The relationship between thoracic kyphosis and age, and normative values across age groups: a systematic review of healthy adults

Mattia Zappalá, Stephen Lightbourne, Nicola R Heneghan

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BACKGROUND: Thoracic kyphosis is reported to increase with ageing. However, this relationship has not been systematically investigated. Peoples' kyphosis often exceeds 40°, but 40° is the widely accepted cut-off and threshold for normality. Consequently, patients may be misclassified. Accurate restoration of kyphosis is important to avoid complications following spinal surgery. Therefore, specific reference values are needed. The objective of the review is to explore the relationship between thoracic kyphosis and age, provide normative values of kyphosis for different age groups and investigate the influence of gender and ethnicity.

METHODS: Two reviewers independently conducted a literature search, including seven databases and the Spine Journal, from inception to April 2020. Quantitative observational studies on healthy adults (18 years of age or older) with no known pathologies, and measuring kyphosis with Cobb's method, a flexicurve, or a kyphometer, were included. Study selection, data extraction, and study quality assessment (AQUA tool) were performed independently by two reviewers. The authors were contacted if clarifications were necessary. Correlation analysis and inferential statistics were performed (Microsoft Excel). The results are presented narratively. A modified GRADE was used for evidence quality assessment.

RESULTS: Thirty-four studies (24 moderate-quality, 10 high-quality) were included (n = 7633). A positive moderate correlation between kyphosis and age was found (Spearman 0.52, p < 0.05, T5-T12). Peoples' kyphosis resulted greater than 40° in 65% of the cases, and it was significantly smaller in individuals younger than 40 years old (x < 40) than in those older than 60 years old (x > 60) 75% of the time (p < 0.05). No differences between genders were found, although a greater kyphosis angle was observed in North Americans and Europeans.

CONCLUSION: Kyphosis increases with ageing, varying significantly between x < 40 and x > 60. Furthermore, kyphosis appears to be influenced by ethnicity, but not gender. Peoples' thoracic sagittal curvature frequently exceeds 40°.

TRIAL REGISTRATION: The review protocol was devised following the PRISMA-P Guidelines, and it was registered on PROSPERO ( CRD42020175058 ) before study commencement.

Original languageEnglish
Article number447
JournalJournal of orthopaedic surgery and research
Issue number1
Publication statusPublished - 9 Jul 2021

Bibliographical note

© 2021. The Author(s).


  • Ageing
  • Correlation
  • Ethnic group
  • Gender
  • Healthy adults
  • Hyperkyphosis
  • Kyphosis
  • Normative value
  • Reference values
  • Thoracic spine

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine


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