Kyphosis: When Physical Therapy Has Not Achieved Adequate Spinal Correction
For patients with thoracic kyphosis in whom a structured physical therapy programme has not met its correction goals, a defined surgical protocol addresses the next stage of management.
Previous Treatment — Goals Not Reached
The initial line of management includes a comprehensive physical therapy programme: thoracic extensor muscle strengthening, abdominal muscle strengthening, pectoralis muscle stretching, and hamstring stretching.
This line is considered insufficient when it fails to achieve improved thoracic spinal posture or relief of lower extremity contractures. Failure to meet these targets prompts escalation to the surgical protocol described here.
Surgical Approach — Partial Overview
The next-line protocol centres on a posterior spinal surgical approach that combines corrective osteotomies across the apex of the deformity with segmental instrumentation; the full protocol also covers an alternative combined approach and the technical details of each option.
Treatment Goals
- Correction of thoracic kyphosis by 40–50 degrees, or within 50% of preoperative kyphosis
- Restoration of sagittal and spinopelvic balance
- Alleviation of back pain
- Resolution of neurologic impairment
References
DOI: 10.1007/s12178-023-09861-z
- The development of thoracic segmental pedicle screw instrumentation, combined with wide adoption of multilevel corrective osteotomies, now allow surgeons to achieve comparable sagittal correction through a posterior-only approach.
- Multilevel posterior column osteotomies (Schwab type 2 or Ponte osteotomies) are used across the apex of the deformity.
- These osteotomies provide 5 to 10° of sagittal correction per level and improve overall spinal flexibility prior to correction.
- A corrective maneuver is generally sufficient with the cantilever technique.
- Most modern studies demonstrate that the posterior-only approach provides adequate correction with significantly less morbidity.
- A combined anterior-posterior (AP) approach was initially favored for the treatment of SK.
- A correction of 40 to 50°, or within 50% of preoperative kyphosis, is advisable to achieve adequate correction while avoiding junctional kyphosis.
- The goals of treatment are restoration and stabilization of mechanical alignment, alleviation of pain, resolution of neurologic impairment, and improvement of cosmesis.
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