Scoliosis

SCOLIOSIS Definition A condition wherein the spine twists and develops an exaggerated "S" or “C” shaped lateral curvature of the backbone. It is also known as a lateral or sideways curvature of the spine, which is apparent when viewing from behind. AKA ➢ It is also known as Spinal Curvature ➢ "Skoliosis" is used by Hippocrates to denote any curvature of the spinePaul Aegina tried bandaging as a form of bracing in the 7th century. INCIDENCE According to one of the Studies in the United States, Females tend to develop scoliosis than males its ratio is 1:6 (male: female) The overall incidence of scoliosis or curvature of the spine in the general population for kids in the United States greater than 14 years of age is about 1.5 percent. This figure refers to curves that measure greater than 10 degrees. Severe curves of greater than 30 degrees occur in about 0.2 percent of the general population. A closer look at the population at risk indicates that the greatest risk of developing scoliosis occurs in adolescent females, who are five times more likely to have a curve that needs treatment than their male counterparts. A new study revealed a scoliosis rate of nearly 9% in adults 40 years of age or older and links race and increasing age with the prevalence of the condition. Investigators also found that blacks had nearly half the prevalence of scoliosis than whites. However, they found that gender was not a factor in the prevalence of the condition. RISK/PREDISPOSING FACTORS ➢ Genetic Inheritance- People with scoliosis are more likely to have children with

scoliosis like them; however, there is no correlation between the severities of the curve from one generation to the next. ➢ Sex- Curves in girls are more likely to worsen than are curves in boys. ➢ Age- It can be seen at any age, but it is most common in those over 10 years old. The younger the child when scoliosis appears, the greater the chance the curve will worsen. ➢ Size of the curve- The greater the curve size, the higher the likelihood that it will worsen. ➢ Location- Curves in the middle to lower spine are less likely to progress than are those in the upper spine.

➢ Spinal problems at birth- Children who are born with scoliosis (congenital scoliosis) have a greater risk of worsening of the curve. Congenital scoliosis is thought of as a birth defect affecting the size and shape of the bones of the spine. MANIFESTATIONS ➢ Lordosis, axial rotation, and lateral curvature ➢ Asymmetry of hips and shoulders, scapulae, flanks, and breasts ➢ Shortened trunk and unequal leg lengths ➢ Skin and soft-tissue changes ➢ Patches of hair in sacral area ➢ Malalignment of trunk and pelvis ➢ Clothes do not hang right ➢ A rib “hump” CLASSIFICATION There are three main types of scoliosis: ➢ Congenital scoliosis- A result of a bone abnormality such as problem with the abnormal formation of vertebrae during prenatal period. ○ Open types are caused by myelomeningocele which can be severe. ○ Closed types can be classified according to etiology ➢ Neuromuscular scoliosis- A result of abnormal muscles or nerves, frequently

seen in people with spina bifida, muscular dystrophy, cerebral palsy and polio or in those with various conditions that are accompanied by, or result in, paralysis. ➢ Idiopathic scoliosis- The most common type of scoliosis, idiopathic scoliosis, has no specific identifiable cause. There are many theories, but none have been found to be conclusive. There is, however, strong evidence that idiopathic scoliosis is inherited. ○ Infantile: Occurs between birth and 3 years of age. Usually noticed in the first year of life. More common in boys particularly from England. Left thoracic curve occurs more common, and often resolves spontaneously. Few patients will have progressive curves which can be quite severe requiring early bracing and even surgery. ○ Juvenile: Occurs between 4-10 years of age. Incidence is equal for boys and girls. Most curves are right thoracic. Curves are progressive in nature and need close follow up. ○ Adolescent: Usually diagnosed at the age of 10. Most curves are right thoracic and thoracolumbar. Curves have a strong tendency to progress during adolescent growth spurt. Extremely active, athletic teenage girls with delayed menses are most of risk for curve progression.

There are several types of scoliosis in adults: ➢ Degenerative scoliosis- This may result from traumatic (from an injury or

