Raiyyan Tahsan

Raiyyan Tahsan
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TC(985).(05).Orthopedics Case No 63.Kyphosis

Kyphosis — বাংলা Clinical Note

Safety note: নিচের drug list clinical education-এর জন্য। Kyphosis patient-এ self-medication নয়—especially NSAID, osteoporosis drug, anti-TB, biologic drug অবশ্যই physician/orthopedic/rheumatology specialist supervision-এ দিতে হবে।

1) Definition — Kyphosis কী?

Kyphosis হলো spine-এর sagittal plane-এ excessive forward curvature, সাধারণত thoracic spine-এ; clinically upper back rounded/hunched দেখা যায়। Normal thoracic kyphosis প্রায় 20°–45°; সাধারণভাবে >50° curve abnormal/hyperkyphosis হিসেবে ধরা হয়।

Core meaning

পিঠ অতিরিক্ত সামনে বেঁকে গিয়ে upper back গোল/কুঁজো হয়ে যাওয়া = Kyphosis.

2) Causes — কারণগুলো

A. Postural kyphosis

  • সবচেয়ে common, বিশেষ করে adolescent age-এ।
  • Poor posture, দীর্ঘসময় ঝুঁকে বসা, mobile/computer posture, weak back/core muscle।
  • Flexible—সোজা হয়ে দাঁড়ালে অনেকটা ঠিক হয়।

B. Scheuermann’s kyphosis

  • Structural kyphosis; adolescent boys-এ বেশি দেখা যায়।
  • X-ray-এ সাধারণত ৩ বা তার বেশি consecutive vertebra wedge-shaped হয়।
  • Curve stiff/rigid—সোজা হয়ে দাঁড়ালেও পুরো ঠিক হয় না।

C. Congenital kyphosis

  • জন্মগত vertebral formation/segmentation defect।
  • শিশুর বয়স বাড়ার সাথে curve worsen করতে পারে।
  • অনেক case-এ early surgery দরকার হতে পারে।

D. Osteoporotic compression fracture

  • বয়স্ক, postmenopausal female, chronic steroid use, vitamin D deficiency।
  • Vertebral compression fracture হলে spine সামনে ঝুঁকে যায়।

E. Infection / TB spine — Pott disease

  • Bangladesh context-এ important।
  • Vertebral TB → vertebral collapse → kyphotic deformity + neurological deficit হতে পারে। WHO extrapulmonary TB treatment 6-month 2HRZE/4HR core regimen বলে; osteoarticular/spinal TB-তে clinician decision অনুযায়ী 9–12 months পর্যন্ত বাড়তে পারে।

F. Ankylosing spondylitis / inflammatory spondyloarthritis

  • Young male, inflammatory back pain, morning stiffness, HLA-B27 positive হতে পারে।
  • Long-standing disease-এ fixed kyphosis হতে পারে। ACR/SAA/SPARTAN guideline active AS-এ NSAID ও physical therapy strongly recommend করে।

G. Others

  • Trauma/post-traumatic kyphosis
  • Degenerative spine disease
  • Previous spine surgery
  • Neuromuscular disease
  • Tumor/metastasis
  • Rickets/osteomalacia

3) Symptoms — লক্ষণগুলো

  • Upper back round / কুঁজো পিঠ
  • Rounded shoulder
  • Visible hump
  • Back pain — mild to severe
  • Spine stiffness
  • Fatigue — দীর্ঘসময় দাঁড়ালে/বসলে ক্লান্তি
  • Tight hamstring
  • Severe/progressive case-এ:
    • leg weakness, numbness, tingling
    • sensation কমে যাওয়া
    • bowel/bladder problem
    • shortness of breath / breathing difficulty

4) Clinical Diagnosis — clinically কীভাবে diagnose করবেন?

