REPUBLIC OF THE PHILIPPINES

Mariano Marcos State

University
COLLEGE OF HEALTH SCIENCES
Department of Nursing
Batac City, 2906, Ilocos Norte

Kyphosis
Lordosis
Scoliosis
Submitted by:
Danielle B. Quigao
Group 3 | BSNIII-A

Submitted to:
Mrs. Penielle M. Asia
Clinical Preceptor

March 2015

KYPHOSIS
Description
Kyphosis, also known as a round back or hunchback, is a condition in which the spine in the
upper back has an excessive curvature. The upper back, or thoracic region of the spine, is
supposed to have a slight natural curve. The spine naturally curves in the neck, upper back, and
lower back to help absorb shock and support the weight of the head. Kyphosis occurs when this
natural arch is larger than normal.
Other potential causes of kyphosis include:

aging (especially if you have poor posture)

muscle weakness in the upper back

Scheuermanns disease (occurs in children and has no known cause)

arthritis or other bone degeneration diseases

osteoporosis (loss of bone strength due to age)

injury to the spine

slipped discs

scoliosis (spinal curvature)

Less commonly, the following may also lead to kyphosis:

infection in the spine

birth defects, such as spina bifida

tumors

diseases of the endocrine system

diseases of the connective tissues

polio

Pagets disease

muscular dystrophy

Types of Kyphosis
This spinal deformity can take several forms and treatment depends on the cause of the condition
as well as severity of symptoms. The following are the most common causes and treatment
options:

Osteoporosis-related kyphosis. The most common cause of kyphosis in adults is from

vertebral fracture due to osteoporosis. This can occur in both men and women, but is
more common in females than in males.2 As osteoporosis weakens the vertebral bones in
the spine, the vertebrae are susceptible to fracture that typically occurs in a wedge shape
with the front of the vertebra collapsing and losing its height and the back of the
vertebra maintaining its height. As the front of the bone is crushed, that segment of the
spine tips forward, resulting in an excessive kyphotic curve and forward stooped posture.
Treatment typically will address the underlying osteoporosis (to prevent future fractures)
as well as pain reduction and possibly surgical repair of the fracture.

Congenital kyphosis. This form of kyphosis typically presents itself in infants and young
children, due to a malformation of the spinal column in the womb. Unlike other forms of

kyphosis, this form most often requires surgery (at a young age) to re-align the spine and
prevent progression of the deformity.

Degenerative kyphosis. This form of deformity develops due to wear and tear on the
spine over time. The underlying cause of the kyphosis typically is spinal
arthritis with degeneration of the discs.

Neuromuscular kyphosis. This form of the deformity can occur in children with certain
neuromuscular disorders, such as cerebral palsy, spina bifida, or muscular dystrophy.
Surgery can be an option to improve quality of life.

Nutritional kyphosis. This condition is caused by certain vitamin deficiencies during

childhood, such as a vitamin D deficiency.

Postural kyphosis. This form of kyphosis is attributed to poor posture and slouching. It
occurs in both young and older patients, is more prominent in females than in males, and
rarely causes pain.Exercises to strengthen abdominal and back muscles can help correct
kyphosis from poor posture and maintain a more normal alignment.

Scheuermann's Disease. It is estimated that 4 to 8% of the general population may suffer

from Scheuermann's kyphosis.3 This condition occurs in adolescents due to abnormal
growth of the spine and discs. It may become clinically evident in adolescents or adults,
and is more common in males. Patients typically also have a mild scoliosis. The condition
is typically treated with a brace, exercise, and physical therapy. Braces are indicated if the
patient is still growing and has moderate to severe kyphosis with curves of 45 degrees or
more and may have a long-term corrective effect. Bracing in adults for this condition is
uncommon, with a goal of controlling pain, not correcting the kyphosis. Specific
exercises may be recommended to strengthen the abdominal muscles and increase spinal
flexibility. Surgery may be required for painful curves that are greater than 70 degrees or
are progressive.

Traumatic kyphosis. This can occur from mis-aligned healing of a spinal fracture or
injury to the supporting ligaments of the spine.

