A 13-year-old boy is brought to the office by his mother who is concerned that he has "a round back." She says, "He will not sit up straight," and she is afraid that he will have permanent deformity. The boy has no back pain, lower extremity weakness, or difficulty with bowel and bladder control. He is physically active and plays soccer on the local team. He has had no significant trauma. The patient has no chronic health issues and takes no medications. Vital signs are normal. Physical examination shows an awake and alert adolescent with no dysmorphic features. Pubic hair and genitalia are sexual maturity rating score 3. He has a postural round back that is corrected by voluntary hyperextension. Forward bending indicates no lateral deformity and no angulation. Abdominal reflexes are symmetric. Achilles and patellar deep tendon reflexes are 2/4 with normal strength noted in both lower extremities. Gait is normal. Lateral x-rays of the spine reveal a convex alignment of the thoracic spine at 35 degrees (normal:

Question

A 13-year-old boy is brought to the office by his mother who is concerned that he has "a round back."  She says, "He will not sit up straight," and she is afraid that he will have permanent deformity.  The boy has no back pain, lower extremity weakness, or difficulty with bowel and bladder control.  He is physically active and plays soccer on the local team.  He has had no significant trauma.  The patient has no chronic health issues and takes no medications.  Vital signs are normal.  Physical examination shows an awake and alert adolescent with no dysmorphic features.  Pubic hair and genitalia are sexual maturity rating score 3.  He has a postural round back that is corrected by voluntary hyperextension.  Forward bending indicates no lateral deformity and no angulation.  Abdominal reflexes are symmetric.  Achilles and patellar deep tendon reflexes are 2/4 with normal strength noted in both lower extremities.  Gait is normal.  Lateral x-rays of the spine reveal a convex alignment of the thoracic spine at 35 degrees (normal: <20 degrees).  Which of the following is the most accurate statement regarding this patient's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1d2_a2e1_8f63_d1d446e0d25a_MD0005_00 Kyphosis is the forward curvature, or convexity, of the thoracic/thoracolumbar spine. Although the spine is mildly kyphotic by nature to absorb the impact from movement, excessive curvature creates a hump deformity of the upper back. A hump that is easily correctible by voluntary back extension or by lying supine is termed postural (flexible) kyphosis; in contrast, structural kyphosis does not self-correct. This patient has postural kyphosis due to slouching. This is the most common type of kyphosis and is seen frequently in adolescents. Patients are typically asymptomatic with no neurologic abnormalities (2/4 reflexes are normal). On lateral radiographs, the angle of spinal convexity is generally normal to slightly increased (20-40 degrees), as seen in this patient. The deformity is not permanent, and no treatment is required as proper posture is corrective. In contrast, structural kyphosis is a pathologic abnormality of the spinal column that often presents with progressive back pain and deformity. Although some cases are due to congenital or acquired vertebral anomalies (eg, wedging), it is imperative to exclude potentially dangerous secondary causes (eg, spinal infection, fracture, tumor, degeneration). After managing any secondary source, treatment of structural kyphosis generally involves special exercises to strengthen and straighten the back; using a back brace or having surgical correction is considered only for chronic pain or significant spinal convexity (>60 degrees) (Choices B and C). (Choice D) Idiopathic scoliosis is also common in adolescents; however, lateral angulation of a spine with scoliosis causes an asymmetric prominence on forward bending, which is not seen in this patient. Although scoliosis is at high risk of progression during pubertal growth spurts, postural kyphosis is reversible with slouching cessation. (Choice E) Spondylolisthesis, anterior slippage of a vertebral body, usually involves the lower lumbar vertebrae and classically causes pain with lumbar extension. Patients may develop a kyphotic posture to avoid hyperextension, but radiography would demonstrate vertebral subluxation. Educational objective: Postural kyphosis, or slouching, is a common finding in adolescents; it is easily correctable by voluntary back extension and requires no treatment. In contrast, structural kyphosis is due to underlying spinal pathology and does not self-correct. References: Round and angular kyphosis in paediatric patients. (http://www.ncbi.nlm.nih.gov/pubmed/23287399)

A 13-Year-Old Boy Is Brought to the Office by His