History

  • Age of onset: child/adolescent/adult/elderly
  • Pain আছে কি না, pain duration
  • Curve progressive কি না
  • Trauma history
  • Fever, weight loss, night sweat → TB/infection red flag
  • Morning stiffness >30 min, improves with exercise → inflammatory cause
  • Steroid use, menopause, fragility fracture → osteoporosis
  • Neurological symptoms: weakness, numbness, bladder/bowel involvement

Physical examination

  • Side view posture assessment
  • Shoulder rounding, scapular prominence
  • Adam’s Forward Bend Test — patient সামনে ঝুঁকলে deformity better visible হয়।
  • Supine correction test:
    • শুয়ে পড়লে curve কমে গেলে → postural/flexible
    • না কমলে → structural kyphosis suspicion
  • Neurological exam:
    • power, reflex, sensory, gait
    • UMN signs if cord compression
  • Chest expansion / respiratory assessment if severe thoracic curve

5) Investigations — specific test list

First-line imaging

  1. Standing whole-spine X-ray — AP + lateral view
    • Cobb angle measurement
    • Vertebral wedging
    • Compression fracture
    • Sagittal balance
    • Curve >50° abnormal; management depends on cause/severity.
  2. Flexibility X-ray / hyperextension lateral view
    • Flexible vs rigid kyphosis
    • Scheuermann’s evaluation

When MRI is needed

  • Neurological deficit
  • Severe/progressive pain
  • Suspected TB/infection/tumor
  • Rapid curve progression
  • Congenital kyphosis with cord symptoms
    MRI is recommended when symptoms suggest spinal cord/nerve compression.

CT spine

  • Bony anatomy, congenital anomaly, fracture, surgical planning

Osteoporosis work-up

  • DEXA scan — BMD
  • Serum calcium, phosphate, ALP
  • 25-OH vitamin D
  • PTH if indicated
  • Renal function
  • TSH if secondary osteoporosis suspected

TB spine suspicion

  • CBC, ESR, CRP
  • Chest X-ray
  • Mantoux / IGRA
  • MRI spine with contrast
  • CT-guided biopsy / pus aspiration for AFB smear, GeneXpert MTB/RIF, culture, histopathology

Ankylosing spondylitis suspicion

  • ESR/CRP
  • HLA-B27
  • X-ray pelvis/SI joint
  • MRI SI joint if early disease suspected

Pulmonary function test

  • Severe thoracic kyphosis with dyspnea/restrictive lung disease suspicion.

6) Complications — রোগের জটিলতা

  • Chronic back pain — daily activity কমে যায়।
  • Progressive deformity — cosmetic concern, psychological stress।
  • Respiratory restriction — severe thoracic kyphosis chest expansion কমিয়ে breathing difficulty করতে পারে।
  • Neurological deficit — spinal cord/nerve compression হলে weakness, numbness, gait problem, bladder/bowel dysfunction।
  • Osteoporotic recurrent fracture — repeated vertebral collapse → kyphosis worsen।
  • TB spine complication — abscess, vertebral collapse, paraplegia।
  • Functional disability — walking, sitting, sleep, work performance affected।
  • Surgical complications — infection, hardware failure, proximal junctional kyphosis, neurological injury; severe selected cases only surgery করা হয়।

7) Treatment Management — guideline-based

A. Non-pharmacological management — main treatment

1. Observation

  • Mild, painless, non-progressive kyphosis।
  • Periodic clinical exam + X-ray until skeletal maturity in adolescents। AAOS nonsurgical management recommends observation, physiotherapy, NSAID pain relief, and bracing in selected growing Scheuermann cases.

2. Physiotherapy

  • Back extensor strengthening
  • Core strengthening
  • Hamstring stretching
  • Pectoralis stretching
  • Posture training
  • Thoracic extension exercise
  • Breathing exercise if severe thoracic curve
    SRS notes postural kyphosis treatment mainly posture awareness + back/core strengthening.

3. Bracing

  • Growing adolescent with Scheuermann kyphosis, especially moderate progressive curve।
  • Brace hours/day depends on curve severity and skeletal maturity।

4. Surgery

  • Congenital kyphosis progressive/severe
  • Scheuermann kyphosis severe, progressive, refractory pain, neurological deficit
  • AAOS notes surgery may be recommended for Scheuermann curves >70–75° or severe back pain; SRS notes severe 80–90° with frequent back pain may need surgery.

