Pathogenesis of osteochondrosis juvenilis Scheuermann

Bioarchaeological investigations of the princely grave at Helmsdorf attesting to the violent death of an Early Bronze Age leader

The Helmsdorf "princely" tomb, excavated at the beginning of the twentieth century, is one of the most important archaeological discoveries dating from the Early Bronze Age in central Germany. In addition to the burial inventory, which points to an elevated social position of the deceased, a number of highly fragmented skeletal remains were preserved. Forensic anthropological investigation identified three distinctive bone defects, the surfaces of which were macromorphologically and microscopically examined in greater detail. Micro-CT analyses were also carried out. The results of all examinations suggested that the defects represented three perimortem injuries. The wound morphology was indicative of the use of a bladed weapon. The combination of injuries and their locations supported the assumption of a targeted use of force to kill. A comparison of Early Bronze Age weapons and tools with the bone lesions led to the identification of a type of weapon possibly used in the attack.

High Levels of Circulating Type II Collagen Degradation Marker (CTx-II) Are Associated with Specific VDR Polymorphisms in Patients with Adult Vertebral Osteochondrosis

Both vitamin D and collagen have roles in osteocartilaginous homeostasis. We evaluated the association between the circulating 25-hydroxyvitamin D (25(OH)D) type I and II collagen degradation products (CTx-I, and CTx-II), and four vitamin D receptor gene (VDR) polymorphisms, in Italian males affected by low back pain (LBP) due to herniation/discopathy and/or vertebral osteochondrosis. FokI, BsmI, ApaI, and TaqI VDR-polymorphisms were detected through PCR-restriction fragment length polymorphism (RFLP), and circulating 25(OH)D, CTx-I and CTx-II were measured by immunoassays in 79 patients (of which 26 had osteochondrosis) and 79 age-, sex- and body mass index (BMI)-matched healthy controls. Among all 158 subjects, carriers of FF and Ff genotypes showed lower 25(OH)D than ff, which suggested a higher depletion of vitamin D in F allele carriers. Higher CTx-I concentrations were observed in TT versus Tt among controls, and Tt versus tt among LBP cases, which suggested a higher bone-cartilaginous catabolism in subjects bearing the T allele. Higher CTx-II concentrations were observed in patients with osteochondrosis bearing FF, bb, TT, or Aa genotypes in comparison with hernia/discopathy patients and healthy controls. Vertebral osteochondrosis shows peculiar genotypic and biochemical features related to vitamin D and the osteocartilaginous metabolism. Vitamin D has roles in the pathophysiology of osteochondrosis.

The prevalence of abnormal preoperative neurological examination in Scheuermann kyphosis: correlation with X-ray, magnetic resonance imaging, and surgical outcome

STUDY DESIGN

Retrospective.

OBJECTIVE

The purpose of this study was to report the prevalence of abnormal neurological findings detected by physical examination in Scheuermann kyphosis and to correlate it to radiographs, magnetic resonance imaging (MRI) findings, and results of operative treatment.

SUMMARY OF BACKGROUND DATA

There have been sporadic reports about abnormal neurological findings in patients with Scheuermann kyphosis.

METHODS

Among 82 patients with Scheuermann kyphosis who underwent corrective surgery, 69 primary cases were selected. Patients' charts were reviewed retrospectively in terms of pre and postoperative neurological examinations. Sensory or motor change was defined as an abnormal neurological examination. Their duration, associated problems, and various parameters on preoperative radiographs and MRI examinations were also measured to search for any atypical findings associated with an abnormal neurological examination.

RESULTS

There were 6 cases (9%) (group AbN), with an abnormal neurological examination ranging from severe myelopathy to a subtle change (e.g., sensory paresthesias on trunk). Five patients recovered to a normal neurological examination after corrective surgery. The remaining 1 patient with severe myelopathy also showed marked improvement and was ambulatory unassisted by 2-year follow-up. In patients with a normal neurological examination (group N, n = 63), only 1 patient had neurological sequelae because of anterior spinal artery syndrome after combined anterior-posterior correction. No preoperative radiographical parameters were significantly different between groups. Average age was 21.3 (AbN) and 18.6 (N) years (P = 0.55). Average preoperative T5-12 kyphosis was 69.0° (AbN) and 72.5° (N) (P = 0.61). Forty-two magnetic resonance images were obtained and all showed typical findings of Scheuermann kyphosis. Five patients in the AbN group (1 patient underwent computed tomography/myelography) and 37 patients in the N group underwent an MRI.

