Scoliosis
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I.
Definition
Scoliosis (from Greek: skolíōsis meaning "crooked") is a medical condition in which a person's spine is curved from side to side, shaped like an "s or c", and may also be rotated. To adults it can be very painful. It is an abnormal lateral curvature of the spine. On an x-ray, the spine of an individual with a typical scoliosis may look more like an "S" or a "C" than a straight line.
II.
Etiology
It is typically classified as: 1.) congenital (caused by vertebral anomalies present at birth), 2.) idiopathic (sub-classified as infantile, juvenile, adolescent, or adult according to when onset occurred), 3.) Neuropathic ( associated with conditions such as poliomyelitis, cerebral palsy, paralysis and neurofibromatosis), 4.) myopathic (rusults from conditions such as muscular dystrophy and myopathies), and 5.) osteopathic (results from conditions such as fractures, bone diseases, arthritis and infection).
III.
Epidemiology 1. Prevalence: 2% of adolescent population 2. Age a. Girls: After 9-10 years old b. Boys: After 11-12 years old 3. Gender a. Boys and girls affected equally b. Girls are much more likely to significantly progress
IV.
Anatomy and Physiology
•
The Spinal Column
The spinal column consists of individual bones called vertebrae, the building blocks, which provide support for the spine. These vertebrae are connected in the front of the spine by intervertebral discs. Discs are very strong tissues, which are filled with a gel. Discs help to support the spine, and also allow it to move. Many ligaments and muscles attached to the back of the spine (posterior aspect) provide power for movement.
•
Vertebrae in the Spinal Column
You may have heard your doctor using such terms as lumbar spine, or L5. These terms are easy and important to understand. The spinal column consists of:
1. 2. 3. 4.
seven cervical vertebrae (C1–C7) i.e. neck twelve thoracic vertebrae (T1–T12) i.e. upper back five lumbar vertebrae (L1–L5) i.e. lower back five bones (that are joined, or "fused," together in adults) to form the bony sacrum 5. three to five bones fused together to form the coccyx or tailbone. To understand scoliosis, which causes the spine to curve to the left or right, you first need to understand what a normal spine looks like. There are four regions in your spine: •
Cervical Spine: This is your neck, which begins at the base of your skull. It contains 7 small bones (vertebrae), which doctors label C1 to C7 (the 'C' means cervical). The numbers 1 to 7 indicate the level of the vertebrae. C1 is closest to the skull, while C7 is closest to the chest.
•
Thoracic Spine: Your mid-back has 12 vertebrae that are labeled T1 to T12 (the 'T' means thoracic). Vertebrae in your thoracic spine connect to your ribs, making this part of your spine relatively stiff and stable. Your thoracic spine doesn't move as much as the other regions of your spine, like the cervical spine.
•
Lumbar Spine: In your low back, you have 5 vertebrae that are labeled L1 to L5 (the 'L' means lumbar). These vertebrae are your largest and strongest vertebrae, responsible for carrying a lot of your body's weight. The lumbar vertebrae are also your last "true" vertebrae; down from this region, your vertebrae are fused. In fact, L5 may even be fused with part of your sacrum.
•
Sacrum and Coccyx: The sacrum has 5 vertebrae that usually fuse by adulthood to form one bone; the coccyx—most commonly known as your tail bone—has 4 (but sometimes 5) fused vertebrae.
From behind, the normal spine appears straight. However, when viewed from the side, you'll see that the spine has both inward and outward curves. These curves help our back carry our weight and are also important for flexibility. There are two types of curves in your spine: kyphosis and lordosis. You can see those from the side view. Kyphosis means the spine curves inward; lordosis means the spine curves outward. There are two kyphotic and two lordotic spinal curves in a normal spine. Your neck (cervical spine) and low back (lumbar spine) have a lordotic curve. Your mid back (thoracic spine) and pelvis (sacrum) have a kyphotic curve.
