February 24, 2021

Painful Curves: Dowager Hump Explained

Written by: Iris Tabangcora, M.D.
Reviewed by: Mubashar Rehman, PHD

Overview

When viewed from the side, the spine supporting the back and abdomen follows an S-shaped curve. This shape makes the distribution of weight even and has a significant contribution in balance and flexibility.

From the same perspective, there are three normal spine curves, namely: cervical (neck), thoracic (upper back), and lumbar (lower back and abdomen). Both cervical and lumbar curves assume a backward C-shaped curve also called lordotic curve. On the other hand, the thoracic curve assumes a regular C-shaped curve with its opening facing front which is also called kyphotic curve.

Due to multiple reasons, the angles of these curves can be exaggerated leading to pain, immobility, neurologic impairments, and cardiopulmonary complications.

The treatment varies from careful serial observation to surgery. Of the more common spinal curve abnormality is hyperkyphosis or Dowager hump, where there is excessive bowing of the kyphotic curve (more than 500) leading to a hunchback or slouching posture. Needless to say, Dowager hump is a characteristic of a variety of both age-related and pathologic conditions.

Epidemiology 

The incidences of Dowager hump in older adults range between 20-40% and vary in both sexes. However, at age 40, it becomes more common among women, primarily because of hormonal changes that come with the onset of menopause. In fact, Dowager hump in women has been linked to early mortality and poorer quality of life.

While common in the elderly, Dowager hump in adolescents and young adults can also occur and may be due to some congenital conditions like spina bifida and osteogenesis imperfecta.

Scheuermann disease or juvenile hyperkyphosis is usually diagnosed in adolescents aged 12 to 17, more common in males, and affects 1-8% of the population in the United States. Its cause is currently not known. 

Etiologies 

As mentioned above, Dowager hump is a characteristic of a variety of conditions. Dowager hump in older adults can be due to degenerative diseases of the spine like arthritis, osteoporosis-associated fractures, and trauma from falls. 

On the other hand, Dowager hump in young adults can be caused by Scheuermann disease or juvenile hyperkyphosis and postural hyperkyphosis. It is not known what causes juvenile hyperkyphosis. Meanwhile, postural hyperkyphosis is often seen in adolescents and can improve with exercise and physical therapy.

Dowager hump in children is rare especially in those younger than age 10 but it can be present in those with congenital conditions like spina bifida and osteogenesis imperfecta. In simpler words, congenital defects which render bone and its connective tissue fragile contribute to the development of Dowager hump in young adults as well as in children. 

Metabolic conditions which can affect the density of the bones can also cause Dowager hump in both young adults and the elderly. Lastly, people who have impairments in their vision and the vestibular system will have difficulties maintaining an upright posture.

Clinical Manifestations

Dowager hump’s symptoms can be insidious. Its main manifestation, the increased in anterior curvature of the thoracic spine, can often be first noticed by family members and friends. Some may also find it difficult to change position from sitting to standing without the extra effort of the arm. Another subtle Dowager hump symptom is the fear of possibly falling due to balance problems. As a result, there is reduced speed when walking and compensation of having a wider stance. 

In addition to this, the head is noticeably lowered forward than the rest of the body. There is also a difference in shoulder height and tightening of the hamstring muscles (muscles at the back of the thigh) as it compensates for the postural and balance problem. 

Pain is also a frequent Dowager hump symptom because of nerve impingement and erosion of bone surfaces against each other. On the more serious Dowager hump, symptoms are easy fatigability and trouble in breathing since the enclosed rib cage compromises the ability of the lungs to maximally inflate for optimum gas exchange. 

Diagnosis and Workup

Diagnosing Dowager hump entails a detailed history and physical exam. Dowager hump in young adults and adolescents may involve asking for information on developmental milestones since some delays in achieving these milestones may reflect neuromuscular problems. Family members with the same condition may be asked too in cases of underlying connective tissue disorders like Marfan and Ehlers-Danlos syndrome.

In addition to this, a standing full spine x-ray in lateral view is requested to view the bones, soft tissues, and internal organs. From this, the angle will be measured to rule in Dowager hump.

If the doctor thinks of systemic secondary causes like metabolic and neuromuscular problems, then additional blood tests will be requested accordingly. In this case, it is important to identify the cause while also managing the postural problem and its complications. 

Management

Dowager hump treatment involves both medical and surgical management. For non-pharmacologic interventions, a referral to a physical rehabilitation center may be made.

Strategies include correction of posture, breathing exercises, and pain management modalities like transcutaneous electrical nerve stimulation (TENS). Dowager hump management also involves pharmacologic pain management. Supplements for bone formation may also be given since most age-related Dowager hump patients have osteoporosis and compression fractures.

A cardiopulmonary workup may also be done in people who present with the difficulty of breathing, chest pain, and easy fatigability. 

On the other hand, surgical management involves decreasing the excessive curvature and reducing complications. For children and adolescents, the age and degree of growth are important considerations when planning for surgery. 

Prevention 

Depending on the underlying cause, a combination of appropriate Dowager hump exercises, medical grade back straighteners, and early health-seeking behaviors can slow down if not prevent the development of this postural problem. Dowager hump in adolescents may not be prevented but early surgical corrections will significantly improve their quality of life. 

Conclusion

Dowager hump can occur at any age but is more frequent among the elderly. Its presence in the younger population should warrant a thorough investigation for primary impairments in metabolic and neuromuscular systems. Dowager hump symptoms may present subtly until their later course increases the risk of complications.

Early surgical correction and identification of its cause can dramatically delay its progression and improve the quality of life. Appropriate exercise, supplements, and tools like back straighteners may improve comfort and treatment outcomes

References:

  1. https://www.cedars-sinai.org/health-library/diseases-and-conditions/c/curves-of-the-spine.html
  2. https://www.ncbi.nlm.nih.gov/books/NBK499966/https://www.hopkinsmedicine.org/health/conditions-and-diseases/kyphosis
  3. http://www.lb7.uscourts.gov/documents/12C10971.pdf
  4. https://www.srs.org/professionals/online-education-and-resources/conditions-and-treatments/kyphosis-in-the-adolescent-and-young-adult
  5. https://www.acpjournals.org/doi/10.7326/0003-4819-150-10-200905190-00005?articleid=744498
  6. https://www.physio-pedia.com/Age-related_Hyperkyphosis
Article written by Iris Tabangcora, M.D.
Iris is a Philippine-based physician currently training in Emergency Medicine. She has been writing for various health websites for the last 10 years. Also a Nursing degree holder, she has spent her energy in educating nursing students on Research and Pharmacology. Her interests lie in medical education, research, and public health.

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