Iatrogenic kyphosis. "Iatrogenic" means "as a result of medical intervention," and refers
to kyphosis developing as a complication of surgical treatment of the spine. Postlaminectomy kyphosis is the most common type of iatrogenic kyphosis, which can
develop following decompressive spine surgery requiring removal of the posterior
elements of the spine (the spinous processes, laminae, and intervening ligaments),
typically for tumor removal in children and adolescents.

Risk Factors
o Genetics. Abnormalities in the formation and development of the bone may be inherited
from one generation to another.
o Poor posture. Poor posture in childhood, such as slouching, leaning back in chairs and
carrying heavy schoolbags, can cause the ligaments and muscles that support the
vertebrae to stretch. This can pull the thoracic vertebrae out of their normal position,
resulting in kyphosis.
o Bone abnormalities. Kyphosis can also be caused when the vertebrae do not develop
correctly. They can take on a wedged, triangular shape, rather than the
normal rectangular, box-like shape. This leads to the vertebrae being out of position
and is known as Scheuermanns kyphosis. It is not known what disrupts the normal
formation of the spine. One idea is that the blood supply to the vertebrae becomes
disrupted, affecting the growth of the vertebrae. There also appears to be a genetic link,
as the condition occasionally runs in families.
o Maternal complications during pregnancy. Congenital kyphosis is caused when
something disrupts the normal development of the spine before birth. In many cases, two
or more of the vertebrae fuse together. It is often unclear why certain children are affected

in this way. However, some cases of congenital kyphosis run in families, so it seems
that genetics also play a role in this type of kyphosis.
o Osteoporosis. As bones weaken with age caused by degenerative changes and nutritional
deficits causing bone resorption of Calcium and Phosphorous, a person is more prone to
developing deformities in the spine.
o Obesity. Obesity is recognised as a major public health problem in industrialized
countries and it is associated with various musculoskeletal disorders, including
impairment of the spine, which causes increased anterior pelvic tilt; under dynamic
conditions, to impaired mobility of the thoracic spine.
Pathophysiology
The spine presents 4 balanced sagittal curves (cervical lordosis, thoracic kyphosis, lumbar
lordosis and sacrum-coccigeal kyphosis), which presence has been interpreted from a
biomechanical point of view as increasing mechanic resistance of the spine, increasing its ability
to absorb shocks as well as its flexibility.
Normal limits of vertebral sagittal curves is controversial. At thoracic spine, values above 50 to
55 are considered as a kyphotic deformity and at cervical or lumbar spine, any curve with a
dorsal angulation may be considered as a pathologic kyphosis.
Etiology of pathologic kyphosis includes a number of diseases (congenital, growth alterations,
trauma, tumors, infectious processes, degenerative or iatrogenic) which disturb spine
biomechanics in its basic functions. Elements taking part in anterior portion of the spine
(vertebral body and intervertebral disc) resist to compression forces and the posterior ones
(lamina, joints, supra and interespinous ligaments) resist traction forces. A kyphotic deformity
takes place when the spine is unable to resist to one or both forces (compression or traction).
Manifestations

Difficulty breathing (in severe cases)

Fatigue

Mild back pain

Round back appearance

Tenderness and stiffness in the spine

In rare cases, this can lead to compression of the spinal cord with neurologic symptoms
including:
o weakness
o loss of sensation
o loss of bowel and bladder control
Severe cases of thoracic kyphosis can also limit the amount of space in the chest and cause
o cardiac and pulmonary problems leading to chest pain or shortness of breath
o pulmonary and/or heart failure.
Diagnostic Procedures
o Laboratory Studies
Standard laboratory results should be evaluated whenever surgical intervention is being
considered. The laboratory workup should include determination of a complete blood count,
coagulation studies, and routine chemical analyses.