8) Pharmacological Drugs — Bangladesh brandসহ

Key point

Drug kyphotic curve সোজা করে না। Drug ব্যবহার হয় pain, inflammation, muscle spasm, osteoporosis, TB, AS বা neuropathic pain manage করতে।

8.1 Pain control — Paracetamol

  1. Generic name: Paracetamol
  2. Therapeutic category: Analgesic + Antipyretic
  3. Pharmacological class: Non-opioid analgesic
  4. Why used: mild back pain, fever, safer first-line pain option
  5. Dose: Adult 500 mg every 6–8 hourly PRN; max usually 3–4 g/day depending on liver status
  6. Duration: 3–5 days PRN; chronic daily use avoid unless supervised
  7. Side effects: nausea, rash, hepatotoxicity in overdose
  8. Interaction: alcohol, chronic warfarin, other hepatotoxic drugs
  9. Bangladesh Available Brand:
    • Napa 500 mg — Paracetamol — Beximco
    • Renova 500 mg — Paracetamol — Opsonin
    • Ace 500 mg — Paracetamol — Square
    • Fast 500 mg — Paracetamol — ACME
    • Pyrenol XR 665 mg — Paracetamol ER
      MedEx lists paracetamol as indicated for back pain, myalgia, rheumatic/osteoarthritic pain and multiple 500 mg brands including Napa/Fevac/G-Paracetamol/Paragesic etc.

8.2 NSAID — Ibuprofen

  1. Generic name: Ibuprofen
  2. Therapeutic category: Analgesic + Anti-inflammatory
  3. Pharmacological class: NSAID, propionic acid derivative
  4. Why used: inflammatory back pain, musculoskeletal pain
  5. Dose: 400 mg PO 2–3 times daily after food
  6. Duration: 3–7 days; longer only physician supervision
  7. Side effects: dyspepsia, gastritis, GI bleeding, renal impairment, BP rise, edema
  8. Interaction: anticoagulant/antiplatelet, steroid, SSRI, ACEI/ARB + diuretic, lithium, methotrexate
  9. Bangladesh Available Brand:
    • Brufen 400 mg — Ibuprofen
    • Ibumax 400 mg — Ibuprofen
    • DP-Ibu 400 mg — Ibuprofen
      MedEx lists ibuprofen for mild–moderate pain, inflammation-associated pain, backache, rheumatic pain and muscular pain.

8.3 NSAID — Naproxen

  1. Generic name: Naproxen / Naproxen Sodium
  2. Therapeutic category: Analgesic + Anti-inflammatory
  3. Pharmacological class: NSAID, propionic acid derivative
  4. Why used: moderate back pain, inflammatory pain, ankylosing spondylitis pain
  5. Dose: 250–500 mg PO twice daily after food
  6. Duration: 5–14 days; AS case-এ longer rheumatology supervision
  7. Side effects: GI ulcer/bleeding, renal impairment, edema, BP rise
  8. Interaction: anticoagulant, aspirin, steroid, SSRI, ACEI/ARB, diuretics
  9. Bangladesh Available Brand:
    • Naprox 500 mg — Naproxen Sodium — Eskayef
    • Napryn 250/500 mg — Healthcare
    • Naproxin 250/500 mg — Ambee
    • Naxo 500 mg — Navana
    • Naproxen Plus 500 mg + Esomeprazole 20 mg
      MedEx lists Naproxen 500 mg brands and the Naproxen + Esomeprazole combination for OA/RA/ankylosing spondylitis and NSAID-associated ulcer-risk reduction.

8.4 NSAID — Diclofenac

  1. Generic name: Diclofenac Sodium / Diclofenac Potassium
  2. Therapeutic category: Analgesic + Anti-inflammatory
  3. Pharmacological class: NSAID, acetic acid derivative
  4. Why used: painful vertebral column syndrome, acute musculoskeletal pain
  5. Dose: 50 mg PO 2–3 times daily after food; max 150 mg/day
  6. Duration: 3–7 days preferred
  7. Side effects: gastritis, GI bleed, renal impairment, edema, BP rise, CV risk
  8. Interaction: anticoagulant, antiplatelet, steroid, SSRI, ACEI/ARB, diuretic, lithium, methotrexate
  9. Bangladesh Available Brand:
    • Clofenac 50 mg — Diclofenac
    • Diclorex 50 mg / 75 mg injection / 100 mg SR
    • Diclofen 50 mg
    • Voltalin 50 mg
    • Fastfit Gel 1%
      MedEx lists diclofenac 50 mg tablets, 75 mg/3 ml injection, 100 mg SR preparations and 1% topical gel brands.