CONCLUSION

The prevalence of abnormal neurological findings in Scheuermann kyphosis was 9%, emphasizing the importance of performing a detailed preoperative neurological examination. If congenital stenosis or a herniated thoracic disc is present, myelopathy can occur. No radiographical findings correlated with the abnormal preoperative neurological examinations. A normal MRI can exist in the face of an abnormal neurological examination, and conversely, a normal neurological examination can be seen with an abnormal MRI. Surgery was successful in alleviating abnormal neurological issues.

LEVEL OF EVIDENCE

4.

7th SOSORT consensus paper: conservative treatment of idiopathic & Scheuermann's kyphosis

: Thoracic hyperkyphosis is a frequent problem and can impact greatly on patient's quality of life during adolescence. This condition can be idiopathic or secondary to Scheuermann disease, a disease disturbing vertebral growth. To date, there is no sound scientific data available on the management of this condition. Some studies discuss the effects of bracing, however no guidelines, protocols or indication's of treatment for this condition were found. The aim of this paper was to develop and verify the consensus on managing thoracic hyperkyphosis patients treated with braces and/or physiotherapy.

METHODS

The Delphi process was utilised in four steps gradually modified according to the results of a set of recommendations: we involved the SOSORT Board twice, then all SOSORT members twice, with a Pre-Meeting Questionnaire (PMQ), and during a Consensus Session at the SOSORT Lyon Meeting with a Meeting Questionnaire (MQ).

RESULTS

There was an unanimous agreement on the general efficacy of bracing and physiotherapy for this condition. Most experts suggested the use of 4-5 point bracing systems, however there was some controversy with regards to physiotherapeutic aims and modalities.

CONCLUSION

The SOSORT panel of experts suggest the use of rigid braces and physiotherapy to correct thoracic hyperkyphosis during adolescence. The evaluation of specific braces and physiotherapy techniques has been recommended.

MULTIPLE SEGMENTAL OSTEOTOMIES TO THE KYPHOSIS CORRECTION

OBJECTIVE

To evaluate the results of the surgical treatment of the spinal Kyphosis using the Ponte's technique (multiple posterior osteotomies).

METHODS

Ten patients (8 with Scheuermann's kyphosis and 2 with kyphosis after laminectomy) submitted to surgical correction of kyphotic deformity greater than 70° were retrospectively assessed. The age at the surgical time ranged from 12 to 20 years old (mean age16.8 years ± 2.89). The radiographic parameters evaluated were the kyphosis, the lordosis and the scoliosis - whenever present. The presence of proximal and distal junctional kyphosis, loss of correction, and complications as implants loosening and breakage were also assessed. The radiographic parameters were evaluated at the preoperative, early postoperative and late postoperative time.

RESULTS

The patients were followed through a period that ranged from 24 to 144 months (65.8 ±39.92). The mean value of the kyphosis was 78.8° ± 7.59° (Cobb) before surgery and 47.5° ± 12.54° at late follow up, with mean correction of 33.9° ± 9.53° and lost correction of 2.2°.

CONCLUSION

The surgical treatment of the thoracic kyphosis using multiples posterior osteotomies presented a good correction of the deformity and minimal lost of correction during follow up.

Extracellular matrix changes in early osteochondrotic defects in foals: a key role for collagen?

Osteochondrosis (OC) is the most important developmental orthopaedic disease in the horse. Despite some decades of research, much of the pathogenesis of the disorder remains obscure. Increasing knowledge of articular cartilage development in juvenile animals led to the presumption that the role of collagen in OC might be more important than previously thought. To study collagen characteristics of both cartilage and subchondral bone in young (5 and 11 months of age) horses, samples were taken of subchondral bone and articular cartilage from a group of 43 Dutch Warmblood foals and yearlings that suffered from varying degrees of OC. Based on a histological classification, lesions were graded as early, middle and end stage. Collagen content and some posttranslational modifications (lysyl hydroxylation, hydroxylysylpyridinoline (HP) and lysylpyridinoline (LP) cross-links) were determined, as was proteoglycan content. Data were compensated for site effects and analysed for differences due to the stage of the lesion. In early lesions total collagen was significantly decreased in both cartilage and subchondral bone of 5- and 11-month-old foals. Also in cartilage, HP cross-linking was reduced in the early lesions of 5- and 11-month-old foals, while LP cross-linking was decreased in subchondral bone of the end-stage lesions of both 5- and 11-month-old foals. Hydroxylysine content was unaffected. Collagen content remained reduced in cartilage from middle- and end-stage lesions, but returned to normal in subchondral bone. In cartilage there was a decrease in proteoglycan content in the end-stage lesions of both age groups. Thus, alterations of the collagen component, but not of the proteoglycan component, of the extracellular matrix might play a role in early OC. More severe lesions show a more general picture of an unspecific repair reaction. Biomarkers of collagen metabolism can be expected to be good candidates for early detection of OC.