Autodonation of blood can be recommended to the patient in anticipation of the need for
intraoperative transfusion.
In patients with a known or suspected infectious etiology, the sedimentation rate and C-reactive
protein level should be measured to help identify a potential infection or to help track the
progress of treatment.
Before a major operation, the patient's nutritional status might also be checked, because it
considerably influences a patient's ability to heal.
o Imaging Studies
Radiography
Radiographs are crucial for both diagnosing kyphosis and for planning treatment. The most
useful radiographs are upright posteroanterior and lateral images of the entire spine. These views
enable the reviewer to assess the sagittal balance of the entire spine and to determine if a
scoliosis is present. Measurements are made on radiographs by using the standard Cobb
technique for scoliosis, which has been adapted to the measurement of kyphosis. Thoracic
kyphosis is measured from T1-T12, though the upper thoracic vertebral endplates are often
difficult to see. Normal measurements for thoracic spine vary widely, but the accepted definition
of normal according to the Scoliosis Research Society is 20-40. A plumb line dropped from C7
should pass through or just anterior to S1 on a lateral full-length image. This technique helps in
assessing and quantifying the patient's overall sagittal alignment.
Magnetic resonance imaging
MRI can be a useful adjunct in planning treatment for patients with kyphosis. If a neurologic
abnormality is present, MRI may aid in localizing impingement on neural structures. If surgery is
being planned for the treatment of postinfectious kyphosis, an MRI helps in planning an anterior
approach with regard to the amount of resection needed (if any) to remove diseased bone.
o Other Tests
Ensuring the adequacy of bone density is imperative when surgical correction of kyphosis is
being considered. Correction of the kyphosis relies on instrumentation to reduce the spine, and
considerable forces are placed on the instrumentation-bone interface. Osteopenic bone can
predispose to loss of correction over time, if the instrumentation cuts through the relatively less
dense vertebrae. If a patient's bone density is in question, bone densitometry can be perform to
quantify it. Efforts should be made to a patient's improve bone density before and following
surgery. When bone density is poor, the surgeon must usually increase the number of points of
fixation to reduce the stress at each point.
Treatment
Medical therapy for kyphosis consists of exercise, medication, and bracing. Physical therapy,
which usually consists of extension-focused activities, may be of some benefit; however, this has
not been proven.
Medications to treat discomfort associated with kyphosis should be limited to nonsteroidal antiinflammatory drugs and, possibly, muscle relaxants. Narcotics should be avoided as long-term
treatment of pain associated with kyphosis.
If a patient has an active infection, such as diskitis or vertebral osteomyelitis, appropriate
antibiotics based on culture results should be started as soon as possible.
A diagnosis of kyphosis is generally made through observation and measurement. Idiopathic
causes, such as vertebral wedging or other abnormalities, can be confirmed through X-ray.
thoracic kyphosis can often be treated with posture reeducation and focused strengthening
exercises. Idiopathic thoracic kyphosis due to vertebral wedging, fractures, or vertebral
abnormalities is more difficult to manage, since assuming a correct posture may not be possible
with structural changes in the vertebrae. Children who have not completed their growth may
show long-lasting improvements with bracing. Exercises may be prescribed to alleviate

discomfort associated with overstretched back muscles. A variety of gravity-assisted positions or

gentle traction can minimize pain associated with nerve root impingement. Surgery may be
recommended for severe idiopathic kyphosis.
o Orthosis (brace)
Modern brace for the treatment of a thoracic kyphosis. The brace is constructed using a
CAD/CAM device. Body braces showed benefit in
a randomised controlled trial.
The Milwaukee brace is one particular body brace that is
often
used
to
treat
kyphosis
in
the
US.
Modern CAD/CAM braces are used in Europe to treat
different types of kyphosis. These are much easier to wear
and have better in-brace corrections than reported for the
Milwaukee brace. Since there are different curve patterns
(thoracic, thoracolumbar and lumbar), different types of
brace are in use, with different advantages and disadvantages.
Modern brace for the treatment of a lumbar or thoracolumbar kyphosis. The brace is constructed
using a CAD/CAM device. Restoration of the lumbar lordosis is the main aim.
o Specialised physical therapy
In Germany, a standard treatment for both Scheuermann's disease and lumbar kyphosis is the
Schroth method, a system of physical therapy for scoliosis and related spinal deformities. It
involves lying supine, placing a pillow under the scapular region and posteriorly stretching the
cervical spine.
o Surgery
Surgical treatment can be used in severe cases. In patients with progressive kyphotic deformity
due to vertebral collapse, a procedure called a kyphoplasty may arrest the deformity and relieve
the pain. Kyphoplasty is a minimally invasive procedure, requiring only a small opening in the
skin. The main goal is to return the damaged vertebra as close as possible to its original height.
Complications
The risk of serious complications from spinal fusion surgery for kyphosis is estimated to be 5%,
similar to the risks of surgery for scoliosis. Possible complications may be inflammation of the
soft tissue or deep inflammatory processes, breathing impairments, bleeding, and nerve injuries.
According to the latest evidence, the actual rate of complications may be substantially higher.
Even among those who do not suffer serious complications, 5% of patients require re-operation
within five years of the procedure, and in general it is not yet clear what to expect from spine
surgery in the long-term. Taking into account that signs and symptoms of spinal deformity
cannot be changed by surgical intervention, surgery remains to be a cosmetic indication.
Unfortunately, the cosmetic effects of surgery are not necessarily stable.
Nursing Responsibilities
o Continually assess motor function by requesting patient to perform certain actions like
shrugging shoulders, spreading fingers.
Rationale: Evaluates status of individual situation, affecting type and choice of interventions.
o Assist with full range of motion exercises in all extremities and joints using slow, smooth
movements.
Rationale: Enhances circulation, restores muscle tone and joint mobility.
o Position arms at 90-degree angle at regular intervals.
Rationale: Prevents frozen shoulder contractures.