8.5 COX-2 selective NSAID — Etoricoxib

  1. Generic name: Etoricoxib
  2. Therapeutic category: Analgesic + Anti-inflammatory
  3. Pharmacological class: Selective COX-2 inhibitor NSAID
  4. Why used: inflammatory back pain, AS pain, OA-type pain when GI risk is a concern but CV risk low
  5. Dose:
    • Musculoskeletal pain/OA: 60 mg once daily
    • Ankylosing spondylitis: 90 mg once daily
  6. Duration: shortest possible; usually 5–14 days unless specialist indicates
  7. Side effects: BP rise, edema, dyspepsia, renal impairment, cardiovascular risk
  8. Interaction: warfarin/anticoagulants, ACEI/ARB, diuretics, lithium, methotrexate
  9. Bangladesh Available Brand:
    • Etorix 60/90/120 mg — Eskayef
    • Etoshine 60/90/120 mg — Sun Pharma
    • Recox 60/90/120 mg — Renata
    • Oricox 60/90/120 mg — Incepta
    • Ribox 60/90/120 mg — Beximco
      MedEx lists many Etoricoxib 60/90/120 mg brands including Etorix, Etoshine, Recox, Oricox, Ribox and others; MedEx Bangla dose page notes AS dose 90 mg once daily.

8.6 Gastric protection with NSAID — PPI

  1. Generic name: Omeprazole / Esomeprazole
  2. Therapeutic category: Anti-ulcerant
  3. Pharmacological class: Proton pump inhibitor
  4. Why used: NSAID-induced gastritis/ulcer risk কমাতে
  5. Dose:
    • Omeprazole 20 mg once daily before breakfast
    • Esomeprazole 20 mg once daily before breakfast
  6. Duration: NSAID duration বা high-risk patient-এ 2–4 weeks; chronic unnecessary use avoid
  7. Side effects: headache, diarrhea/constipation, low magnesium/B12 with long-term use
  8. Interaction: omeprazole may reduce clopidogrel activation; may affect warfarin/phenytoin; long-term use affects calcium/magnesium/B12
  9. Bangladesh Available Brand:
    • Seclo 20/40 mg — Omeprazole — Square
    • Losectil 20/40 mg — Omeprazole — Eskayef
    • PPI 20/40 mg — Omeprazole — ACME
    • Maxpro 20/40 mg — Esomeprazole — Renata
    • Nexum 20/40 mg — Esomeprazole — Beximco
      MedEx lists omeprazole 20/40 mg brands and GERD/NSAID-induced ulcer dosing; MedEx lists esomeprazole for GERD, ulcer and acid-related conditions.

8.7 Muscle relaxant — short course only

A. Tizanidine

  1. Generic name: Tizanidine Hydrochloride
  2. Therapeutic category: Muscle relaxant
  3. Pharmacological class: Centrally acting alpha-2 agonist skeletal muscle relaxant
  4. Why used: painful muscle spasm around kyphotic spine
  5. Dose: 2 mg at night or 2 mg 2–3 times daily; severe spasm 2–4 mg TID
  6. Duration: 3–7 days, rarely 2 weeks
  7. Side effects: sedation, dizziness, hypotension, dry mouth, liver enzyme rise
  8. Interaction: ciprofloxacin/fluvoxamine contraindicated; alcohol, benzodiazepine, opioid increase sedation
  9. Bangladesh Available Brand:
    • Sirdalud 2 mg
    • Tizadin 2 mg
    • Tizalud 2 mg
    • Tizan 2 mg
      MedEx lists painful muscle spasm dose as 2–4 mg three times daily and brands including Sirdalud/Tizadin/Tizalex/Tizalud/Tizan.

B. Eperisone

  1. Generic name: Eperisone Hydrochloride
  2. Therapeutic category: Muscle relaxant
  3. Pharmacological class: Centrally acting skeletal muscle relaxant
  4. Why used: back muscle stiffness/spasm
  5. Dose: 50 mg 2–3 times daily after food
  6. Duration: 5–14 days
  7. Side effects: dizziness, GI upset, drowsiness, rash
  8. Interaction: alcohol/CNS depressants increase sedation
  9. Bangladesh Available Brand:
    • Myonil 50 mg — Square
    • Eprel 50 mg — Orion
    • Ezymas 50 mg — Novelta
      MedEx lists Eperisone 50 mg brands Myonil, Eprel and Ezymas.