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illness) bone collapse, previous major back surgery or osteoporosis (thining of the bones). Unlike the other forms of scoliosis that are found in children and teens, degenerative scoliosis occurs in older adults. . It is caused by changes in the spine due to arthritis. Weakening of the normal ligaments and other soft tissues of the spine combined with abnormal bone spurs can lead to an abnormal curvature of the spine. Paralytic Curve - "Paralytic" means that muscles do not work. When muscles do not work around the spine, the spine itself may be thrown out of balance. Over several years, this can result in a curvature of the spine developing. This type of scoliosis is often caused by spinal cord injuries that lead to paralysis. Myopathic Deformity - "Myopathic" means muscle that does not work properly. Like paralytic curves described above, this curve results from a muscular or neuromuscular disease, such as muscular dystrophy, cerebral palsy, or polio. b – Scoliosis- developed in adulthood can be a "secondary" cause of another spinal condition that affects the vertebrae, such as degeneration, osteoporosis (loss of bone mass), or osteomalacia (softening of the bones). Scoliosis can also appear following spinal surgery. The surgery may cause an imbalance in the spine that leads to scoliosis. Functional-: In this type of scoliosis, the spine is normal, but an abnormal curve develops because of a problem somewhere else in the body. This could be caused by one leg being shorter than the other or by muscle spasms in the back. Neurofibromatosis- First described by Kolliker in 1860, but von Recklinghausen coined the term in 1882. Associated with peripheral nerves, causing cutaneous and subQmanifestations. High incidence of kyphosis and scoliosis. Etiologyis unknown but may be due to neurofibromas enlargement in the foramina between vertebral bodies. Spinal deformities must be treated aggressively with anterior and posterior fusion. Others- There are other potential causes of scoliosis, including spine tumors such as osteoid osteoma. This is a benign tumor that can occur in the spine and cause pain. The pain causes people to lean to the opposite side to reduce he amount of pressure applied to the tumor. This can lead to a spinal deformity.

PATHOPHYSIOLOGY ➢ The vertebra turn toward the convex side and spinous processes rotate

toward the concave side in the area of the major curve. ➢ As the vertebra rotate, they push the ribs on the convex side posteriorly and

at the same time, crowd the ribs on the concave side together as well as push them anteriorly. The posterior displaced ribs cause the characteristic hump in the back with forward flexion. Young girls with scoliosis would often complain

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of unequal breasts. This is due to recess of the chest wall on the convex side of the curve. Disc space is narrower on the concave side and wider on the convex side. The vertebra may become wedged on the concave side in serve cases. The lamina and pedicles are also shorter. Vertebral canal is narrower on the concave side. Spinal cord compression is rare even in serve cases. Physiological changes include: ○ Decrease in lung vital capacity due to a compressed intrathoracic cavity on the convex side. ○ With left scoliosis, the heart is displaced downward; and in conjunction with intrapulmonary obstruction, this can result in right cardiac hypertrophy.

DIAGNOSTIC STUDIES ➢ Forward Bending Test- is a test used most often in schools and doctor’s offices to screen for scoliosis. During the test, the child bends forward with the feet together and knees straight while dangling the arms. ➢ Cobb Diagnostic Method- This method relies on the accuracy of identifying the vertebra at the upper and lower end of the curve. These end vertebrae are those with maximal tilt toward the concave side. Horizontal lines are then drawn at the superior border of the superior end vertebrae and at the inferior border of the inferior end vertebrae. Perpendicular lines to these two horizontal lines will intersect. The angle formed is the Cobb angle, the degree of scoliosis. The advantage of the Cobb method is that it has high inter-rater reliability. ➢ AP and Lateral X-rays of the Spine ➢ Risser-Ferguson method- Straight lines are drawn from the middle of the end vertebra to the middle of the vertebrae at the apex of the curve. This method is not frequently used. ➢ Scoliometer- A device used to measure the curvature of the spine. ➢ MRI- It is used if there are any neurologic changes noted on the exam or there is something unusual in the X-ray. MANAGEMENT a. Medical

➢ Spinal bracing 1. In 1945, Blount developed the Milwaukee brace, which has undergone several modification to reduce weight and bulkiness. Bracing was enthusiastically endorsed in the 1960's. Sentiment shifted in the 1980's to the extreme that Professor Robert Dickson of Leeds, England, stated that there was no place for bracing in the treatment of idiopathic scoliosis. Since then, the pendulum has

swung back. Several good studies looking at the natural progression of scoliosis and bracing for each specific curve patterns and age groups clearly demonstrated the effectiveness of bracing in preventing the progression of scoliosis. 2. Based on study on the natural history by Lonstein, it is obvious that bracing is not needed for curve less than 19 with a Risser of 2,3, or 4. In contrast, a child with a Risser 0 or 1 with a curve between 20-29 degrees is at a significant risk of curve progression. 3. Three studies that set the standards of bracing for this high risk group: ○ Lonstein and Winter: 1020 patients treated with Milwaukee brace. Those patients with thoracic curves of 20-29 degrees and Risser 0-1, only 40% showed progression at the end of bracing (vs 68% if not braced). ○ Bassett: 71 patients with curves 20-29 degrees and Risser 0-1. Only 36% of those with thoracic curves progressed. ○ Durand: 477 patients. At 2-5 year follow up, only 21% of patients had progressed. 4. The purpose of bracing is to halt progression of the curve. It may provide a temporary correction, but usually the curve will assume its original magnitude when bracing is eliminated. In children with immature skeletons and remaining growth potential, Schroth-method physical therapy is used in combination with the Rigo System-Cheneau brace, not only to prevent progression of (and often reduce) the abnormal curvature, but also to train and strengthen patients in holding their bodies in a corrected position after completion of the bracing treatment (i.e., when the skeleton has reached maturity). A patient’s consistent practicing of an individualized Schroth program has been clinically shown to inhibit the mechanical forces, exacerbated by poor postural habits and gravity, that otherwise perpetuate the progression of the curvature over time (the so-called “vicious cycle”), even after the cessation of physical growth b. Surgical ➢ Spinal fusion Those who have curves beyond 40 to 50 degrees are often considered for scoliosis surgery. Spinal fusion is the most widely performed surgery for scoliosis. In this procedure, bone (either harvested from elsewhere in the body [autograft], or donor bone [allograft]) is grafted to the vertebrae so that when it heals, they will form one solid bone mass and the vertebral column becomes rigid. This prevents worsening of the curve at the expense of spinal movement. This can be performed from the anterior (front) aspect of the spine by entering the thoracic or abdominal cavity, or performed from the back (posterior). A combination of both is used in more severe cases. In 1914 the first fusion performed by Russell Hibbs