o Elevate lower extremities at intervals when in chair or raise foot or bed when permitted in
individual situation.
Rationale: Loss of vascular tone and muscle action results in pooling of blood and venous
stasis in the lower abdomen and lower extremities, with increased risk of hypotension and
thrombus formation.
o Plan activities to provide uninterrupted rest periods. Encourage involvement within
individual tolerance ability.
Rationale: Prevents fatigue, allowing opportunity for maximal efforts or participation by the
patient.
o Encourage use of relaxation techniques.
Rationale: Reduces muscle tension, may limit pain of muscle spasm.
o Inspect skin daily. Observe for pressure areas and provide meticulous care.
Rationale: To assess for altered circulation, loss of sensation or paralysis which may
potentiate pressure sore formation.
o Consult with physical therapist.
Rationale: Helpful in planning and implementing individualized exercise program and
identifying assistive devices to maintain function, enhance mobility and independence.

LORDOSIS
Description
The term lordosis refers to the abnormal inward curvature of the lumbar and cervical regions of
the spine. Excessive or hyperlordosis can happen and lumbar hyperlordosis is commonly referred
to as sway back, hollow back or saddle back, a term that originates from the similar condition
that arises in some horses. A major factor of lordosis is forward pelvic tilt, when the pelvis tips
forward when resting on top of the thighs. Curvature in the opposite direction is
termed kyphosis.
Normal lordotic curvatures, also known as secondary curvatures results in a difference in the
thickness between the front and back parts of the intervertebral disc. Lordosis may also increase
at puberty sometimes not becoming evident until the early or mid-20s. Imbalances in muscle
strength and length are also a cause, such as weak hamstrings, or tight hip flexors (psoas).
Other health conditions and disorders can cause lordosis. Achondroplasia (a disorder where
bones grow abnormally which can result in short stature as in dwarfism), Spondylolisthesis (a
condition in which vertebrae slip forward) and osteoporosis (the most common bone disease in
which bone density is lost resulting in bone weakness and increased likelihood of fracture) are
some of the most common causes of lordosis. Other causes include obesity, kyphosis (spine
curvature disorder in which the thoracic curvature is abnormally rounded), discitits (an
inflammation of the intervertebral disc space caused by infection) and benign juvenile lordosis.
Excessive lordotic curvature is also called hyperlordosis, hollow back, saddle back,
and swayback, although swayback can also refer to a nearly opposite postural misalignment that
can initially look quite similar.Common causes of excessive lordosis include tight low
back muscles, excessive visceral fat, and pregnancy. Rickets, a vitamin D deficiency in children,
can cause lumbar lordosis.
Risk Factors
o Genetics. Abnormalities in the formation and development of the bone may be inherited
from one generation to another.
o Congenital defects of the Spine. All congenital disorders involve small anomalies and
anatomical defects that can throw out the smooth-running operation of the spine by subtly
altering the biomechanics and the forces through the joints. This creates
an acquired strain that makes the pain levels - and the breakdown rate - of the original
spinal condition much more variable.
o Poor posture. Poor posture in childhood, such as slouching, leaning back in chairs and
carrying heavy schoolbags, can cause the ligaments and muscles that support the
vertebrae to stretch. This can pull the thoracic vertebrae out of their normal position,
resulting in lordosis.
o Presence of underlying abnormalities such as:
Achondroplasia a genetic disorder that results in abnormal cartilage growth and
dwarfism

