Cervical Kyphosis
A Patient's Guide to Cervical Kyphosis
Introduction
The word kyphosis is used to describe a "C"-shaped curve in the spine. A "kyphosis" curve has the opening of the "C" in the front of the body. This type of curve is the opposite of a "lordotic" curve in the spine. A lordotic curve has the opening facing towards the back. The normal spine has both types of curves, but in small amounts. These curves become a problem when they are larger than normal - the larger the curve, the more serious the problem. Many different conditions can lead to an excessive kyphosis.
The thoracic, or mid portion of the spine, normally has a kyphotic curve. The curves of the spine are usually measured in degrees. A thoracic kyphosis is normal when measured at 20-40 degrees. The cervical spine (neck) and lumbar spine (lower back) have "lordotic" curves that face the opposite direction - like a backward "C".
When the thoracic spine curves outside of the normal range, it creates a "hunchback" look and the shoulders slump forward. If the cervical or lumbar spines lose their lordotic shape and start to curve forward instead, it is an abnormal condition referred to as "kyphosis". The abnormal forward curvature can lead to problems within the spine in addition to an unusual appearance.
Kyphosis can have varying symptoms and degrees of severity, from minor changes to the shape of your back and neck, to severe deformity, neurologic deficits, and chronic pain. Kyphosis is most common in the thoracic spine, though it can also affect the cervical and lumbar spine.
This document will provide information about:
- The cervical spine anatomy
- The causes of cervical kyphosis
- Nerve problems caused by cervical kyphosis
- The surgical treatment of cervical kyphosis
Anatomy
As mentioned above, the cervical spine naturally has a lordotic curve, so a kyphotic spinal deformity means there is an abnormal forward curvature to that part of the spine. The loss of the normal cervical lordosis might be localized, occurring in just one or a few segments of the vertebrae, or it can involve the majority of the cervical spine segments.
In order to understand your symptoms and treatment options, you should start with some understanding of the general anatomy of your neck. This includes becoming familiar with the various parts that make up the neck and how these parts work together.
Please review the document, entitled:
The stability of the cervical spine, and its ability to resist kyphosis, depends on several different parts of the spine. First, the vertebral bodies need to be strong enough to support the head and keep a normal shape. Second, the facet joints, ligaments, and soft tissues in the back of the spine must be strong enough to keep the neck from curving forward due to the pull of the weight of the head. Finally, the muscles in the back must be strong enough to resist the forward pull of the weight of the head. If there is damage to any of these three areas, a kyphotic deformity can develop. After the kyphosis begins, the weight of the head can cause a progression of the curvature.
Causes
There are several causes of cervical kyphosis. This condition can develop in children and adults.
The first cause is degenerative disc disease. The process of degeneration of the intervertebral discs causes many spine problems. In older adults, the wear and tear of aging on the discs between each vertebra can cause the disc to collapse. As the discs collapse and grow thinner, the head tilts forward and the neck begins to curve forward. This begins a process that may continue to progress for years. The weight of the head causes an imbalance of forces pushing the neck increasingly forward. This slowly leads to an increasing curve and may end with a kyphosis.
For more information concerning degenerative disc disease, you may wish to refer to the document, entitled:
The second cause of cervical kyphosis is congenital, meaning it is a birth defect affecting the development of the spine. A person is born with some sort of defect, such as incomplete formation of the spine, which leads to an increasing kyphosis type curve in the neck. Congenital kyphosis usually leads to a growth disturbance of the vertebrae themselves. Instead of growing normally, the vertebrae grow into a triangular-shape with the small end pointing forward. Because the vertebrae are stacked one atop the other, the triangle shape causes the spine to have a forward curvature.
When a child has congenital kyphosis, there are generally additional birth defects in other areas of the body. Most commonly, there are defects of the kidneys and urinary system.
Treatment for congenital kyphosis is typically surgery. Early surgical intervention usually produces the best results and can prevent progression of the curve. The type of surgical procedure will depend on the nature of the abnormality. Conservative (non-surgical) treatment plans do not have much success at correcting this type of kyphosis. Without surgery, there is a critical need for observation and close medical follow-up to prevent serious problems.
The third cause of cervical kyphosis is traumatic, meaning it is the result of an injury to the cervical spine. This may be from a compression fracture of the vertebrae or from an injury to the ligaments in the back of the cervical spine. When a compression fracture of the vertebra occurs, the vertebral body may heal in a wedge shape. This causes a similar situation discussed above for the triangle-shaped vertebrae of a congenital kyphosis. The resulting imbalance can lead to increasing forward curvature of the neck. If the kyphosis becomes bad enough, it can narrow the spinal canal causing a condition known as spinal stenosis. Pressure on the spinal cord due to the narrowing can lead to neurological problems, such as pain, numbness, and a loss in muscle strength.
