Thoracic Lordosis and Hypokyphosis Charlotte NC | Flat or Reversed Mid Back | Clear Life Scoliosis

By Dr. Justin M. Dick, DC · Clear Life Scoliosis and Chiropractic Center, Charlotte, NC · Published November 01, 2026

The thoracic spine normally curves outward. Hypokyphosis means that curve is reduced; thoracic lordosis means it is reversed so the mid back curves inward. Both are most often seen with thoracic adolescent idiopathic scoliosis, where flattening is part of the deformity: Clément and colleagues found hypokyphosis in 42 of 86 thoracic idiopathic curves and showed it was independent of pelvic shape. Severe thoracic lordosis can narrow the chest enough to compress a main bronchus, as reported in two children treated at Great Ormond Street Hospital.

I am Dr. Justin M. Dick, DC, at Clear Life Scoliosis and Chiropractic Center in Charlotte, NC. Because rotation distorts side-view measurements in scoliosis, a flat mid back is easy to miss or mismeasure, and this post explains why.

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Why the Mid Back Flattens in Scoliosis

One proposed mechanism, which remains debated, is that in thoracic idiopathic scoliosis the vertebrae rotate and the front of the spine grows relatively longer than the back, reducing kyphosis. Clément and colleagues divided 86 thoracic curves into hypokyphotic and normokyphotic groups. Hypokyphosis was not explained by pelvic parameters and was linked with reduced upper lumbar lordosis, so they described it as a structural feature of the deformity. This is why I measure the side view in every scoliosis patient.

Measurement Is Harder Than It Looks

Ilharreborde and colleagues studied 35 hypokyphotic patients (T4 to T12 under 15°) with three-dimensional reconstruction and found that two-dimensional side-view measurements overestimated kyphosis after surgery because of rotation. A standard lateral film can make a flat or lordotic thoracic spine look more normal than it is. My post on spinal rotation explains why the third dimension matters.

Lungs and Airway

Bartlett and colleagues reported two children with thoracic lordoscoliosis whose right main bronchus was obstructed by the deformity. After correction surgery, ventilation to that lung returned and lung function improved. These are rare cases, but they show why a severely lordotic thoracic curve with breathing symptoms needs pulmonary evaluation. My post on thoracic scoliosis covers lung function in thoracic curves more broadly.

The Heart

Hirschfeld and colleagues found mitral valve prolapse in 36 percent of adolescents with scoliosis plus thoracic hypokyphosis, compared with 28 percent of all 74 adolescents with scoliosis they examined. Patients with a flat or reversed mid back and a murmur or cardiac symptoms should have cardiac evaluation.

Treatment Considerations

Ilharreborde's surgical series restored thoracic kyphosis in about two thirds of hypokyphotic patients, and 7 of 8 with true thoracic lordosis were corrected, but 31.4 percent remained hypokyphotic. For conservative care, braces and exercises that push the thoracic spine further into flexion can be counterproductive in a hypokyphotic curve. That is my clinical reasoning from biomechanics, and it is one reason sagittal profile is part of brace and exercise selection at our office.

How Dr. Justin M. Dick, DC Evaluates Thoracic Lordosis at Clear Life

At our Charlotte office, standing front and side radiographs are read together, with attention to rotation when measuring kyphosis. Breathing or cardiac symptoms prompt referral. Our bracing and exercise page covers how sagittal profile shapes care.

Comparison

Research and Evidence

Evidence tiering: Clément is a radiographic cohort, Ilharreborde a multicenter surgical case series, Bartlett a two-patient case series, Hirschfeld a small observational study. Conservative treatment of thoracic lordosis has no trial evidence I could find. The bracing and exercise point above is biomechanical reasoning.

My own published work includes thoracolumbar curves treated without surgery. The Lenke 5C case report, A Non-surgical Multimodal Approach to Adolescent Idiopathic Scoliosis (Lenke 5C) Using an Intensive Two-Week CLEAR Institute Protocol: A Report of Two Cases (Cureus, 2026, PMID 41640942), describes two adolescents. It does not address thoracic lordosis directly.

References

1. Clément JL, Geoffray A, Yagoubi F, et al. Relationship between thoracic hypokyphosis, lumbar lordosis and sagittal pelvic parameters in adolescent idiopathic scoliosis. Eur Spine J. 2013;22(11):2414-20. doi:10.1007/s00586-013-2852-z
2. Ilharreborde B, Pesenti S, Ferrero E, et al. Correction of hypokyphosis in thoracic adolescent idiopathic scoliosis using sublaminar bands: a 3D multicenter study. Eur Spine J. 2018;27(2):350-357. doi:10.1007/s00586-017-5166-8
3. Bartlett W, Garrido E, Wallis C, Tucker SK, Noordeen H. Lordoscoliosis and large intrathoracic airway obstruction. Spine. 2009;34(1):E59-65. doi:10.1097/BRS.0b013e318191f389
4. Hirschfeld SS, Rudner C, Nash CL, Nussbaum E, Brower EM. Incidence of mitral valve prolapse in adolescent scoliosis and thoracic hypokyphosis. Pediatrics. 1982;70(3):451-4. PMID 7110820
5. Whelan J, Paige P, Dick JM. A non-surgical multimodal approach to adolescent idiopathic scoliosis (Lenke 5C) using an intensive two-week CLEAR Institute protocol: a report of two cases. Cureus. 2026;18(1):e102006. doi:10.7759/cureus.102006

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Service Area

Clear Life Scoliosis and Chiropractic Center sees patients from Charlotte NC, Huntersville NC, Ballantyne NC, Matthews NC, Concord NC, Mooresville NC, Rock Hill SC, Fort Mill SC. Families from across the Charlotte region and the South Carolina border communities come to the Rachel Freeman Way office for radiographic scoliosis evaluation with Dr. Justin M. Dick, DC.

Related Pages

• Thoracic Scoliosis
• Spinal Rotation in Scoliosis
• Scoliosis Biomechanics and Sagittal Alignment
• About Scoliosis
• Kyphosis Treatment in Charlotte
• Scoliosis Bracing and Exercises
• Cobb Angle Measurement
• Bracing for Scoliosis
• Scoliosis Care Program
• Dr. Justin M. Dick, DC Research

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If your teen's films show a flat or reversed mid back, it changes what treatment fits. Dr. Justin M. Dick, DC reviews both views at our Charlotte office.

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