Spondylolisthesis displaced vertebrae of back

o Osteoporosis. As bones weaken with age caused by degenerative changes and nutritional
deficits causing bone resorption of Calcium and Phosphorous, a person is more prone to
developing deformities in the spine.
o Obesity. Obesity is recognised as a major public health problem in industrialized
countries and it is associated with various musculoskeletal disorders, including
impairment of the spine, which causes increased anterior pelvic tilt; under dynamic
conditions, to impaired mobility of the thoracic spine.

o Anatomical Risk Factors:

Spines - Natural factors of how spines are formed greatly increase

certain individuals likelihood to experience a strain or sprain in their back or
neck. Factors such as having more lumbar vertebrae allowing for too
much flexibility, and then in cases of less lumbar having the dancer not reaching
their necessity for flexibility and then pushing their bodies to injury.

Legs and Knees - Another odd body formation is when an

individual has a leg shorter than the other, which can be immediate cause for
imbalance of hips then putting strain on the posture of the back which a dancer
has to adjust into vulnerable positions to meet aesthetic appearances. This can
lead to permanent damage in the back. Genu recurvatum (Sway back knees) is
also a factor that forces a dancer to adjust into un-stable postures.

Hips - Common problems in the hips are tight hip flexors, which
causes for poor lifting posture, hip flexion contracture, which means the lack of
postural awareness, and thoracic hyperkyphosis, which causes the dancer to
compensate for limited hip turn out (which is essential to dances such as ballet).
Weak psoas (short for iliopsoas-muscle that controls the hip flexor) force the
dancer to lift from strength of their back instead of from the hip when lifting their
leg into arabesque or attitude. This causes great stress and risk of injury,
especially because the dancer will have to compensate to obtain the positions
required.

Muscles - One of the greatest contributors is uneven muscles.

Because all muscles have a muscle that works in opposition to it, it is imperative
that to keep all muscles protected, the opposite muscle is not stronger than the
muscle at risk. In the situation of lumbar lordosis, abdominal muscles are weaker
than the muscles in the lumbar spine and the hamstring muscles. The muscular
imbalance results in pulling down the pelvis in the front of the body, creating the
swayback in the spine.

Growth Spurt -Younger dancers are more at risk for development

of lumbar hyperlordosis because the lumbar fascia and hamstrings tighten when a
child starts to experience a growth spurt into adolescence.

o Being a dancer causing:

Improper Lifts -When male dancers are performing dance lifts with another
dancer they are extremely prone to lift in the incorrect posture, pushing their arms
up to lift the other dancer, while letting their core and spine curve which is easy to
then hyperlordosis in a dancers back.
Bad Dance Floors -Dancing on too hard of dance floors like concrete or pavement
can be bad for lower limbs and joints. In comparison dancing on too soft of floors
such as carpet gives no support for ankles.
Overuse -Over 45% of anatomical sites of injury in dancers are in the lower back.
This can be attributed to the strains of repetitive dance training may lead to minor
trauma. If the damaged site is not given time to heal the damage of the injury will
increase. Abrupt increases in dance intensity or sudden changes in dance
choreography do not allow the body to adapt to the new stresses. New styles of
dance, returning to dance, or increasing dance time by a great deal will result in
exhaustion of the body.
Manifestations
o

C-shape back when seen from a lateral aspect, with the buttocks being more prominent