8.8 Neuropathic/radicular pain — only if nerve pain present

Pregabalin

  1. Generic name: Pregabalin
  2. Therapeutic category: Neuropathic pain agent
  3. Pharmacological class: Gabapentinoid anticonvulsant
  4. Why used: tingling, burning pain, radicular pain, nerve compression-related pain
  5. Dose: 25–75 mg at night initially; titrate to 75 mg BID if needed
  6. Duration: 2–6 weeks then reassess; renal dose adjustment needed
  7. Side effects: dizziness, somnolence, edema, weight gain
  8. Interaction: alcohol, opioid, benzodiazepine → respiratory/CNS depression risk
  9. Bangladesh Available Brand:
    • Pregaben 75 mg — Incepta
    • GABA-P 75 mg — Renata
    • Pregaba 75 mg — Opsonin
    • Pregabid 75 mg — Albion
    • Pregacap 75 mg — Concord
      MedEx lists pregabalin brands including GABA-P 75 mg, Pregaben/Pregabid/Pregacap etc.

Gabapentin

  1. Generic name: Gabapentin
  2. Therapeutic category: Neuropathic pain agent
  3. Pharmacological class: Gabapentinoid anticonvulsant
  4. Why used: neuropathic/radicular pain
  5. Dose: 300 mg at night day 1, 300 mg BD day 2, 300 mg TID day 3; titrate as needed
  6. Duration: 2–6 weeks then reassess; renal adjustment needed
  7. Side effects: dizziness, sedation, ataxia, edema
  8. Interaction: opioid/benzodiazepine/alcohol; antacid reduces absorption
  9. Bangladesh Available Brand:
    • Gaba 300 mg — Renata
    • Gabapen 100/300 mg — Incepta
    • Gabastar 100/300 mg — Square
    • Gabantin 100/300 mg — Sun Pharma
    • Gabamax 300 mg — Beacon
      MedEx lists gabapentin neuropathic pain titration and multiple 100/300 mg brands.

8.9 Osteoporosis-related kyphosis / vertebral fracture prevention

A. Calcium + Vitamin D3

  1. Generic name: Calcium carbonate + Cholecalciferol
  2. Therapeutic category: Bone health supplement
  3. Pharmacological class: Mineral + Vitamin D supplement
  4. Why used: osteoporosis/osteomalacia/vitamin D deficiency support; fracture prevention adjunct
  5. Dose: Calcium 500 mg + Vitamin D3 200 IU, 1 tab BD after meal; adjust to total daily calcium/vit D target
  6. Duration: long-term if deficient/osteoporosis; monitor calcium/renal stone risk
  7. Side effects: constipation, bloating, hypercalcemia, renal stone
  8. Interaction: levothyroxine, iron, tetracycline/quinolone, bisphosphonate—separate by 4 hours
  9. Bangladesh Available Brand:
    • Calbo-D 500 mg + 200 IU
    • Calcin-D 500 mg + 200 IU — Renata
    • A-Cal D 500 mg + 200 IU — ACME
    • Oscal-D Forte 600 mg + 400 IU
    • Orthocal-D 500 mg + 200 IU
      MedEx lists calcium + vitamin D3 for osteoporosis/osteomalacia/rickets and many 500 mg + 200 IU or 600 mg + 400 IU brands.

B. Cholecalciferol — Vitamin D3

  1. Generic name: Cholecalciferol
  2. Therapeutic category: Vitamin
  3. Pharmacological class: Vitamin D3 preparation
  4. Why used: vitamin D deficiency, osteomalacia, osteoporosis adjunct
  5. Dose: commonly 20,000 IU weekly for 6–8 weeks if deficient, then maintenance 1,000–2,000 IU/day; tailor to 25-OH vitamin D
  6. Side effects: hypercalcemia, nausea, constipation, renal stone
  7. Interaction: thiazide diuretic, digoxin, calcium supplement
  8. Bangladesh Available Brand:
    • D-Rise 20,000/40,000/50,000 IU — Beximco
    • D-Fill 20,000/40,000 IU — General
    • D-Cap 20,000/40,000 IU
    • D-Star 20,000/40,000 IU — NIPRO JMI
      MedEx lists D-Rise 20,000 IU and many cholecalciferol 20,000/40,000 IU brands.