The fourth, and the most common cause of cervical kyphosis, is iatrogenic. Iatrogenic means the problem results from the effects of a medical treatment, such as surgery. Kyphosis following laminectomy surgery is quite common. It happens much more frequently with children than with adults.
A laminectomy is a type of surgical procedure that is done in the spine to relieve pressure on the spinal nerves. Laminectomy means "remove the lamina", which is exactly what is done. The lamina is the back side of the spinal canal and forms the roof over the spinal cord. By removing the lamina, there is more room for the nerves and bone spurs can be removed from around the nerves. A laminectomy reduces the pressure on the spinal cord and the irritation and inflammation of the spinal nerves.
However, in the cervical spine, removing the lamina completely can cause problems with the stability of the facet joints between each vertebra. If the joints are damaged during the laminectomy, the spine may begin to tilt forward. This is what is responsible for causing an "iatrogenic" problem such as kyphosis.
An iatrogenic cervical kyphosis can also occur after a failed attempt at a cervical spine fusion. Problems can arise if the fusion is too short, meaning there are not vertebrae included in the fusion. In this case, the spine will begin to "bend" over the top of the fusion site. As the imbalance continues, a cervical kyphosis will result.
Problems can also arise if the fusion fails to heal properly. Failure of a fusion site to heal is called a pseudoarthrosis. If the fusion fails to heal, the spine may begin to curve forward leading to a kyphosis. Even in a healed fusion, improper alignment of the fused vertebrae can result in an imbalance that leads to a kyphosis.
Other less common causes of cervical kyphosis include infection in the spine, tumors of the spine, and systemic diseases that affect the spine (such as ankylosing spondylitis). A cervical kyphosis may also occur years after radiation therapy for cancer involving the neck. The radiation therapy may affect the growth of the cervical vertebrae in children who received radiation therapy in childhood.
Symptoms
The symptoms of cervical kyphosis can range from a simple nuisance to a severe deformity, which can lead to paralysis if untreated. Symptoms can include mechanical neck pain if the kyphosis is due to degenerative changes in the cervical spine. You may have a reduced range of motion in the neck. This means you may not be able to rotate your neck fully and you may have difficulty looking up for any length of time.
If the kyphosis is severe, you may begin to have problems with the nerve roots or the spinal cord, due to pressure on the nerves in the cervical spine. This may cause: weakness in the arms or legs, loss of grip strength, or difficulty walking due to spasticity in the legs. You may have problems controlling your bladder or bowels. In extremely severe cases that are left untreated, paralysis from the neck down may even result.
Diagnosis
Finding the cause of your neck problem begins with a complete history and physical examination. After the history and physical exam, your doctor will have a good idea of the cause of your pain. To make sure of the exact cause of your neck pain, your doctor can use several diagnostic tests. These tests are used to find the cause of your pain, not make it better. Regular X-rays, taken in the doctor's office, are usually a first step in looking into any neck problem and will help determine if more tests will be needed.
Complete History
A "complete history" usually consists of two parts. The first part is written; a form that you fill out while you wait to see the doctor. While you fill out the form, take time to think about everything you can remember that relates to your neck pain and write it down. The more you can tell your doctor, the faster he or she can diagnose the cause and help relieve your pain. The second part of your history will be answering questions. Your doctor will ask you to describe when your neck pain began and the type of pain you are having.
Examples of questions that may be asked include:
- When did the pain first begin?
- Do you have weakness in your arms or legs?
- Have you had an injury, or surgery, to your neck at any time?
- Does the pain go down into your arms or legs?
- Have you had problems walking?
- Have you had any problems with your bowels or bladder?
Physical Examination
Once most of the information is gathered, your doctor will give you a thorough physical exam. During the exam, your doctor will look at your neck to find out how well your neck is functioning.
This includes:
- How well you can bend your neck and roll your head in all directions
- How well you can twist your neck
- If there is tenderness around the neck
- If there are muscle spasms around the neck and shoulders
Tests that examine the nerves that leave the spine are also important. These include:
- Testing for numbness in the arms and hands
- Testing the reflexes
- Testing the strength of the muscles in the arms, hands, and legs
- Testing for signs of nerve irritation
With a kyphotic deformity, the spinal cord takes on a frontal position, causing it to be stretched over the peak of the kyphotic curve/deformity. This enormous pressure to the spinal cord can lead to myelopathy - a diseased spinal cord, and quadriplegia - paralysis of all four limbs. The spinal cord is the body's connection to the brain, and when it is damaged or compressed, the body loses some of its ability to function properly. If the pressure needs to be alleviated through decompression surgery, it will to be done through the front of the body so that the spinal cord is not further injured.
