Clinical History
A 19 year-old male patient referred to the hospital with back pain increasing with exercise. Pain was apparent for the last two years.
Imaging Findings
A 19 year-old male patient referred to the hospital with back pain increasing with exercise. Pain was apparent for the last two years. MRI of the lumbar spine was performed in two planes with a 1.5 T MR scanner with FSE T1,T2 and PD sequences. MR images showed a slightly decreased lumbar lordosis. Lower thoracic and lumbar vertebral bodies had increased diameter in the sagittal plane giving the appearance of a decreased height.Vertebral body end plates were irregular with formation of multiple Schmorl nodes. All disk spaces were narrowed.The signal intensities of the lumbar intervertebral disks were decreased on T2 weighted sequence. Also, the osseous spinal canal anteroposterior diameter was narrowed by constitution.
Discussion
Scheuermann's disease(=spinal osteochondrosis=vertebral epiphysitis) is a kyphotic deformity of the spine that develops in early adolescence with a peak incidence from 15 to 16 years. This condition has been reported to occur in 0.4% to 8% of the general population, with an equal distribution between sexes. The mid and lower thoracic spine is the region most commonly affected and usually several adjacent vertebrae are involved. Less frequently, the lesion may be found in the lumbar spine and in the upper thoracic spine.Lumbar Scheuermann's disease consists of a "classic" Scheuermann's and an "atypical" type characterized by vertebral end plate changes, disc space narrowing, and anterior Schmorl's nodes.This group tends to occur in more athletic adolescents or those with a history of increased axial stress to the spine like hard laborers. Sometimes changes are confined to a single vertebra. In osteochondrosis juvenilis Scheuermann, foci of various sizes in the cartilaginous end plates of the vertebral bodies display a loosening or complete interruption of the collagen fibers. These findings, together with an alteration and occasional absence of the growth zone, may result in the typical deformation of the vertebral bodies. Electron micrographs of the areas with optically absent collagen fibers reveal collagen fibrils. They are arranged in an irregular pattern. A disturbance of collagen or ground substance biosynthesis is of importance in the pathogenesis of juvenile osteochondrosis.
Radiographs are the standard imaging modality used to confirm the diagnosis of Scheuermann's disease. Classic signs include vertebral end plate irregularity and Schmorl nodes, disk space narrowing, and anterior wedging (>5°) of involved vertebral bodies. Residual wedging in late cases may be indistinguishable from a previous compression fracture. The ring apophysis may be displaced by diskal herniation never to unite. It is then seen as a triangular fragment of bone to the adjacent end plate. Other diagnostic tools such as computed tomography scans or magnetic resonance imaging (MRI) may also be of value in the evaluation of Scheuermann's disease. MRI is especially useful in evaluating the disks. The affected disk is narrowed and usually shows a loss of signal, indicating dehydration. The disk herniate through the end plates and beneath the non-fused ring apophysis.
For the adult who presents with pain, the early mainstays of treatment are physical therapy and anti-inflammatory medication. In order to avoid hyperkyphosis and chronic pain, back and abdominal musculature must be strengthened and mobility in the spine improved. Gymnastics, swimming and cycling on stationary bicycles may be recommended but sports associated with marked stress for the spine must be warned against. In patients, either adolescent or adult, with a progressive deformity, refractory pain, or neurologic deficit, surgical correction of the deformity may be indicated. Surgical correction should not exceed 50% of the initial deformity.
Differential Diagnosis List