C. Alendronic acid

  1. Generic name: Alendronic acid / Alendronate
  2. Therapeutic category: Anti-osteoporosis drug
  3. Pharmacological class: Bisphosphonate, antiresorptive
  4. Why used: osteoporotic vertebral fracture prevention; osteoporosis causing/worsening kyphosis
  5. Dose: 70 mg once weekly early morning empty stomach with full glass water; remain upright 30–60 min
  6. Duration: usually 3–5 years then fracture-risk reassessment
  7. Side effects: esophagitis, dyspepsia, musculoskeletal pain, rare osteonecrosis jaw, atypical femur fracture
  8. Interaction: calcium/iron/antacid/food reduce absorption; NSAID increases GI irritation
  9. Bangladesh Available Brand:
    • Alendon 10 mg / 70 mg — Beximco
    • Ostel-D 70 mg + 2800 IU — Square
    • Bonemass D 70 mg + 2800 IU — Incepta
      Endocrine Society recommends bisphosphonates as initial treatment for postmenopausal women at high fracture risk, and MedEx lists alendronic acid 70 mg once weekly dosing and Bangladesh brands.

D. Risedronate

  1. Generic name: Risedronate Sodium
  2. Therapeutic category: Anti-osteoporosis drug
  3. Pharmacological class: Bisphosphonate
  4. Why used: alternative to alendronate in osteoporosis
  5. Dose: 35 mg once weekly
  6. Duration: 3–5 years then reassess
  7. Side effects/interactions: similar to alendronate
  8. Bangladesh Available Brand:
    • Risonet 35 mg — Opsonin
    • Sedron 35 mg — General
    • Salost DR 35 mg — UniMed UniHealth
    • Risedon Plus 35 mg + Calcium 500 mg — Square
      MedEx lists risedronate 35 mg weekly dosing and available brands.

E. Denosumab — specialist only

  1. Generic name: Denosumab
  2. Therapeutic category: Anti-osteoporosis biologic
  3. Pharmacological class: RANKL inhibitor monoclonal antibody
  4. Why used: high-risk osteoporosis, intolerance/contraindication to bisphosphonate
  5. Dose: 60 mg SC every 6 months
  6. Side effects: hypocalcemia, infection risk, eczema, rare osteonecrosis jaw
  7. Interaction: hypocalcemia risk with low vitamin D/CKD; ensure calcium/vit D
  8. Bangladesh Available Brand:
    • Denomab 60 mg/ml — Healthcare
    • Denosis 60 mg/ml — Incepta
      MedEx lists denosumab 60 mg/ml brands Denomab and Denosis.

F. Teriparatide — very high fracture risk

  1. Generic name: Teriparatide
  2. Therapeutic category: Anabolic osteoporosis drug
  3. Pharmacological class: Recombinant PTH analog
  4. Why used: severe osteoporosis, multiple vertebral fractures, very high fracture risk
  5. Dose: 20 mcg SC once daily
  6. Duration: specialist-directed; commonly up to 24 months then antiresorptive follow-up
  7. Side effects: hypercalcemia, nausea, dizziness, leg cramps
  8. Interaction: digoxin caution if hypercalcemia
  9. Bangladesh Available Brand:
    • Forteo 20 mcg/80 mcl — Healthcare
    • Teripen 20 mcg/80 mcl — Incepta
      MedEx lists teriparatide 20 mcg SC once daily and Bangladesh brands.

8.10 TB spine / Pott disease — only confirmed/suspected TB under NTP/specialist

  1. Generic name: Rifampicin + Isoniazid + Pyrazinamide + Ethambutol
  2. Therapeutic category: Anti-tubercular
  3. Pharmacological class: Combined first-line anti-TB chemotherapy
  4. Why used: spinal TB causing vertebral destruction and kyphosis
  5. Typical regimen: 2 months HRZE then HR continuation; duration 6–12 months depending on guideline, extent, response and clinician decision
  6. Side effects: hepatitis, GI upset, rash; ethambutol optic neuritis; pyrazinamide hyperuricemia; rifampicin orange urine
  7. Interaction: rifampicin strongly reduces effect of OCP, warfarin/DOAC, many antiretrovirals, azoles, steroids
  8. Bangladesh Available Brand:
    • Rimstar 4-FDC 150 mg + 75 mg + 400 mg + 275 mg — Rifampicin + Isoniazid + Pyrazinamide + Ethambutol
    • Rifagen 450 mg + 300 mg — Rifampicin + Isoniazid
    • Rimactazid 300 mg + 150 mg / 450 mg + 300 mg — Rifampicin + Isoniazid
    • Sural 400 mg — Ethambutol
      MedEx lists Rimstar 4-FDC and Rifampicin + Isoniazid continuation-phase combinations; WHO notes extrapulmonary TB uses 2HRZE/4HR core regimen with possible prolongation for osteoarticular TB.