X-rays
X-rays show the bones of the cervical spine. Most of the soft tissue structures of the spine, such as the nerves, discs, and muscles, do not show up on X-ray. X-rays can show problems that affect the bones, such as infection, fractures, or tumors of the bones. X-rays may also give some idea of how much degeneration has occurred in the spine. The X-rays will be useful in showing how much degeneration and arthritis are affecting the neck and give your doctor an idea whether cervical spinal stenosis exists.
Magnetic Resonance Imaging (MRI)
The MRI is the most commonly used test to evaluate the spine because it can show abnormal areas of the soft tissues around the spine. The MRI is better than X-ray because in addition to the bones, it can also show pictures of the nerves and discs. The MRI is done to find tumors, herniated discs, or other soft-tissue disorders. The MRI is painless and lasts about 90 minutes. During the MRI, very detailed computer images of sections of the spine are taken. Unlike most other tests, which use X-rays, the MRI uses magnetic fields and radio waves to see the structures of the neck. Pictures can also be taken in a cross-section view. The MRI allows the doctor to clearly see the nerves and discs without using special dyes or needles. In many cases, the MRI scan is the only special test that needs to be done to find what is causing your neck pain.
The MRI scanner is a very large machine with a tunnel-like area in the center. While you lie on a table, the table slides into the tunnel of the scanner. Once in position, you will be asked to remain very still for the rest of the test. During the test, you will hear the clicking and thumping noises as the scanner moves. While the scanner is taking pictures, the technician can see the pictures on a monitor and record them.
Treatment
Conservative Treatment (Non-surgical)
Treatment for cervical kyphosis is very much dependent on whether there is pressure on the spinal cord. If there is, then surgery may be suggested immediately. If the cervical kyphosis is primarily causing pain and concern about your appearance, then your doctor may consider trying to control your pain and deformity with: a physical therapy program, mild pain medications, and a neck brace.
To learn more about the pain medications used to treat back and neck problems you may wish to refer to the document, entitled:
Surgical Treatment
Excessive kyphosis can be treated, and the methods of treatment have evolved over time. Today, surgery to treat cervical kyphosis is usually a spinal fusion combined with "segmental instrumentation". This means that some type of metal plate or rod is used to hold the spine in the proper alignment in order to straighten it.
If the deformity is fixed (meaning that it is not getting worse), and there are no neurological problems due to pressure on the spinal cord, surgery is usually not recommended because the problem is not going to get worse. Spinal surgery is serious, and unless necessary, it is rarely recommended. However, if the fixed deformity is accompanied by neurological problems from pressure on the spinal cord, surgery becomes more likely. Surgical correction is the most difficult type of treatment for cervical kyphosis. Surgery may require an operation from the front of the spine to relieve the pressure on the spinal cord, and an operation from the back to fuse the spine and prevent the kyphosis from returning.
If the kyphosis is flexible, the decision to go ahead with surgery should be based upon: the progression of the deformity, the severity of the deformity, and the amount of pain it causes. If the curve and pain are minor, surgery will not be recommended simply because the deformity looks bad. However, if the deformity is severe and the pain is chronic, surgery may be a good option.
If the kyphosis is due to ankylosing spondylitis, the problem area of the spine usually extends over the area where the cervical and thoracic spines join each other. This type of cervical kyphosis is usually a fixed deformity. Ankylosing spondylitis (AS) causes the discs between each vertebra of the entire spine to calcify and actually creates a fusion of the entire spine. If there is a cervical kyphosis after the spine fuses due to AS, the surgery may have to include performing an "osteotomy" of the fused spine. The term osteotomy means "bone (osteo) cut (otomy)". During an osteotomy, the front of the spine column may need to be cut to allow the surgeon to straighten the spine. The spinal cord is not cut, only the bone of the vertebrae in the front of the spinal column.
For a complete description of the surgical procedures used to perform a fusion for conditions such as cervical kyphosis, you may wish to review the documents, entitled:
Rehabilitation
Physical Therapy
Whether you have surgery or not, your doctor may have a physical therapist create an exercise program developed just for you. The physical therapist will teach you ways to prevent further injury to your neck. Many problems in the cervical spine can be improved greatly with a good exercise program and some basic education on neck mechanics.
For a complete description of the rehabilitation of neck pain, you may wish to review the document, entitled:
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