Posterior Spinal Fusion for Kyphosis

In Scheuermann's kyphosis the vertebrae at the front of the upper spine grow into a wedge shape, tipping the spine forward into a fixed, exaggerated round back. Most people with kyphosis do not need surgery, and are managed with observation, physiotherapy and sometimes bracing during growth. An operation is generally considered only when the curve is large, when it is rigid and unlikely to improve, when it causes significant or progressive pain, or when its appearance and its effect on daily life are severe. The rationale for surgery is to reduce the excessive curve towards a more normal profile, to relieve the mechanical back pain that a stiff, over-rounded spine can cause, and to prevent further progression, producing a balanced, stable spine. Because the deformity is structural, it is corrected by reshaping and fixing the bony spine rather than by exercise or bracing at this stage.

This is what is generally done, although techniques vary between surgeons and centres. The operation is performed through the back. The spine is exposed across the kyphotic segment, and pedicle screws are placed into the vertebrae on both sides, providing strong, three-column anchor points. To make a stiff spine flexible enough to straighten, the surgeon performs a series of posterior osteotomies at the apex of the curve — these are called Ponte or Smith-Petersen osteotomies, and involve removing wedges of bone and the small posterior joints so the spine can hinge and shorten at the back. Two contoured rods are then attached to the screws and used to reduce the curve towards a normal profile, and bone graft is laid so the instrumented segments fuse into one solid, well-aligned column over the following months. Choosing the top and bottom levels of the fusion is a critical part of the plan, aimed at leaving the spine balanced and reducing the chance of a new bend developing just above or below the fused area. The nerves are monitored throughout.

Modern posterior-only correction, using segmental pedicle screws and apical osteotomies, reliably achieves a large correction of the kyphosis — commonly around 50 to 60 percent — that is well maintained over time, with good patient-reported quality-of-life scores. Compared with the older combined front-and-back operation, the posterior-only approach generally involves less operating time, less blood loss and a shorter hospital stay, with comparable or better correction, which is why it has become the standard for most flexible-to-moderate structural kyphoses. The evidence also identifies the two most important instrumentation-related complications: proximal junctional kyphosis, a bend developing just above the top of the fusion, and distal junctional kyphosis, a bend just below the bottom. Studies show these can be reduced by careful choice of the top and bottom levels — for example, starting the construct high enough and extending the lower end far enough down — which is why level selection is emphasised so strongly in the literature.

Recovery is a staged process, and the team supports patients throughout. After the operation there is a hospital stay of typically several days, with active pain relief and help to get up and walk, usually within a day or two. Many people are struck by how much taller and straighter they stand once the curve is corrected. Strenuous activity, heavy lifting, and contact sport are limited for a period of months while the fusion becomes solid, and a graded return to normal life — school or work, then gradually more activity — is guided by the team. Full fusion takes several months, and the spine is then followed up to confirm the correction holds and that no junctional bend has developed. It is normal for the back to feel stiff across the fused segment, since those levels are now joined, while the rest of the spine continues to move.

This is major spinal surgery, and it carries risks that the team discusses fully beforehand — including bleeding, infection, and, because the work is near the spinal cord, a small risk of nerve injury, which is why the nerves are monitored during the operation. The complications most particular to kyphosis correction are the junctional problems described above — a new bend developing just above or below the fusion — which can occasionally require further surgery, and implant-related issues. The decision to operate weighs the benefits for shape, pain and progression against these risks for each individual. This page is educational and does not recommend or advise for or against surgery in any individual case.

• —Lonner BS et al. Comparison of Scheuermann kyphosis correction by posterior-only thoracic pedicle screw fixation versus combined anterior/posterior fusion. (PMID 16985459)
• —Posterior-only approach with pedicle screws for the correction of Scheuermann's kyphosis. (PMID 28874968 / PMC5573844)
• —All pedicle screw instrumentation for Scheuermann's kyphosis correction: is it worth it? (PMID 18640879)
• —Geck MJ et al. The Ponte procedure: posterior-only treatment of Scheuermann's kyphosis using segmental posterior shortening and pedicle screw instrumentation. (PMID 18046172)
• —Multiple segmental osteotomies for kyphosis correction. (PMID 27077062 / PMC4816822)
• —Scheuermann's kyphosis: posterior approach with Smith-Petersen osteotomy versus combined anterior-posterior fusion. (PMID 27047831 / PMC4799343)
• —Health-related quality of life in adolescent Scheuermann's kyphosis treated with posterior spinal fusion vs matched controls. (PMC9382711)
• —Risk of distal junctional kyphosis is decreased by selecting the LIV two vertebrae distal to the first lordotic disc. (PMID 35840788)
• —Selection of distal fusion level in Scheuermann kyphosis: is fusion to the sagittal stable vertebra necessary? (PMID 26195078)
• —Distal fusion level selection in Scheuermann's kyphosis: lordotic disc segment versus sagittal stable vertebra. (PMID 28660108 / PMC5476354)
• —Severe rigid Scheuermann kyphosis in adults: correction with a posterior-only approach. (PMID 29150740)
• —Long-term outcome after surgical treatment of Scheuermann's kyphosis. (PMID 34533775)
• —Complications of spinal fusion for Scheuermann kyphosis: report of the SRS Morbidity and Mortality Committee. (PMID 20042960)
• —Surgical strategies and challenges in Scheuermann's kyphosis: a comprehensive review. (PMC12194637)
• —Treatment approaches for Scheuermann kyphosis: a systematic review of historic and current management. (PMID 31675699)