Kyphosis

Candidate:

Good morning. Thank you for the opportunity. I will begin by taking a comprehensive history from the patient. I would inquire about the onset, duration, and progression of the kyphosis. I would ask about any associated symptoms such as chronic back pain, stiffness, or breathing difficulties. Additionally, I would explore any relevant medical history, including any history of trauma, infections, or inflammatory disorders. May I proceed with the examination now?

Candidate:

Thank you. Firstly, I would observe the patient’s gait as they enter the room, looking for any abnormalities in their walking pattern. This can provide initial insights into their overall spinal alignment and potential compensatory mechanisms.
Next, I would perform a visual inspection of the patient’s posture and alignment. I would note the position of the head in relation to the pelvis and assess for any sagittal imbalance. I would also look for any compensatory lumbar hyperlordosis or pelvic tilt.

Candidate:

To further evaluate the thoracic kyphosis, I would proceed with the following physical examinations:

Flexibility assessment: I would ask the patient to stand upright and assess the flexibility of the kyphotic deformity. By observing if the deformity can be reduced with the patient standing upright or if it remains fixed, I can differentiate between a structural kyphosis and a non-structural or postural roundback.
Forward flexion assessment: I would ask the patient to perform forward flexion of the spine, noting the appearance of the kyphotic deformity. A structural kyphosis would typically reveal a sharp deformity, while a postural kyphosis would present as a rounded deformity.
Neurological assessment: I would perform a thorough neurological evaluation, including assessing motor strength, sensory function, and deep tendon reflexes. This would help identify any associated neurological deficits or abnormalities.
Musculoskeletal assessment: I would examine the patient’s hamstrings, iliopsoas, and anterior shoulder muscles for any signs of tightness or contractures. These findings can be indicative of the effects of the kyphosis on the musculoskeletal system.

Candidate:

Based on the clinical examination, there are several possible causes of thoracic kyphosis, including:

Scheuermann’s disease: This is the most common cause of structural exaggerated kyphosis. It is characterized by anterior wedging of the vertebrae and can cause a rigid hyperkyphosis. Onset is usually in the pre-teen age group, and it often presents with pain. Treatment options may include conservative management with physiotherapy and analgesia or surgical correction for severe symptoms or unacceptable cosmetic deformity.
Post-traumatic or post-infective causes: Kyphosis can develop as a result of trauma or infections affecting the vertebral bodies, such as discitis or vertebral body osteomyelitis, including tuberculosis (TB). The treatment approach would depend on the underlying cause and may involve antibiotics or surgical intervention.
Inflammatory disorders: Conditions like ankylosing spondylitis can lead to thoracic kyphosis. Management often involves a combination of medical therapy and physiotherapy.
Tumours and congenital deformities: These are less common causes but should be considered in the differential diagnosis. Treatment would depend on the specific pathology.

In terms of treatment, conservative measures, including physiotherapy and analgesia, are usually the first line of management. However, surgical correction using posterior pedicle screw constructs with or without anterior release may be indicated for severe symptoms or cosmetic concerns in curves exceeding 70°.

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Kyphosis

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