8.11 Ankylosing spondylitis-related kyphosis — rheumatology specialist

A. NSAIDs

  • Naproxen / Etoricoxib / Diclofenac / Ibuprofen are commonly used first-line for active inflammatory back pain.
  • Physical therapy is essential. ACR/SAA/SPARTAN strongly recommends NSAIDs and physical therapy in active AS.

B. Sulfasalazine — mainly peripheral arthritis, not pure axial disease

  1. Generic: Sulfasalazine
  2. Therapeutic category: DMARD
  3. Pharmacological class: 5-ASA + sulfonamide DMARD
  4. Dose: 500 mg once/twice daily then titrate; often 1 g BD under rheumatology
  5. Side effects: nausea, rash, hepatotoxicity, cytopenia, orange urine
  6. Interaction: warfarin, digoxin, folate antagonist; monitor CBC/LFT
  7. Bangladesh Brand: Salazine 500 mg, Sulfaben 500 mg, Sulfacol 500 mg
    MedEx lists sulfasalazine 500 mg brands.

C. Biologics — refractory active AS

  1. Generic: Adalimumab
    • Class: TNF-alpha inhibitor
    • Dose: commonly 40 mg SC every 2 weeks
    • Bangladesh brand: Adalimab 40 mg/0.8 ml, Adimab 40 mg/0.8 ml, Advixa 40 mg/0.8 ml, Hyrimoz 40 mg/0.8 ml
    • Side effects: serious infection, TB reactivation, injection reaction
    • Interaction/precaution: screen TB, HBV, HCV before starting
      MedEx lists adalimumab 40 mg/0.8 ml brands.
  2. Generic: Secukinumab
    • Class: IL-17A inhibitor
    • Dose: 150 mg at week 0,1,2,3,4 then every 4 weeks
    • Bangladesh brand: Cosentyx 150 mg/ml
    • Side effects: infection, candidiasis, IBD flare
      MedEx lists secukinumab AS dosing and Cosentyx 150 mg/ml brand.

9) Bangladesh doctors commonly prescribe — practical list

Mild postural kyphosis with pain

  • Paracetamol 500 mg PRN
  • Physiotherapy + posture correction
  • Vitamin D/Calcium only if deficiency or low intake

Painful musculoskeletal kyphosis

  • Paracetamol
  • NSAID: Ibuprofen / Naproxen / Etoricoxib / Diclofenac
  • PPI if gastritis/ulcer risk
  • Short-course muscle relaxant if spasm: Tizanidine/Eperisone

Neurological/radicular pain

  • Pregabalin or Gabapentin
  • MRI spine
  • Spine specialist referral

Osteoporotic kyphosis / vertebral compression fracture

  • Calcium + Vitamin D3
  • Cholecalciferol correction
  • Alendronate/Risedronate
  • Denosumab/Teriparatide if high-risk specialist case
  • DEXA monitoring

Suspected TB spine

  • MRI + ESR/CRP + GeneXpert/culture/biopsy
  • HRZE regimen under NTP/ID/orthopedic supervision
  • Surgery only if neurological deficit, instability, severe deformity/abscess

Ankylosing spondylitis

  • NSAID + physiotherapy
  • Rheumatology review
  • Biologic if refractory active disease after evaluation

10) Prevention — কীভাবে প্রতিরোধ করবেন?

