Dr. Miller: Kyphosis, or a bend in the spine. What is it? What can we do about it? We're going to talk about that next on Scope Radio.
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Dr. Miller: I'm Dr. Thomas Miller and I'm here with Dr. Nicholas Spina. He's an orthopedic surgeon here at the University of Utah in the department of orthopedics. Nick, tell us a little bit about kyphosis and what causes that. I understand there are a couple of causes.
Dr. Spina: Kyphosis basically refers to the curvature of your upper back, or your thoracic spine. The body's natural position is to keep its head centered over its hips. In our lumbar spine, we have a curve backward, and then our thoracic spine reflexively curves forward.
Dr. Miller: Sometimes that curve is too accentuated? Too great?
Dr. Spina: Too accentuated or too great.
Dr. Miller: And that's what we call kyphosis.
Dr. Spina: And that is what we call kyphosis. There is normal kyphosis and there’s also increased kyphosis or abnormal kyphosis.
Dr. Miller: And who gets that?
Dr. Spina: So everyone has a natural portion of kyphosis built into their thoracic spine and so some degree of kyphosis is normal.
Dr. Miller: And also protective, right? Because that little bit of curvature actually mechanically increases the strength of the spine, I think.
Dr. Spina: It does. It's naturally biomechanically favorable to have some degree of thoracic kyphosis through the mid-portion of your upper spine. Some patients, though, develop increased kyphosis. And there are a couple causes of that. One is what we think of sort of an inherited or congenital kyphosis. We call it Scheuermann's kyphosis, and that refers to a natural shape of the vertebral bodies where they're angulated or wedged in the front. So they're shorter in the front than they are in the back. And when you have a section of the spine with two or three of these segments in a row, that is considered abnormal kyphosis or what we call Scheuermanna's Kyphosis.
Dr. Miller: And you tend to be born with that or develop it over time?
Dr. Spina: You tend to develop it over time. It's commonly seen in young, teenage males. As males hit their growth spurt, they tend to notice an increased kyphosis, or increased hunchback, per se, through their upper spine.
Dr. Miller: So what is the other group that might have that? Older folks? Older patients?
Dr. Spina: So the second group of patients that typically develops kyphosis tends to be the older population. This is the population who develop osteoporotic compression fractures. It's also the population that sees significant disc degeneration. And so what we like to say is that life is a kyphosing event, and as we age, we all . . .
Dr. Miller: That doesn't sound good.
Dr. Spina: No, no. It doesn't sound good, but it's normal. And as we age, we all develop a degree of kyphosis. So the natural tendency is for us to lean more and more forward as we hit our upper decades.
Dr. Miller:And as we do that, when does it become a problem so that moving around becomes difficult or even one develops pain?
Dr. Spina: So people tolerate different degrees of kyphosis and it all depends on the patient specific. Some patients can tolerate a high degree of kyphosis and it's mainly due to the large muscles that sit next to your spine and try to keep us upright. And so the more kyphosis we have, the more forward our head is, relative to our pelvis, and the more energy we have to expend to stand upright and keep a horizontal gaze and be able to look at where we're going or who we're talking to. So as we get increasing kyphosis, our back muscles have to do more and more to keep ourselves upright and that's when it tends to become a problem and we see increasing pain associated with increasing kyphosis.
Dr. Miller: So can physical therapy assist in preventing forward kyphosis?
Dr. Spina: So physical therapy is a useful tool in treating acquired kyphosis.
Dr. Miller: So that would be in the first group that you talked about.
Dr. Spina: That would be in the first group. Either the young group or also the older patients that tend to go on to develop kyphosis. The back muscle's job is to keep us upright and looking forward. And the stronger those muscles are, the more we can compensate for increasing degrees of kyphosis. So our body's natural job is to compensate for our alignment, but the energy it takes to compensate is directly related to the degree of kyphosis that you have.
Dr. Miller: So, as an orthopedic surgeon, when do you decide to intervene in cases that are severe? Or do you?
Dr. Spina: So treating kyphosis is a very difficult subject and it's a very difficult task. We tend to intervene when everything else fails, as in a lot of other areas of orthopedics. We tend to start with physical therapy. We tend to start with trying to help people compensate for their natural alignment. When they cannot compensate any longer or their pain becomes debilitating, we consider intervening.
And the problem with interventions for kyphosis is they tend to be on the larger scale. We don't have a simple surgical tool or a simple intervention that can correct kyphosis. It often involves a multi-level thoracic fusion with some type of procedure where we cut the bone and realign it. And so it's a pretty large endeavor that we try to reserve as a last resort in treating patients with acquired kyphosis.
Dr. Miller: So what would you say to patients that are looking to prevent kyphosis from becoming worse?
Dr. Spina: So . . .
Dr. Miller: How do they do that?
Dr. Spina: Yeah.
Dr. Miller: Because I think a number of people that might be listening may not know when to seek assistance or seek advice.
Dr. Spina: So it's sort of a three-fold way to try to prevent kyphosis. In my mind, it all starts with activity and, as we age, to try to stay as active as possible. The second aspect would be trying to keep your core musculature and your paraspinal muscles as strong as possible. And so that would be through a course of increased physioactivity, core strengthening programs, a program that can be shown through physical therapy. And then, finally, it's to keep an eye on your bone quality. Osteoporosis is a significant risk factor and contributor to increasing acquired kyphosis, due to vertebral compression fractures.
Dr. Miller: So in that last category, having bone density studies done according to when you should have them done, if you're 65 and older or if you have risk factors, then that would help determine if you have a risk of vertebral fracture, thoracic fracture. And you could begin to intervene to prevent those fractures with certain medications.
In the second group that you mentioned, this is the physical therapy that you prescribe. Now, you have a set of physical therapists that work at the orthopedic center and I'm sure that other physical therapists in the valley, you prescribe certain therapies for your patients with the physical therapists.
Dr. Spina: We do. We work closely with the physical therapist based on the presenting symptoms. And often times with kyphosis, we focus on an extension strengthening program, so, an effort to strengthen the paraspinal muscles that run along the spine through a postural-based exercise program. We also, as patients, we also focus on flexion, because flexion is also involved in the core muscles of the abdomen, which all help stabilize the thoracic and lumbar spine.
Dr. Miller: In the first group, you mentioned the thing that I love is "use it or lose it." So what type of physical therapy would you . . . not physical therapy. What kind of exercises? Would you just recommend walking? Is that good enough?
Dr. Spina: So walking is great. Any exercise is better than no exercise. But, ideally, as we age, the lower impact exercises are great and exercises that incorporate a lot of muscle groups are great. So I try to encourage people to get into a pool when they can. If they are unable to swim, just walking laps in a pool also helps. The reason is it takes gravity out of the picture and so the stress on the joints is much lower, but you're still getting that resistance that strengthens the muscles. And it also works on your balance.
Dr. Miller: So the bottom line is if you're worried about kyphosis or the development of kyphosis, stay physically active. That might be your number one preventative treatment. The second thing is if you are developing kyphosis, you can see an orthopedic specialist or a sports medicine specialist who understands spine and then go to a physical therapist for focused treatment. And then the last piece would be to make sure that you don't have osteoporosis through appropriate screening.
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