Originally, spinal fusions were done without metal implants. A cast was applied after the surgery, usually under traction to pull the curve as straight as possible and then hold it there while fusion took place. Unfortunately, there was a relatively high risk of pseudarthrosis (fusion failure) at one or more levels and significant correction could not always be achieved. In 1962, Paul Harrington introduced a metal spinal system of instrumentation which assisted with straightening the spine, as well as holding it rigid while fusion took place. The original, now obsolete Harrington rod operated on a ratchet system, attached by hooks to the spine at the top and bottom of the curvature that when cranked would distract, or straighten, the curve. A major shortcoming of the Harrington method was that it failed to produce a posture where the skull would be in proper alignment with the pelvis and it didn't address rotational deformity. As a result, unfused parts of the spine would try to compensate for this in the effort to stand up straight. As the person aged, there would be increased wear and tear, early onset arthritis, disc degeneration, muscular stiffness and pain with eventual reliance on painkillers, further surgery, inability to work full-time and disability. "Flatback" became the medical name for a related complication, especially for those who had lumbar scoliosis.[vague] Modern spinal systems are attempting to address sagittal imbalance and rotational defects unresolved by the Harrington rod system. They involve a combination of rods, screws, hooks and wires fixing the spine and can apply stronger, safer forces to the spine than the Harrington rod. This technique is known as the Cotrel-Dubousset instrumentation, currently the most common technique for the procedure. In young children, another technique that does not involve fusion may be used since fusion stops growth of the fused part of the spine. In this case, a brace must always be worn after surgery.

➢ Surgery without fusion New implants have been developed that aim to delay spinal fusion and to allow more spinal growth in young children. For the youngest patients, whose thoracic insufficiency compromises their ability to breathe and applies significant cardiac pressure, ribcage implants that push the ribs apart on the concave side of the curve may be especially useful. These Vertical Expandable Prosthetic Titanium Ribs (VEPTR) provide the benefit of expanding the thoracic cavity and straightening the spine in all three dimensions while allowing the spine to grow. Although these methods are novel and promising, these treatments are only suitable for growing patients. Spinal fusion remains the "gold standard" of surgical treatment for scoliosis. Surgery is usually required if the spine has a curve of 40 to 50 degrees. ➢ A new scoliosis treatment that uses screws to secure flexible, stainless steel, or titanium rods to the spinal column. NURSING DIAGNOSIS 1.) Body Image concerns related to the appearance of the deformity and immobilization in attractive devices. 2.) Pain related to the extent of the defect or surgery.

3.) Impaired skin integrity related to pressure from braces, traction or casts. 4.) Potential for serious post operative complications (neurology impaired, shock, infection, urinary retention, paralytic ileusand cardiopulmonary problems) related to surgery. 5.) Anxiety related to hospitalization and surgery.

NURSING RESPONSIBILITIES Pre-Op Nursing Considerations for Scoliosis: ➢ Health Teachings and orientation to the patient and relatives concerning scoliosis and its treatment procedures that they can chose from. Post-Op Nursing Considerations for Scoliosis: ➢ Monitor for s/s to determine if there are any potential complications ➢ Promote proper body alignment ➢ Promote pulmonary ventilation by breathing and coughing exercises. ➢ Monitor fluid and electrolyte balance to assess dehydration. ➢ Provide pain relief measures as necessary. Discharge Planning and Home Care - post-op for Scoliosis: ➢ Instruct the patient and family about the various aspects of care that can be done for scoliosis patients at home. ➢ Encourage to patient ventilate fears and body image concerns to his/her relatives and love one’s. ➢ Encourage adherence to follow-up regimen ILLUSTRATIONS

REFERENCES: www.medicinenet.com www.webmd.com www.encarta.com www.spinalmedicine.com