Kyphosis

Kyphosis is the backward curve of the spine in the chest region — the one that makes the upper back look rounded. Everybody has it: it is what leaves room in the chest for the heart and lungs. It becomes a condition when the curve grows excessive. On an X-ray it is measured in degrees, and anything from roughly forty-five upwards is outside the normal range. Degrees on their own say little, though. What matters more is whether the back straightens, whether it hurts, at what age it rounded, and whether it is increasing over time.

What it looks like and what it feels like

The visible part is noticed first: the shoulders come forward, the head pushes ahead of the body, the upper back rounds, and in marked kyphosis a hump appears. In a teenager it is usually the parents who spot it; in an older person, the person themselves, on discovering that they have lost height and can no longer touch the wall with the back of the head while standing against it.

Many people feel nothing at all. When there are complaints, they are a dull ache and stiffness in the middle of the back that worsen towards evening and after long sitting, easy tiredness, and tenderness on pressing along the spine. Adults suffer more than children: holding the gaze level with a rounded back means constantly tensing the muscles of the neck and lower back, and part of the pain comes from that compensation rather than from the curve itself.

Marked kyphosis genuinely gets in the way: breath runs short on exertion because the chest cannot expand fully; swallowing is harder and fullness comes on quickly; lying flat on the back becomes uncomfortable. If someone cannot look straight ahead without tilting the head back, that alone is a reason to discuss surgery.

The test that separates posture from altered vertebrae

There is a simple way to get your bearings at home. Ask the person to lie face down on a firm surface and, better still, to bend forwards with straight legs while you look at the back from the side.

If the back straightens out when the person stands tall and when they lie down, and the curve looks smooth and even, this is postural kyphosis — a rounded back from habit rather than from any change in the bones. It is flexible, rarely hurts much, and responds well to muscle work.

If bending forwards reveals a sharp angle at chest level, like the roof of a house, and lying down does not flatten the back, the curve is structural: the shape of the vertebrae themselves has changed. In teenagers this is most often Scheuermann's disease, in older people the aftermath of vertebral fractures, and in children from birth congenital kyphosis. The distinction is not academic: a flexible kyphosis is treated with exercise, a rigid one cannot be straightened by exercise.

Where kyphosis comes from

• Habitual posture. Slumping at a desk and over a phone, soft chairs that are sat in half-lying, and a heavy bag on one shoulder stretch the ligaments and the muscles at the back. The bone does not change; what changes is the position the body has grown used to holding.
• Scheuermann's disease. In adolescence several neighbouring chest vertebrae grow unevenly and become wedge-shaped rather than rectangular, lower at the front than at the back. A stack of such wedges produces the rigid angle. The exact cause is unknown; there is a hereditary streak. The disease stops when growth stops, but the shape acquired stays for life.
• Congenital kyphosis. The vertebrae form wrongly before birth: they fail to separate from one another, or form only in part. It is the rarest variant and the most treacherous, because the deformity advances as the child grows and it more often than any other ends in surgery. It is frequently accompanied by kidney and heart malformations, so these children are investigated more widely.
• Osteoporosis and vertebral fractures. The leading cause of a rounded back in the second half of life: a weakened vertebra sinks under body weight, the front edge crumples, and the spine tips forwards. Even without fractures, age adds its share — the discs lose height and the extensor muscles weaken.
• Injury. A chest vertebra fractured and healed out of position leaves an angle for life.
• Other conditions. Paget's disease of bone, in which bone is rebuilt abnormally; spina bifida; neurofibromatosis; muscular dystrophies, in which the muscles no longer hold the back up; ankylosing spondylitis, which fuses the spine in a stooped position.
• Infection and tumour. Tuberculosis of the spine destroys vertebral bodies and produces a sharp angular hump; other spinal infections and tumours, primary or secondary, behave the same way. These are rare causes, but precisely the ones that must not be missed.

A back that rounds in adulthood

In a child or teenager kyphosis almost always comes down to posture or to how the vertebrae grew. In an adult the back does not round by itself, and here the number of degrees matters less than the answer to a different question: what produced them.

The commonest answer is a crush fracture of a vertebra on a background of osteoporosis. It can happen without any fall: lifting a bag, stumbling or sneezing hard is enough. Sometimes the fracture goes unnoticed and its only traces are a few centimetres of lost height and a rounder back. Losing height and stooping in an older person is therefore a reason to measure bone density rather than to put everything down to age.

Separately, here is what makes it necessary to look for infection or tumour: pain that wakes a person at night and does not depend on position, fever and night sweats, weight loss, cancer of any kind in the past, long-term treatment with drugs that suppress immunity, and a deformity that grows over weeks or months. With that picture, investigation should not be put off.

