Patient History:

13 year old female with thoracolumbar junction pain.

Images:

Imaging findings:

There is endplate irregularity and anterior wedging of L1 and, to a lesser degree, T12 and T11. The T12/L1 disc space is slightly narrowed. The anterior vertebral wedging results in a focal 25° kyphosis from L1 to T11. The overall sagittal thoracic curve measures 40°.  Multiple Schmorl’s nodes are also present in the T11, T10, T9, and T7 vertebral bodies, best seen on the AP projection.  A small upper thoracic convexity is present. 

The combination of these findings is consistent with Scheuermann’s disease. 

Discussion:

The clinical presentation of Scheuermann’s disease is varied.  Pain may be present, although many cases are seen incidentally.  The condition most often occurs between the ages of 13 and 17 years.  There is a slight male predominance. 

The thoracic region is most commonly affected, owing to up to 75% of cases.  The thoracolumbar junction region is affected approximately 25% of the time. There is a variant of the disease with purely lumbar involvement. The cervical spine is rarely involved.

The radiographic classification of Scheuermann's disease includes anterior vertebral body wedging of 5° or more across three contiguous segments. Other common radiographic features associated with Scheuermann's disease include endplate irregularity, multiple Schmorl's nodes, and loss of intervertebral disc height. Mild scoliosis may also be seen with Scheuermann's disease.

Imaging of Scheuermann’s disease typically only includes plain radiographs.  MR imaging may be used to distinguish active from inactive Scheuermann’s or for evaluation of associated pathology, such as disc herniation or cord impingement.  Vertebral bone marrow edema seen on MR imaging is an indicator of active disease. 

The pathogenesis of the disease is unclear, but aseptic necrosis of the secondary ring apophyses is the most commonly supported theory.

Treatment is conservative in most cases, consisting of rehabilitative exercise, postural modification, and flexion activity avoidance. Conservative management is recommended with a kyphosis of less than 50°. Bracing is recommended at 50°-75°. Surgical fixation may be performed with a kyphosis greater than 75°.

References:

Yochum TR, Rowe LJ. Yochum and Rowe’s Essentials of Skeletal Radiology. 3rd ed. Baltimore (MD): Lippincott Williams & Wilkins; 2005.  p. 1473-1476.

Tsirikos AI, Jain AK. Scheuermann's kyphosis; current controversies. J Bone Joint Surg Br. 2011;93 (7): 857-64.

Radiopaedia.org

Dr. Aaron Welk is a 2009 graduate of Logan College of Chiropractic. He went on to complete an additional 4.5 years of Residency and Fellowship training in the Logan University Department of Radiology, earning Board Certification in Chiropractic Radiology in 2013. He is also certified as a Chiropractic Physician. Through the course of his radiology training he enjoyed the opportunity to examine patients ranging from “Weekend Warriors” to All-Star professional athletes.

Visit his website for more information.