A large gap between the lower back and the floor when lying on ones back

Pain and discomfort in the lower back

Problems in moving in certain ways

Diagnostic Procedures
To diagnose lordosis, a doctor may take the patient's medical history and perform a physical
examination. The medical history will cover such issues as when the excessive curve became
noticeable, if it is getting worse and whether the amount of the curve seems to change. During
the examination, the patient will be asked to bend forward and to the side to see whether the
curve is flexible or fixed, how much range of motion the patient has and if the spine is aligned
properly. The doctor may feel the spine, checking for abnormalities.
The doctor may order a neurological assessment if the person is having pain, tingling, numbness,
muscle spasms or weakness, sensations in his or her arms or legs or changes in bowel or bladder
control. Other tests may be ordered, including X-rays of the spine as a whole and the lower back
where the spine joins the pelvis.
Measurement and diagnosis of lumbar lordosis can be difficult. Obliteration of vertebral endplate landmarks by interbody fusion may make the traditional measurement of segmental lumbar
lordosis more difficult. Because the L4-L5 and L5-S1 levels are most commonly involved in
fusion procedures, or arthrodesis, and contribute to normal lumbar lordosis, it is helpful to
identify a reproducible and accurate means of measuring segmental lordosis at these levels.
A visible sign of lordosis is an abnormally large arch of the lower back and the person appears to
be puffing out his or her stomach and buttocks. Precise diagnosis of lordosis is done by looking
at a complete medical history, physical examination and other tests of the patient. X-rays are
used to measure the lumbar curvature, bone scans are conducted in order to rule out possible
fractures and infections, magnetic resonance imaging (MRI) is used to eliminate the possibility
of spinal cord or nerve abnormalities, and computed tomography scans (CT scans) are used to
get a more detailed image of the bones, muscles and organs of the lumbar region.
Diagnostic procedures may include:
o

X-rays. This diagnostic test uses invisible electromagnetic energy beams to produce
images of internal tissues, bones, and organs onto film. This test is used to measure and
evaluate the curve. With the use of a full-spine X-ray, the doctor or radiologist measures
the angle of the spinal curve. A determination for treatment can often be made based on
this measurement.

Bone scans. Bone scans are a nuclear imaging method to evaluate any degenerative
and/or arthritic changes in the joints; to detect bone diseases and tumors; to determine the
cause of bone pain or inflammation. This test is to rule out any infection or fractures.

Magnetic resonance imaging (MRI). This diagnostic procedure uses a combination of

large magnets and a computer to produce detailed images of organs and structures within
the body. This test is done to rule out any associated abnormalities of the spinal cord and
nerves.

Computed tomography (CT) scan. This diagnostic imaging procedure uses a

combination of X-rays and computer technology to produce horizontal, or axial, images
(often called slices) of the body. A CT scan shows detailed images of any part of the
body, including the bones, muscles, fat, and organs. CT scans are more detailed than
general X-rays.

Treatment
o Non-Surgical Treatment
Analgesics and anti-inflammatory medication.
Physical therapy enabling the patient to build strength, flexibility, and increase range of
motion. The therapist may provide a customized home exercise program. Exercises.
There are many postural and muscle related factors that contribute to lordosis. These are

weak core muscles, tight hip flexors, poor exercise techniques and weak gluteal muscles.
Some of these problems may be corrected with lordosis exercises. These include:

Pelvic tilt- pelvic tilt position is the position exactly opposite of the arched back
position. It can help to correct lordotic posture if applied daily. The patient must lie on
his/ her back with his/her knees bent and feet flat on the floor. Then he/she should
inhale properly. After that, he/she should exhale and tilt the lower part of pelvis
simultaneously. Twenty repetitions of this exercise must be performed daily.

Stability Ball Bridge- this exercise strengthens the gluteal muscles. Patient must lie on
his back with his calves draped over the ball. Start with a pelvic tilt and the squeeze the
butt until a bridge position is obtained. When the patient rolls down, he must try to feel
that each vertebra is touching the floor. The patients lower back should touch the floor
before your pelvis. Make 12 repetitions daily.

Knees to Chest Stretch and Heel Slide- Patient must lie on his back with his knees bent
and then he should lift both legs from the floor and draw the knees to his chest. After
that, he should lower one heel to the floor. He should keep the opposite knee close to
his chest. Then he shall rotate the other heel along the floor until the leg is straight.
Make 8 repetitions daily

Bracing may be used control curve progression in adolescents.