Signs that will not wait

A deformed spine can compress the spinal cord or the nerve roots. Seek help the same day, and if things are worsening fast call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine on the single European number 112), if any of these appear:

• weakness in the legs, a feeling that they will not hold you, a changed way of walking, loss of balance;
• numbness or tingling in the legs, in the perineum or around the buttocks;
• inability to pass urine or, conversely, incontinence of urine and stool;
• a band of pain running from the back around the chest like a hoop;
• sudden severe back pain after a fall or for no reason, particularly in an older person or someone taking glucocorticoids.

Delay is costly here: recovery of function depends directly on how quickly the compression is relieved.

How the diagnosis is made

The doctor examines the back standing, bending forwards and lying down, checks whether the curve corrects, and assesses movement along with power, sensation and reflexes in the legs. It is usually clear at that stage whether the deformity is flexible or rigid.

The key investigation is an X-ray of the spine taken standing, from the front and from the side. It gives the angle of the curve and shows wedged vertebrae, fused or incomplete bodies, and the marks of old fractures. A repeat film at six to twelve months shows whether the angle is growing or holding steady, and that is the decisive argument when choosing treatment.

An MRI scan is not needed by everyone: it is done when there are neurological symptoms, when infection or tumour is suspected, and before planned surgery, since it is the only scan that shows the spinal cord. A CT scan details the bone and helps the surgeon. An adult with newly appeared kyphosis also has blood tests and a bone density scan.

What actually helps

Most people with kyphosis need neither a brace nor an operation. Treatment is built around three aims: to take away the pain, to halt the growth of the angle, and to stop the back from weakening.

For postural kyphosis one thing works: regular exercise. The point is not to "hold yourself up straight" but to extend the upper back and strengthen the muscles that extend it — extension exercises, stretching of the chest muscles and hip flexors, and core work. Swimming, walking, Pilates and yoga all serve, but the result comes from doing it consistently over months rather than from the choice of activity. It helps if a physiotherapist sets the programme for the first few weeks: most of these exercises are done wrongly. Pain is managed with paracetamol and, when that is not enough, a short course of non-steroidal anti-inflammatory drugs, which are prescribed cautiously in older people and in anyone with kidney, stomach or heart disease.

A brace makes sense only in a teenager who is still growing and only in marked structural kyphosis: the rigid frame does not straighten the back but keeps the curve from worsening while the bones are still growing, so it is worn until skeletal growth is complete, judged on X-rays rather than by age. In an adult a brace will not change the shape of the spine. It is worth telling a teenager in advance that a brace bans neither PE nor sport and that the first awkward weeks pass. Embarrassment about the shape of the back, or about the brace itself, troubles people at that age more than pain does and leads them to avoid changing rooms and swimming pools and to withdraw. That should not be brushed aside, and if low mood drags on it is worth seeing a psychologist.

Surgery — joining the vertebrae with metal rods and screws together with a bone graft — is offered rarely. The reasons are a very large angle, a deformity that keeps increasing, pain that yields to nothing else, compression of nerve structures, or interference with breathing. The operation takes several hours, requires a general anaesthetic and a few days in hospital; people return to school or work at about six weeks and to sport nearer a year. The risks are substantial: infection, blood loss, displacement or breakage of the metalwork, further surgery and, rarely, nerve damage extending to loss of leg function and bladder and bowel control. That is exactly why it is weighed up rather than prescribed on a number of degrees alone.

Looking after your back

Structural kyphosis cannot be prevented — nobody chooses Scheuermann's disease or a congenital curve. The other two roads to a rounded back, though, are largely in our own hands.

The first is habitual posture. What helps a child is not being told to sit up straight but the surroundings: a desk and chair matched to their height, a screen at eye level, a break to move at least every half hour, a rucksack with two straps instead of a shoulder bag, and a school bag weighing no more than an eighth to a tenth of the child's own weight. For adults, the same plus regular work for the back muscles.

The second is bone strength, and it is worth attending to long before old age: enough protein, calcium and vitamin D, weight-bearing exercise, no smoking and moderation with alcohol. Anyone who has already broken a bone in a minor fall, whose parents fractured a hip, who has taken glucocorticoids long-term or who reached the menopause early should discuss bone testing with their doctor. Timings and referral criteria differ from country to country, but the principle is one: the sooner osteoporosis is found, the fewer fractures and the fewer degrees there will be later.

Online consultation

At an online appointment, from a photograph of the back in profile and bending forwards and from your account of it, the doctor can help tell a simply stooped posture from a structural kyphosis, explain which X-ray is needed and why it is taken standing, and go through a report you already have that gives the angle of the curve, since it is hard to know whether that figure is a lot or a little without an explanation. You will be advised which exercises are worth starting and what to use for pain given your other conditions, and assessed for any signs calling for a face-to-face examination in the next few days. An adult whose back has rounded recently and who has lost height will be told which tests confirm osteoporosis and what happens next.

This material is for information only and does not replace medical advice.