changes of the vertebra and disc are considered to reflect the physical stress effects. Treatment is by elimination of the offending activity.

Figure 21. 14yr-old girl with Scheuermann's disease (radiograph T-L spine).

Congenital Kyphosis/Lordosis
Sagittal plane deformities may be due to congenital defects of vertebral formation or failure of vertebral segmentation (Fig.22). Deformities due to congenital vertebral formation failure are predictably progressive and require early surgical treatment. Because of potential associated renal anomalies, renal ultrasonographic assessment is recommended. MRI of the spinal canal may also be needed to rule out associated spinal cord abnormalities (Fig.23).

Figure 22. Congenital kyphosis & scoliosis radiographs.

Figure 23. MRI: Congenital kyphosis due to
formation defect with normal cord, roots.

Summary
Spinal deformity is due to a myriad of causes. Scoliosis, kyphosis and lordosis are descriptive and not diagnostic terms and efforts must be made to establish the deformity's cause. The etiology of the most common type of spinal deformity, adolescent idiopathic scoliosis, is unknown, but it is strongly familial. Initial radiographic examination for scoliosis requires a standing back-to-front (PA) thoracolumbar spine radiograph on a single film. Sagittal plane concerns are evaluated by side view radiographs (Fig.24ab).

Figure 24ab. AP and lateral adolescent AIS radiographs.

Treatment varies according to the deformity's cause, location, magnitude, patient maturity and evidence of progression. Treatment decisions are based on a complex equation taking such factors into account. Modern bracing techniques provide cosmetic braces which allow patients to continue their routine activities including sport participation. Modern methods of surgical management allow for patients' rapid mobilization and return to routine daily activity.