V. Pathophysiology:
VI. Manifestation 1. Whole body leaning to one side 2. Uneven shoulder height 3. One hip sticks up higher than the other (Parents often first notice possible
scoliosis when they see that one pant leg is shorter than the other.) 4. Uneven rib cage 5. Rib protrusion on one side of the spine o o o
o
o
o
o
Scoliosis screening should begin at age 6 years Right thoracic and left lumbar curvature is the norm Landmarks Shoulder height Scapular prominence Flank crease Pelvic symmetry Leg Length Discrepancy See Scoliosis Examination Forward Bending Test Scoliometer (measures trunk rotation) Adam's Test Determine growth spurt Assessment Tools Measure Sitting Height (Truncal Height) q3 months Obtain Risser Grading (Iliac XRay) Functional exam Neurologic Exam Gait Red Flags Left thoracic curve (possible spinal cord lesion) Neurofibromatosis stigmata Marfan's Syndrome stigmata
VII. Diagnostic Test The Adam's Forward Bending Test helps identify an unusual curve, but it can't tell you how severe the curve is. For that, you'll need to go to a doctor. Using different tests, the doctor will be able to see and measure the curve. 2. Plumb line test: This is a quick visual check to see if the spine is straight. In scoliosis, the plumb line will fall to the left or right of the spine instead of through the middle of the buttocks. 1.
3.
Scoliometer: If the doctor sees a rib hump, he or she can use a scoliometer to measure the size of the hump. It's a painless and non-invasive test.
X-ray: An x-ray can help the doctor confirm scoliosis by showing exactly where the scoliosis affects the spine and the extent of the curve. 5. Plain Radiographs (X-Rays): X-rays are not "routinely" necessary for most episodes of acute low back pain and have generally been overused. The main purpose of plain x-ray is to detect serious underlying structural, pathologic conditions. Selective criteria can be used to improve the usefulness of plain x-ray. These studies are generally not recommended in the first month of symptoms in the absence of "red flags." Oblique views are rarely indicated and increase both the cost and radiation exposure. The exception would include a young patient with an acute injury or repetitive extension activities, which can result in fracture of the pars interarticularis. 4.
VIII. Treatments •
Conservative treatment: Braces, electrical stimulation, and traction may be used to prevent progression of scoliosis and kyphosis in younger clients whose skeletons have not yet matured. Unfortunately, these approaches are ineffective in adult clients. Conservative treatments for adults include weight reduction, active and passive exercises, and the use of braces for support.
•
Surgery For adolescents and adults, the use of surgery to correct spinal deformities depend on the factors such as degree of curvature and the client’s aver-all physical, emotional, and neurologist status. Even with surgery, it is not possible to correct the abnormal curvature completely. The surgical procedures involve attaching metal reinforcing rods to the vertebrae, and are usually performed using an interior approach, although more severe curvature may require both anterior and posterior approach. The types of straightening devices used most frequently are bilateral rods with wire hooks or screws that stabilize the spine and correct the deformity.
IX. Nursing Diagnosis 1. 2. 3. 4.
Potential alteration in comfort Potential activity intolerance Risk for injury Risk for peripheral neurovascular dysfunction
X. Planning and Implementation
• •
Counseling and teaching: splint or brace use (Milwaukee or Orthoplast braces are commonly used). Teach the patient to apply and remove the splint or brace and how to care for it. Therapeutic exercises: exercises are prescribed forms of activity designed to preserve joint mobility and to strengthen specific muscle group. These may include the following: a. ROM exercises b. Active restrictive exercises ( performed against resistance of another person or with weights)
• •
•
•
Medications: medications are rarely needed except for salicylates for antiinflammatory and analgesic effects. Nutrition: a special diet is usually not prescribed except when the patient is overweight or laboratory studies indicate metabolic problems such as rickets. Assist the patient and family in planning meals that include fruits, and vegetables, proteins, and vitamins. Teach clients in ways to reduce irritation of skin surfaces beneath the brace: wearing a smooth cotton t-shirt or cotton tube under the brace at all times, changing undergarments at least once daily, and washing them with a mild soap. Undergarments should be changed more frequently in warmer weather. Teach the client to loosen braces during meals and for the first 30 minutes after each meal because these allows adequate nutritional intake and promote comfort.
XI. Evaluation and Outcome 1. Expected patient outcomes: • • •
Patient avoids potential complications. Patient maintains maximal functioning and independence. Patient participates in long-range planning of care.
2. Evaluation for conservative therapy: •
Based on the expected patient outcomes, the questions related to therapy would include the following: a. Have spinal complications been avoided? b. To what degree has the patient been able to function without back support? c. Is the patient able to describe long-range plans of care?
3. Evaluation for patient with spinal fusion: •
Based on the expected patient outcomes, the patient:
a. Can explain the nature of the surgery that has been performed. b. Maintains maximum functioning c. Is participating in physician’s follow-up program.
“SCOLIOSIS”
Submitted by: BELTRAN, Karl Leo D. BOLANTE, Sheila Marie H. BSN033 Submitted To: Prof. Pepito B. Ruzol Jr.