Reduction of body weight to ideal.
Surgery may be considered if the lordotic curve is severe with neurologic involvement.
o Spine Surgery
Surgical intervention is considered if the lordotic curve is severe, when neurologic involvement
exists, or non-surgical conservative treatment has failed to provide relief. A spine surgeon
decides which surgical procedure and approach (anterior/posterior, front or back) is best for the
patient. His decisions are based on the patient's medical history, symptoms, and radiographic
findings. A variety of surgical treatment options are utilized. One should discuss what is best for
his condition with his spine surgeon.
Nursing Responsibilities
Nursing Priorities
1. Maximize respiratory function.
2. Prevent further injury to spinal cord.
3. Promote mobility/independence.
4. Prevent or minimize complications.
5. Support psychological adjustment of patient/SO.
6. Provide information about injury, prognosis and expectations, treatment needs, possible
and preventable complications.
Discharge Goals
1. Ventilatory effort adequate for individual needs.
2. Spinal injury stabilized.
3. Complications prevented/controlled.
4. Self-care needs met by self/with assistance, depending on specific situation.
5. Beginning to cope with current situation and planning for future.
6. Condition/prognosis, therapeutic regimen, and possible complications understood.
7. Plan in place to meet needs after discharge.

o Perform and assist with full ROM exercises on all extremities and joints, using slow,
smooth movements. Hyperextend hips periodically.
Rationale: Enhances circulation, restores and maintains muscle tone and joint mobility, and
prevents disuse contractures and muscle atrophy.
o Plan activities to provide uninterrupted rest periods. Encourage involvement within
individual tolerance and ability.
Rationale: Prevents fatigue, allowing opportunity for maximal efforts and participation by
patient.
o Prepare for weight-bearing activities like the use of tilt table for upright position,
strengthening and conditioning exercises for unaffected body parts.
Rationale: Early weight bearing reduces osteoporotic changes in long bones and reduces
incidence of urinary infections and kidney stones. Note: Fifty percent of patients develop
heterotopic ossification that can lead to pain and decreased joint flexibility.
o Administer medications as indicated: muscle relaxants: dantrolene (Dantrium), baclofen
(Lioresal); analgesics; antianxiety agents: diazepam (Valium).
Rationale: May be desired to relieve muscle spasm and pain associated with spasticity or to
alleviate anxiety and promote rest.

SCOLIOSIS
Description
Scoliosis is an abnormal curving of the spine. The normal spine has gentle natural curves that
round the shoulders and make the lower back curve inward. Scoliosis typically causes
deformities of the spinal column and rib cage. In scoliosis, the spine curves from side-to-side to
varying degrees, and some of the spinal bones may rotate slightly, making the hips or shoulders
appear uneven. It may develop in the following way:

As a single primary side-to-side curve (resembling the letter C), or

As two curves (a primary curve along with a compensating secondary curve that forms an
S shape)

Scoliosis most commonly develops in the area between the upper back (the thoracic area) and
lower back (lumbar area). It may also occur only in the upper or lower back. The doctor attempts
to define scoliosis by the following characteristics:

The shape of the curve

Its location

Its direction

Its magnitude

Its causes, if possible

The severity of scoliosis is determined by the extent of the spinal curve and the angle of the trunk
rotation (ATR). It is usually measured in degrees. Curves of less than 20 degrees are considered
mild and account for 80% of scoliosis cases. Curves that progress beyond 20 degrees need
medical attention. Such attention, however, usually involves periodic monitoring to make sure
the condition is not becoming worse.
Causes of the Different Types of Scoliosis
IDIOPATHIC SCOLIOSIS
In 80% of patients, the cause of scoliosis is unknown. Such cases are called idiopathic scoliosis.
(Idiopathic means without a known cause.) Idiopathic scoliosis may be due to multiple, poorly
understood inherited factors, most likely from the mother's side. However, the severity often
varies widely among family members who have the condition, suggesting that other factors must
be present.
Idiopathic scoliosis may be classified based on age of presentation. Age of onset may also
determine the treatment approach. The classification is as follows:

Infantile: Up to 3 years old

Juvenile: Four to 9 years old

Adolescent: Ten years old through the teen years

Idiopathic scoliosis may be initially diagnosed in adults during evaluation for other back
complaints or disorders, although the curve is unlikely to be significant.
CONGENITAL SCOLIOSIS
Congenital scoliosis is caused by inborn spinal deformities that may result in absent or fused
vertebrae. Kidney problems, particularly having only one kidney, often coincide with congenital
scoliosis. The condition usually becomes evident at either age 2 or in children ages 8 - 13 as the
spine begins to grow more quickly, putting additional stress on the abnormal vertebrae. It is
essential to diagnose and monitor such curvatures as early as possible, since they can progress
quickly. Early surgical treatment -- before age 5 -- may be important in many of these patients to
prevent serious complications.