Premature vertebral endplate ossification and mild disc degeneration in mice after inactivation of one allele belonging to the Col2a1 gene for Type II collagen

STUDY DESIGN

Skeletal tissues of mice with an inactivated allele of the Col2a1 gene for Type II collagen ("heterozygous knockout") were studied.

OBJECTIVE

To determine whether a heterozygous inactivation of the Col2a1 gene has a role in the etiology of spine disorders such as disc degeneration.

SUMMARY OF BACKGROUND DATA

Mutations in the COL2A1, COL11A1, COL11A2, and COL9A2 genes have been linked to spine disorders. However, the mechanism by which genetic factors lead to disc degeneration still are largely unknown.

METHODS

Spine tissues were studied using radiograph analyses; conventional, quantitative, and polarized light microscopy; immunohistochemistry for the major extracellular components, and in situ hybridization for procollagens alpha1(I) and alpha1(II). Voluntary running activity also was monitored in half of the mice.

RESULTS

As the findings showed, 1-month-old heterozygous knockout mice had shorter limb bones, skulls, and spines, as well as thicker and more irregular vertebral endplates, which calcified earlier than in the control mice. They also had a lower concentration of glycosaminoglycans in the anulus fibrosus, in the endplates, and in the vertebral bone than the controls. These features in the heterozygous knockout mice were compensated by the age of 15 months. However, the long bones and skulls of the mature heterozygous mice remained shorter than those of the controls. Gene-deficient mice used the running wheel less. However, physical exercise did not induce any marked structural changes in the skeleton.

CONCLUSION

Mice with heterozygous knockout of Col2a1 show subtle early skeletal manifestations that bear some resemblance to those of human spine disorders.

Mice with a targeted deletion of the tetranectin gene exhibit a spinal deformity

Tetranectin is a plasminogen-binding, homotrimeric protein belonging to the C-type lectin family of proteins. Tetranectin has been suggested to play a role in tissue remodeling, due to its ability to stimulate plasminogen activation and its expression in developing tissues such as developing bone and muscle. To test the functional role of tetranectin directly, we have generated mice with a targeted disruption of the gene. We report that the tetranectin-deficient mice exhibit kyphosis, a type of spinal deformity characterized by an increased curvature of the thoracic spine. The kyphotic angles were measured on radiographs. In 6-month-old normal mice (n = 27), the thoracic angle was 73 degrees +/- 2 degrees, while in tetranectin-deficient 6-month-old mice (n = 35), it was 93 degrees +/- 2 degrees (P < 0.0001). In approximately one-third of the mutant mice, X-ray analysis revealed structural changes in the morphology of the vertebrae. Histological analysis of the spines of these mice revealed an apparently asymmetric development of the growth plate and of the intervertebral disks of the vertebrae. In the most advanced cases, the growth plates appeared disorganized and irregular, with the disk material protruding through the growth plate. Tetranectin-null mice had a normal peak bone mass density and were not more susceptible to ovariectomy-induced osteoporosis than were their littermates as determined by dual-emission X-ray absorptiometry scanning. These results demonstrate that tetranectin plays a role in tissue growth and remodeling. The tetranectin-deficient mouse is the first mouse model that resembles common human kyphotic disorders, which affect up to 8% of the population.

Osteoporosis: A possible aetiological factor in the development of Scheuermann's disease

The aim of this study was to test the hypothesis that spinal osteoporosis is an aetiological factor in the development of Scheuermann's disease in adolescents. Clinical and radiological data was collected on 12 individuals with Scheuermann's disease (SD). Lumbar spine bone mineral density (L2-4) was measured using dual energy X-ray absorptiometry. Age and sex-matched adolescents were used as controls. The number of standard deviations from the mean of age and sex-matched controls were calculated. In regards to results, SD patients demonstrated high bone densities of between 1 and 1.5 standard deviations above the mean of age-matched controls. These results suggest that osteoporosis is not an aetiological factor in Scheuermann's disease and that bone density measurements may indeed be higher than aged-matched controls in the general population.

Scheuermann's disease

Scheuermann's disease is the most common cause of structural kyphosis in adolescence. The mode of inheritance is likely autosomal dominant and the etiology remains largely unknown. Indications for treatment remain controversial because the true natural history of the disease has not been clearly defined. Brace treatment appears to be very effective if the diagnosis is made early. Surgical treatment is rarely indicated for severe kyphosis (> 75 degrees ) with curve progression, refractory pain, or neurologic deficit.

Commented glossary for rheumatic spinal diseases, based on pathology

OBJECTIVES

To redefine and comment on terms on a pathological basis, in order to avoid the confusion due to the use of terms with different meanings, to standardise usage among clinicians, radiologists and pathologists, and to facilitate literature searches.