Definition
Scoliosis (from Greek: skolíōsis meaning "crooked") is a medical condition in which a person's spine is curved from side to side, shaped like an "s or c", and may also be rotated. To adults it can be very painful. It is an abnormal lateral curvature of the spine. On an x-ray, the spine of an individual with a typical scoliosis may look more like an "S" or a "C" than a straight line.
II.
Etiology
It is typically classified as: 1.) congenital (caused by vertebral anomalies present at birth), 2.) idiopathic (sub-classified as infantile, juvenile, adolescent, or adult according to when onset occurred), 3.) Neuropathic ( associated with conditions such as poliomyelitis, cerebral palsy, paralysis and neurofibromatosis), 4.) myopathic (rusults from conditions such as muscular dystrophy and myopathies), and 5.) osteopathic (results from conditions such as fractures, bone diseases, arthritis and infection).
III.
Epidemiology 1. Prevalence: 2% of adolescent population 2. Age a. Girls: After 9-10 years old b. Boys: After 11-12 years old 3. Gender a. Boys and girls affected equally b. Girls are much more likely to significantly progress
IV.
Anatomy and Physiology
•
The Spinal Column
The spinal column consists of individual bones called vertebrae, the building blocks, which provide support for the spine. These vertebrae are connected in the front of the spine by intervertebral discs. Discs are very strong tissues, which are filled with a gel. Discs help to support the spine, and also allow it to move. Many ligaments and muscles attached to the back of the spine (posterior aspect) provide power for movement.
•
Vertebrae in the Spinal Column
You may have heard your doctor using such terms as lumbar spine, or L5. These terms are easy and important to understand. The spinal column consists of:
1. 2. 3. 4.
seven cervical vertebrae (C1–C7) i.e. neck twelve thoracic vertebrae (T1–T12) i.e. upper back five lumbar vertebrae (L1–L5) i.e. lower back five bones (that are joined, or "fused," together in adults) to form the bony sacrum 5. three to five bones fused together to form the coccyx or tailbone. To understand scoliosis, which causes the spine to curve to the left or right, you first need to understand what a normal spine looks like. There are four regions in your spine: •
Cervical Spine: This is your neck, which begins at the base of your skull. It contains 7 small bones (vertebrae), which doctors label C1 to C7 (the 'C' means cervical). The numbers 1 to 7 indicate the level of the vertebrae. C1 is closest to the skull, while C7 is closest to the chest.
•
Thoracic Spine: Your mid-back has 12 vertebrae that are labeled T1 to T12 (the 'T' means thoracic). Vertebrae in your thoracic spine connect to your ribs, making this part of your spine relatively stiff and stable. Your thoracic spine doesn't move as much as the other regions of your spine, like the cervical spine.
•
Lumbar Spine: In your low back, you have 5 vertebrae that are labeled L1 to L5 (the 'L' means lumbar). These vertebrae are your largest and strongest vertebrae, responsible for carrying a lot of your body's weight. The lumbar vertebrae are also your last "true" vertebrae; down from this region, your vertebrae are fused. In fact, L5 may even be fused with part of your sacrum.
•
Sacrum and Coccyx: The sacrum has 5 vertebrae that usually fuse by adulthood to form one bone; the coccyx—most commonly known as your tail bone—has 4 (but sometimes 5) fused vertebrae.
From behind, the normal spine appears straight. However, when viewed from the side, you'll see that the spine has both inward and outward curves. These curves help our back carry our weight and are also important for flexibility. There are two types of curves in your spine: kyphosis and lordosis. You can see those from the side view. Kyphosis means the spine curves inward; lordosis means the spine curves outward. There are two kyphotic and two lordotic spinal curves in a normal spine. Your neck (cervical spine) and low back (lumbar spine) have a lordotic curve. Your mid back (thoracic spine) and pelvis (sacrum) have a kyphotic curve.
