Non-operative Kyphosis Treatments

What is Thoracic Kyphosis?

Thoracic kyphosis is an increase in the sagittal curvature of the thoracic spine (mid-back) that can give an appearance of a “hunchback.”

Early treatment is especially important to the adolescent patient. Left untreated, the curve progression can lead to significant problems during adulthood with. If there is significant progression of kyphosis, it may cause compression of the nerves in the spine, resulting in weakness or affect the internal organs and lead to respiratory or cardiovascular issues.

Other areas of the spine can also be affected due to compensation for the thoracic curvature. This can lead to increased pressure in the cervical and/or lumbar spine.  

Diagnosis of Thoracic Kyphosis

Diagnosis can be made with history, physical examination, and x-rays of the spine. Additional imaging including CT or MRI of the may or may not be needed depending on symptoms and to rule out other sources of pain.

Routine follow-up is essential to properly monitor curve progression. Patient- or family-reported changes in posture can also help when evaluating for progression of curvature. 

Treatment of Thoracic Kyphosis

Treatment of thoracic kyphosis is determined by the underlying cause and presenting symptoms but typically involve multiple modalities.  

Treatment of Postural Kyphosis 

Postural kyphosis can be due to muscle imbalance and weakness in the muscles that support the spine, usually in the setting of poor posture. This is most commonly seen in adolescents and young adults. This is not a fixed curvature and is easily reversible when lying on a flat surface.  

Physical Therapy:

Certain exercises may be recommended (e.g. physical therapy) to strengthen the patient's paravertebral muscles. A recent meta-analysis looking at treatment for increased kyphosis and posture improvement in adults found that stretching and strengthening was more effective than stretching alone.

Further, the patient must make a conscious effort to work toward correcting and maintaining proper posture. 

Medications and Interventions for Pain Control:

Analgesics and anti-inflammatory medication may be used to provide relief. Over-the-counter topical pain reliever ointments or patches can also be helpful for pain management. Heating pads can be helpful to help ease muscle soreness or tightness.

Bracing:

Wearable posture correction devices have limited evidence to suggest meaningful long-term effects on patient posture however, may be helpful in addition to a strength training regimen. Bracing is less effective for postural kyphosis and prolonged use may lead to muscle weakness.

Treatment of Structural Kyphosis in Adolescents

Scheuermann's Disease is a developmental deformity of the spine that can affect up to 8% of children in the US. The exact cause of this is unknown but thought to be multifactorial and likely has a genetic component. The patient's age, remaining growth potential, degree of kyphosis, curve progression, and the amount of vertebral wedging determine treatment of Scheuermann's Disease.

Physical Therapy:

Physical therapy, in particular Schroth physical therapy – a specific physical therapy technique developed for the treatment of scoliosis– has been found to be an effective treatment for preventing and significantly improving the thoracic kyphosis in Scheuermann’s patients.

Bracing:

Bracing is the standard treatment to control curve progression in adolescents. For curve correction, a Cervical Thoraco Lumbar Sacral Orthotic (CTLSO) may be worn for 24 hours per day for a period of one year. The physician determines the type of brace and how it is to be worn (e.g. hours per day, length of time). After the initial bracing period, the patient is weaned out of the brace. Bracing does not provide permanent benefit to patients 16 years or older. Adolescents may find bracing difficult because the brace can be uncomfortable.

Surgery:

Surgery is a consideration when kyphosis is severe (e.g. greater than 70 degree curve), progression of the curve despite bracing, and/or symptoms (e.g. pain) are unrelieved by conservative treatment.

Treatment of Structural Kyphosis in Adults

Older patients, typically seen in post-menopausal women with underlying osteoporosis, can develop thoracic kyphosis due to deterioration of the spine and vertebral bodies.

Lifestyle Changes:

The Bone Health and Osteoporosis Foundation (BHOF) has released a consensus statement regarding prevention and management of osteoporosis which can help prevent development of thoracic hyper-kyphosis. Non-pharmacologic recommendations for the prevention of osteoporosis and risk of fracture include adequate intake of calcium and vitamin D, cessation of tobacco use, identification and treatment of excessive alcohol intake, regular weight-bearing and muscle-strengthening exercise, and remediation of conditions associated with falls, such as visual impairment and use of sedating medications.

Calcium and Vitamin D:

BHOF supports the Institute of Medicine’s (IOM) calcium intake recommendations: 1000 mg/day for men aged 19–70 years and women aged 19–50 years; 1200 mg/day for women 51 years and older and men 71 years and older. However, there is evidence that intake of supplemental calcium above 1200 to 1500 mg/day can increase risk for developing kidney stones in at-risk individuals.

The BHOF recommends a daily intake of 800 to 1000 units of vitamin D for adults aged 50 years and older. The Institute of Medicine Dietary Reference Intakes for vitamin D are 600 units daily until age 70 years and 800 units/day for adults age 71 years and older to maintain serum vitamin D sufficiency (≥ 30 ng/mL but below ≤ 50 ng/mL).

Physical Therapy:

A supervised, high-intensity resistance and impact training program in postmenopausal women with low bone mass and thoracic kyphosis has been found to be more effective at improving thoracic kyphosis when compared to an unsupervised, low-intensity, home-based exercise program. In addition to a structured exercise program, medication management for pain relief can be added to the treatment plan.

Medications and Interventions for Pain Control:

Analgesics and anti-inflammatory medication may be used to provide pain relief. Padded orthoses can be used to control pain, but these do not control curve progression. Over-the-counter topical pain reliever ointments or patches can also be helpful for pain management.  Heating pads can be helpful to help ease muscle soreness or tightness.

Bracing:

A systematic review found that the use of dynamic hyperextension braces for at least two hours a day for six months improved functionality, mobility, back extensor strength, respiratory function, and reduced the thoracic kyphosis angle in patients with hyper-kyphosis due to osteoporosis.

Osteoporosis Medications:

There are several classes of medication that are used for the treatment of osteoporosis. In general, a therapy that has been shown to reduce risk of both vertebral and non-vertebral fractures (alendronate, risedronate, zoledronic acid, denosumab, teriparatide, abaloparatide, or romosozumab) should be considered over one that has not (raloxifene, calcitonin, ibandronate). It is important to speak with your physician to determine if starting medication for the management of osteoporosis is appropriate.

Injections:

Acute compression fractures can lead to wedging of the vertebral bodies and result in kyphosis. If indicated, injections into the vertebral body (kyphoplasty) can be performed to restore vertebral body height and help limit residual kyphosis and minimize progression of the curve. If the increased curvature causes compression to a nerve, an epidural steroid injection may be helpful to reduce radicular symptoms.

Surgery:

Surgery may be indicated if there is severe progression of the curve and/or the spinal deformity causes other symptoms such as weakness, respiratory or cardiac issues, or balance impairment.  

When to see a doctor about kyphosis?

Children and adolescents with any posture abnormality should be evaluated by an orthopedic specialist. Older individuals should be evaluated if they are experiencing pain or changes in their posture.