METHODS

Within the Committee of Pathology of the European League against Rheumatism, a study group was set up to analyse the medical literature and common practice concerning the nomenclature of rheumatic spinal diseases. The group tried to amalgamate the main trends in the field, to reconcile etymology, historical background, morphology, and common practice.

RESULTS

The group warns against use of the terms 'acquired hyperostosis syndrome', '(von) Bechterew's disease', 'Kümmel's disease', 'pseudospondylolisthesis', 'rheumatoid spondylitis', 'spondylarthropathy' in the sense of spondarthritis, and 'spondylosis'. It recommends intercorporal or interapophyseal rather than intervertebral (osteo) chondrosis, zygapophyseal diverticulum rather than cyst, disc hernia rather than prolapse, spondyloarthritis rather than spondyloarthropathy, marginal rather than anterior spondylitis, and discarthrosis. It proposes 'zygarthrosis' to designate zygapophyseal osteoarthrosis.

CONCLUSIONS

Knowledge of the pathological basis of diseases and an understanding of the original definitions given by those who coined new terms make it possible to avoid most of the confusion arising from improper use of spinal terms.

Scintigraphy of spinal disorders in adolescents

Bone scintigraphy in adolescents is useful in helping to differentiate between developmental (atypical lumbar Scheuermann disease), infectious (discitis, osteomyelitis), neoplastic (osteoid osteoma, osteoblastoma), and traumatic (occult fractures, spondylolysis, pseudoarthrosis) disease of the spine. Double-phase (blood pool, delayed images) scintigraphy can characterize the pattern (i.e., linear in fracture, ovoid in nidus of osteoid osteoma). Single-photon emission computed tomography (SPECT) can be helpful in detecting the subtle presence of stress reaction (spondylolyses) not noted on routine planar scintigraphy and radiography. Bone scintigraphy is most beneficial when correlated with other imaging modalities in refining the diagnosis of spinal diseases.

The natural history and long-term follow-up of Scheuermann kyphosis

Sixty-seven patients who had a diagnosis of Scheuermann kyphosis and a mean angle of kyphosis of 71 degrees were evaluated after an average follow-up of thirty-two years (range, ten to forty-eight years) after the diagnosis. All sixty-seven patients completed a questionnaire; fifty-four had a physical examination and radiographs; fifty-two, pulmonary function testing; and forty-five, strength-testing of the trunk muscles. The results were compared with those in a control group of thirty-four subjects who were matched for age and sex. The patients who had Scheuermann kyphosis had more intense back pain, jobs that tended to have lower requirements for activity, less range of motion of extension of the trunk and less-strong extension of the trunk, and different localization of the pain. No significant differences between the patients and the control subjects were demonstrated for level of education, number of days absent from work because of low-back pain, extent that the pain interfered with activities of daily living, presence of numbness in the lower extremities, self-consciousness, self-esteem, social limitations, use of medication for back pain, or level of recreational activities. Also, the patients reported little preoccupation with their physical appearance. Normal or above-normal averages for pulmonary function were found in patients in whom the kyphosis was less than 100 degrees. Patients in whom the kyphosis was more than 100 degrees and the apex of the curve was in the first to eighth thoracic segments had restrictive lung disease. Five patients had an unexplained, mildly abnormal neurological examination. Mild scoliosis was common; spondylolisthesis was not observed.

Pathogenesis of square bodies in ankylosing spondylitis

The pathogenesis of squaring of the vertebral bodies is analysed in a 25 year old patient with ankylosing spondylitis. The squaring derives from a straightening of the anterior contour. The disease was diagnosed five years before the patient's death. The remodelling of bone that explains squaring of the vertebral bodies is described for the first time. Histologically, an acute and chronic spondylitis with destruction and simultaneous rebuilding of the cortex and the spongiosa of the vertebral bodies has been found. The development of square vertebral bodies is shown to be based on a combination of a destructive osteitis and repair.

Scheuermann's Disease: A Review

Scheuermann's disease (or more correctly, spinal osteochondrosis) is not confined to the thoracic spine: all parts of the spine may be affected. Major signs are endplate irregularity, more than 5° vertebral wedging, and sagittal overgrowth. Minor signs are Schmorl's nodes, anterior flattening of the vertebral endplate, and anterior detachment of a ring apophysis. Symptoms are of little diagnostic value. Scheuermann's affects 20 per cent to 30 percent of the population; males and females equally. A hereditary predisposition is a major factor in the aetiology of Scheuermann's disease. There is evidence that this condition follows an autosomal dominant pattern of inheritance. Treatment consists of either exercises; bracing and exercises; or in very severe cases, surgery.