V. Pathophysiology:
VI. Manifestation 1. Whole body leaning to one side 2. Uneven shoulder height 3. One hip sticks up higher than the other (Parents often first notice possible
scoliosis when they see that one pant leg is shorter than the other.) 4. Uneven rib cage 5. Rib protrusion on one side of the spine o o o
o
o
o
o
Scoliosis screening should begin at age 6 years Right thoracic and left lumbar curvature is the norm Landmarks Shoulder height Scapular prominence Flank crease Pelvic symmetry Leg Length Discrepancy See Scoliosis Examination Forward Bending Test Scoliometer (measures trunk rotation) Adam's Test Determine growth spurt Assessment Tools Measure Sitting Height (Truncal Height) q3 months Obtain Risser Grading (Iliac XRay) Functional exam Neurologic Exam Gait Red Flags Left thoracic curve (possible spinal cord lesion) Neurofibromatosis stigmata Marfan's Syndrome stigmata
VII. Diagnostic Test The Adam's Forward Bending Test helps identify an unusual curve, but it can't tell you how severe the curve is. For that, you'll need to go to a doctor. Using different tests, the doctor will be able to see and measure the curve. 2. Plumb line test: This is a quick visual check to see if the spine is straight. In scoliosis, the plumb line will fall to the left or right of the spine instead of through the middle of the buttocks. 1.
3.
Scoliometer: If the doctor sees a rib hump, he or she can use a scoliometer to measure the size of the hump. It's a painless and non-invasive test.
X-ray: An x-ray can help the doctor confirm scoliosis by showing exactly where the scoliosis affects the spine and the extent of the curve. 5. Plain Radiographs (X-Rays): X-rays are not "routinely" necessary for most episodes of acute low back pain and have generally been overused. The main purpose of plain x-ray is to detect serious underlying structural, pathologic conditions. Selective criteria can be used to improve the usefulness of plain x-ray. These studies are generally not recommended in the first month of symptoms in the absence of "red flags." Oblique views are rarely indicated and increase both the cost and radiation exposure. The exception would include a young patient with an acute injury or repetitive extension activities, which can result in fracture of the pars interarticularis. 4.
VIII. Treatments •
Conservative treatment: Braces, electrical stimulation, and traction may be used to prevent progression of scoliosis and kyphosis in younger clients whose skeletons have not yet matured. Unfortunately, these approaches are ineffective in adult clients. Conservative treatments for adults include weight reduction, active and passive exercises, and the use of braces for support.
•
Surgery For adolescents and adults, the use of surgery to correct spinal deformities depend on the factors such as degree of curvature and the client’s aver-all physical, emotional, and neurologist status. Even with surgery, it is not possible to correct the abnormal curvature completely. The surgical procedures involve attaching metal reinforcing rods to the vertebrae, and are usually performed using an interior approach, although more severe curvature may require both anterior and posterior approach. The types of straightening devices used most frequently are bilateral rods with wire hooks or screws that stabilize the spine and correct the deformity.
IX. Nursing Diagnosis 1. 2. 3. 4.
Potential alteration in comfort Potential activity intolerance Risk for injury Risk for peripheral neurovascular dysfunction
X. Planning and Implementation
• •
Counseling and teaching: splint or brace use (Milwaukee or Orthoplast braces are commonly used). Teach the patient to apply and remove the splint or brace and how to care for it. Therapeutic exercises: exercises are prescribed forms of activity designed to preserve joint mobility and to strengthen specific muscle group. These may include the following: a. ROM exercises b. Active restrictive exercises ( performed against resistance of another person or with weights)
• •
•
•
Medications: medications are rarely needed except for salicylates for antiinflammatory and analgesic effects. Nutrition: a special diet is usually not prescribed except when the patient is overweight or laboratory studies indicate metabolic problems such as rickets. Assist the patient and family in planning meals that include fruits, and vegetables, proteins, and vitamins. Teach clients in ways to reduce irritation of skin surfaces beneath the brace: wearing a smooth cotton t-shirt or cotton tube under the brace at all times, changing undergarments at least once daily, and washing them with a mild soap. Undergarments should be changed more frequently in warmer weather. Teach the client to loosen braces during meals and for the first 30 minutes after each meal because these allows adequate nutritional intake and promote comfort.
XI. Evaluation and Outcome 1. Expected patient outcomes: • • •
Patient avoids potential complications. Patient maintains maximal functioning and independence. Patient participates in long-range planning of care.
2. Evaluation for conservative therapy: •
Based on the expected patient outcomes, the questions related to therapy would include the following: a. Have spinal complications been avoided? b. To what degree has the patient been able to function without back support? c. Is the patient able to describe long-range plans of care?
3. Evaluation for patient with spinal fusion: •
Based on the expected patient outcomes, the patient:
a. Can explain the nature of the surgery that has been performed. b. Maintains maximum functioning c. Is participating in physician’s follow-up program.
“SCOLIOSIS”
Submitted by: BELTRAN, Karl Leo D. BOLANTE, Sheila Marie H. BSN033 Submitted To: Prof. Pepito B. Ruzol Jr.
