SCOLIOSIS

Rey Anthony M. Saguid

Group IV Block 01
 SCOLIOSIS

Definition

Scoliosis is a medical disorder that causes an abnormal curve of the spine or backbone when viewed
from side to side. The word originated from the Greek word skoliōsis meaning "crooked condition". It
is a condition wherein the spine twists and develops an exaggerated “S” or “C” shaped lateral
curvature.

Etiology

In most cases, the cause is unknown or idiopathic, having been inherited through multiple factors,
including genetics.

Risk factors for developing the most common type of scoliosis include:

 Genetic Inheritance. Scoliosis tends to run in families, however, there is no correlation

between the severities of the curve from one generation to the next.
 Age. Signs and symptoms typically begin during the growth spurt that occurs just prior to
puberty.
 Sex. Although both boys and girls develop mild scoliosis at about the same rate, girls have a
much higher risk of the curve worsening and requiring treatment.
 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.

Incidence

A Scoliosis spinal columns curve of 10° or less affects 1.5% to 3% of individuals. The prevalence of
curves less than 20° is about equal in males and females. It is most common during late childhood,
particularly in girls.

There are congenital causes of scoliosis which often cause patients to have large curves at a very
young age due to malformed vertebrae. These scolioses can be associated with spinal cord
abnormalities as well as heart and kidney problems. The majority of scoliosis in adolescents is
idiopathic. Adult scoliosis can be from an adolescent scoliosis, or it can be what is termed a
degenerative scoliosis. Neuromuscular scoliosis occurs in patients who have abnormal nerve and/or
spinal cord function such as in cerebral palsy, spina bifida, or spinal cord injury.

Classification

There are two main classification of scoliosis:

A. Non-structural or Functional Scoliosis

A structurally normal spine appears curved due to one or more underlying conditions such as
difference in leg length, hip deformity, or spasm of the spinal muscles.

B. Structural Scoliosis
1. Congenital Scoliosis – A result of a bone abnormality such as problem with the abnormal
formation of vertebrae during prenatal period

2. Idiopathic Scoliosis – It is the most common type of scoliosis and has no specific identifiable
cause. It is further sub-classified according to when onset occurred:
a. Infantile
b. Juvenile
 c. Adolescent
d. Adult

3. Neuromuscular Scoliosis – Developed as a secondary symptom of another condition, such as

spina bifida, cerebral palsy, spinal muscular atrophy or physical trauma.

It is also described according to its curve pattern as determined by the location of the curve.

1. Thoracic – 90% of the curves occur on the right side

2. Lumbar – 70% of the curves occur on the left side
3. Thoracolumbar – 80% of the curves occur on the right side
4. Double Major – curves that occur on the right and left side

At the same time, it is also rated by the degree of the curvature. The higher the degree, the more
pronounced the scoliosis.

1. Mild – less than 25 degrees curvature

2. Moderate – 30 to 50 degrees curvature
3. Severe – Cobb’s curvature with kyphosis

Signs and Symptoms

Patients who have reached skeletal maturity are less likely to have a worsening case. Some severe
cases of scoliosis can lead to diminishing lung capacity, putting pressure on the heart, and restricting
physical activities.

The symptoms of scoliosis can include:

 Abnormal curve of the spine

 Uneven musculature on one side of the spine
 A rib prominence and/or a prominent shoulder blade, caused by rotation of the ribcage in
thoracic scoliosis
 Uneven hips / leg lengths
 Mal-alignment of trunk and pelvis
 Asymmetric size or location of breast in females
 Slow nerve action (in some cases)
 Back pain (in some cases)
Anatomy and Physiology

In human anatomy, the vertebral column (backbone or spine) is a column usually consisting of 33
vertebrae, the sacrum, intervertebral discs, and the coccyx situated in the dorsal aspect of the torso,
separated by spinal discs. It houses and protects the spinal cord in its spinal canal.

Curves

Viewed laterally the vertebral column presents several curves, which correspond to the different
regions of the column, and are called cervical, thoracic, lumbar, and pelvic.

The cervical curve, convex forward, begins at the apex of the odontoid (tooth-like) process, and ends
at the middle of the second thoracic vertebra; it is the least marked of all the curves.

The thoracic curve, concave forward, begins at the middle of the second and ends at the middle of the
twelfth thoracic vertebra. Its most prominent point behind corresponds to the spinous process of the
seventh thoracic vertebra. This curve is known as a tt curve.

The lumbar curve is more marked in the female than in the male; it begins at the middle of the last
thoracic vertebra, and ends at the sacrovertebral angle. It is convex anteriorly, the convexity of the
lower three vertebrae being much greater than that of the upper two. This curve is described as a
lordotic curve.

The pelvic curve begins at the sacrovertebral articulation, and ends at the point of the coccyx; its
concavity is directed downward and forward. .

The thoracic and pelvic curves are termed primary curves, because they alone are present during
fetal life. The cervical and lumbar curves are compensatory or secondary, and are developed after
birth, the former when the child is able to hold up its head (at three or four months) and to sit upright
(at nine months), the latter at twelve or eighteen months, when the child begins to walk.