  • Correct posture: reading/mobile/computer eye-levelে রাখুন।
  • Back extensor + core exercise: সপ্তাহে 4–5 দিন।
  • Hamstring ও chest stretching: daily।
  • Long sitting break: প্রতি 30–45 মিনিটে 2–3 মিনিট দাঁড়ানো/হাঁটা।
  • Weight-bearing exercise: walking, stair climbing, resistance training।
  • Calcium + vitamin D adequate intake: deficiency থাকলে test করে correction।
  • Smoking stop: osteoporosis ও spinal degeneration কমাতে সাহায্য করে।
  • Fall prevention: elderly patient-এ footwear, lighting, home safety।
  • Steroid rational use: chronic steroid হলে osteoporosis prophylaxis ভাবতে হবে।
  • TB prevention: chronic back pain + fever/weight loss/night sweat হলে early screening।
  • Adolescent screening: shoulder rounding/visible hump হলে early orthopedic assessment।

Overview / Summary

Kyphosis হলো thoracic spine-এর excessive forward curvature। Mild postural kyphosis সাধারণত physiotherapy ও posture correction-এ ভালো হয়। Scheuermann, congenital, osteoporotic fracture, TB spine, ankylosing spondylitis—এগুলো structural/secondary cause হিসেবে evaluate করতে হবে। Medicine curve সোজা করে না; medicine pain, inflammation, muscle spasm, osteoporosis, TB বা inflammatory disease control-এর জন্য ব্যবহৃত হয়।

Actionable Plan / Steps

  1. Standing whole-spine AP/lateral X-ray করে Cobb angle measure করুন।
  2. Red flag থাকলে — MRI spine: neurological deficit, severe pain, fever/weight loss, rapid progression।
  3. Elderly/postmenopausal/steroid user হলে — DEXA + vitamin D/calcium profile।
  4. TB suspicion হলে — ESR/CRP, MRI contrast, GeneXpert/culture/biopsy।
  5. AS suspicion হলে — ESR/CRP, HLA-B27, SI joint imaging।
  6. Mild case: posture + physiotherapy।
  7. Pain: paracetamol ± short NSAID; GI/renal/CV risk assess করুন।
  8. Structural/progressive/severe curve: orthopedic spine specialist referral।
  9. Neurological deficit/bladder-bowel problem: urgent referral/emergency evaluation।

Reference List — Textbook + Guideline + DOI

Textbook

  1. Harrison’s Principles of Internal Medicine, 21st ed. Chapters: Back and Neck Pain; Osteoporosis; Tuberculosis; Spondyloarthritis.
  2. Davidson’s Principles and Practice of Medicine, 24th ed. Chapters: Musculoskeletal disorders; Infectious diseases—TB; Metabolic bone disease.
  3. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Bone and joint pathology; granulomatous inflammation/TB.
  4. Guyton and Hall Textbook of Medical Physiology, 14th ed. Bone physiology; calcium/vitamin D/PTH physiology.

Guidelines / Professional sources

  1. AAOS OrthoInfo — Kyphosis/Roundback of the Spine.
  2. Scoliosis Research Society — Kyphosis; Scheuermann’s Kyphosis.
  3. Endocrine Society Clinical Practice Guideline — Pharmacological Management of Osteoporosis in Postmenopausal Women.
  4. WHO TB Knowledge Sharing Platform — Treatment of extrapulmonary TB.
  5. ACR/SAA/SPARTAN — Treatment recommendations for ankylosing spondylitis/non-radiographic axial spondyloarthritis.

Peer-reviewed DOI references

  1. Sardar ZM, Ames RJ, Lenke L. Scheuermann’s Kyphosis: Diagnosis, Management, and Selecting Fusion Levels. J Am Acad Orthop Surg. 2019;27(10):e462–e472. DOI: 10.5435/JAAOS-D-17-00748.
  2. O’Donnell JM, Wu W, Youn A, Mann A, Swarup I. Scheuermann Kyphosis: Current Concepts and Management. Curr Rev Musculoskelet Med. 2023;16:521–530. DOI: 10.1007/s12178-023-09861-z.
  3. Ward MM et al. 2019 Update of the ACR/SAA/SPARTAN Recommendations for AS and nr-axSpA. Arthritis Rheumatol. 2019;71(10):1599–1613. DOI: 10.1002/art.41042.
  4. Eastell R et al. Pharmacological Management of Osteoporosis in Postmenopausal Women. J Clin Endocrinol Metab. 2019. DOI: 10.1210/jc.2019-00221.
  5. Nahid P et al. Official ATS/CDC/IDSA Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis. 2016;63(7):e147–e195. DOI: 10.1093/cid/ciw376

Md.Rafiqul Islam Lipu,Date:-08-06-2026 Monday,Time:-03-58-49 Pm

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