Names of individual vertebrae

There are a total of 33 vertebrae in the vertebral column, if assuming 4 coccygeal vertebrae.

The individual vertebrae, named according to region and position, from superior to inferior, are:

 Cervical: 7 vertebrae (C1–C7)

o C1 is known as "atlas" and supports the head, C2 is known as "axis"
 Thoracic: 12 vertebrae (T1–T12)
 Lumbar: 5 vertebrae (L1–L5)
 Sacral: 5 (fused) vertebrae (S1–S5)
 Coccygeal: 3–5 (fused) vertebrae
Pathophysiology

 The vertebra turn toward the convex side and spinous process 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 often complain 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.
 Vertebral canal is narrower on the concave side and may cause spinal cord compression,
although rare, resulting in slow nerve action &/or back pain.
 Physiological changes include:
o Decrease in vital lung capacity due to compressed intrathoracic cavity on the convex
side.
o With left scoliosis, the heart is displaced downward; and in conjunction with
intrapulmonary obstruction, this can result in right cardiac hyperthrophy.

Diagnostics

Patients who initially present with scoliosis are examined to determine whether there is an underlying
cause of the deformity.

 Adams Forward Bend Test. During the exam, the patient is asked to remove his or her shirt
and bend forward trying to touch their toes.
 AP and lateral x-rays of the spine. A confirmatory diagnosis if a prominence is noted.
 Risser-Ferguson method. This utilizes straight lines drawn from the middle of the end vertebra
to the middle of the vertebrae at the apex of the curve.
 MRI. This is used if there are any neurologic changes noted on the exam or there is
something unusual in the x-ray.
 CT Scan. This is a diagnostic imaging procedure that shows detailed images of any part of
the body.
 Ultrasound. This is used to view internal organs as they function and to asses blood flow
through various vessels.

Prognosis

The prognosis of scoliosis depends on the likelihood of progression. The general rules of progression
are that larger curves carry a higher risk of progression than smaller curves, and that thoracic and
double primary curves carry a higher risk of progression than single lumbar or thoracolumbar curves.
In addition, patients who have not yet reached skeletal maturity have a higher likelihood of
progression (i.e., if the patient has not yet completed the adolescent growth spurt).

Medical Management

The medical management of scoliosis is complex and is determined by the severity of the curvature
and skeletal maturity, which together help predict the likelihood of progression.
The conventional options are, in order:

1. Observation: routine X-rays and measurements can be obtained and compared on future
visits to determine if the curve is getting worse.

2. Non-surgical approaches: conventional chiropractic and physical therapy use joint

mobilization techniques and therapeutic exercises to increase a scoliosis patient's flexibility
and strength

3. Bracing is done when the patient has bone growth remaining and is generally implemented to
hold the curve and prevent it from progressing to the point where surgery is indicated. Braces
are sometimes prescribed for adults to relieve pain. This involves fitting the patient with a
device that covers the torso and may, in some cases, involve the neck. It is usually worn 22–
23 hours a day and applies pressure on the curves in the spine. Two of the common braces
used are the Milwaukee and Yamamoto Braces.

Milwaukee Brace Yamamoto Brace

4. Surgery is usually indicated for curves that have a high likelihood of progression (i.e., greater
than 45 to 50 degrees magnitude), curves that would be cosmetically unacceptable as an
adult, curves in patients with spina bifida and cerebral palsy that interfere with sitting and
care, and curves that affect physiological functions such as breathing.
a. Harrington Rod: It is a stainless steel surgical device implanted along the spinal
column to hold correction until fusion occurs.
b. Cotrel-Dubouset Instrumentation: This treatment allows correction of some of the
features of scoliosis untreatable by Harrington rods, such as rib hump.
c. Casts and traction: This is used for pre-operative correction
i. Risser’s jacket – plaster jacket wedged open on the concave side and may be
used to gain as much soft tissue stretching as possible

ii. Halo-pelvic traction – allows greater mobility

Nursing Diagnosis

 Body image concerns related to the appearance of the deformity and immobilization in
attractive devices.
 Pain related to the extent of the defect or surgery.
 Impaired skin integrity related to pressure from braces, traction, or casts.
 Potential for serious post operative complications (neurology impaired, shock, infection,
urinary retention, paralytic ileus and cardiopulmonary problems) related to surgery.
 Anxiety related to hospitalization and surgery.

Nursing Management

Pre-Op Nursing Considerations

 Health teachings and orientation to the patient and relatives concerning scoliosis and its
treatment procedures that they can choose from.

Post-Op Nursing Considerations

 Monitor signs and symptoms to determine if there are any potential complications.
 Promote proper body alignment.
 Promote pulmonary ventilation by breathing and coughing exercises.
 Provide pain relief measures as necessary.

Discharge Planning and Home Care

 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.
 Encourage adherence to follow-up regimen.