NEUROMUSCULAR SCOLIOSIS
Neuromuscular scoliosis may result from a variety of causes, including:

A traumatic spine injury

Neurological or muscle disorders

Cerebral palsy

A traumatic brain injury

Poliomyelitis (Polio)

Myelomeningocoele (a hernia of the central nervous system)

Spinal muscle dystrophy

Spinal cord injuries

Myopathies

These patients frequently have significant complications, including an increased risk for skin
ulcers, lung problems, and significant pain.
CAUSES OF DEGENERATIVE LUMBAR SCOLIOSIS IN ADULTS
Adult scoliosis has two primary causes:

Progression of childhood scoliosis.

Degenerative lumbar scoliosis. Degenerative lumbar scoliosis is a condition that typically

develops after age 50. With this condition, the lower spine is affected, usually due to disk
degeneration.

CONDITIONS THAT AFFECT THE SPINAL COLUMN AND SURROUNDING MUSCLES

Scoliosis may be a result of various conditions that affect bones and muscles associated with the
spinal column. They include the following:

Tumors, growths, or other small abnormalities on the spinal column. For example,
syringomyelia, a disorder in which cysts form along the spine, can cause scoliosis. These
spinal abnormalities may play a larger role in causing some cases of scoliosis than
previously thought.

Stress fractures and hormonal abnormalities that affect bone growth in young,
competitive athletes.

Turner syndrome, a genetic disease in females that affects physical and reproductive
development.

Other diseases that can cause scoliosis are Marfan syndrome, Aicardi syndrome,
Friedreich ataxia, Albers-Schonberg disease, rheumatoid arthritis, Cushing syndrome, and
osteogenesis imperfecta.

Risk Factors
o Physical Abnormalities. Researchers are investigating possible physical abnormalities
that may cause imbalances in bones or muscles that would lead to scoliosis. Among them
are the following: Some research suggests that imbalances in the muscles around the
vertebrae may make children susceptible to spinal distortions as they grow.
o Problems in Coordination. Some experts are looking at inherited defects in perception
or coordination that may cause unusual growth in the spine of some children with
scoliosis.
o Other Biological Factors. Several other biological factors are being investigated for
some contribution to scoliosis:

Elevated levels of the enzyme matrix metalloproteinases may cause abnormalities

in components in the spinal disks, contributing to disk degeneration.

Abnormalities in a protein called platelet calmodulin that binds to calcium. This

protein acts like a tiny muscle and pulls clots together.

o Genetics. Abnormalities in the formation and development of the bone may be inherited
from one generation to another.
o Congenital defects of the Spine. All congenital disorders involve small anomalies and
anatomical defects that can throw out the smooth-running operation of the spine by subtly
altering the biomechanics and the forces through the joints. This creates
an acquired strain that makes the pain levels - and the breakdown rate - of the original
spinal condition much more variable.
o Poor posture. Poor posture in childhood, such as slouching, leaning back in chairs and
carrying heavy schoolbags, can cause the ligaments and muscles that support the
vertebrae to stretch. This can pull the thoracic vertebrae out of their normal position,
resulting in lordosis.
o Presence of underlying abnormalities such as:
Achondroplasia a genetic disorder that results in abnormal cartilage growth and
dwarfism

Spondylolisthesis displaced vertebrae of back

o Osteoporosis. As bones weaken with age caused by degenerative changes and nutritional
deficits causing bone resorption of Calcium and Phosphorous, a person is more prone to
developing deformities in the spine.
o Obesity. Obesity is recognised as a major public health problem in industrialized
countries and it is associated with various musculoskeletal disorders, including
impairment of the spine, which causes increased anterior pelvic tilt; under dynamic
conditions, to impaired mobility of the thoracic spine.
Manifestations
Scoliosis is often painless. The curvature itself may often be too subtle to be noticed, even by
observant parents. Some parents may notice abnormal posture in their growing child that
includes:

A tilted head that does not line up over the hips

A protruding shoulder blade

One hip or shoulder that is higher than the other,

causing an uneven hem or shirt line

An uneven neckline

Leaning more to one side than the other

In developing girls, breasts appearing to be of

unequal size

One side of the upper back is higher than the

other when the child bends over, knees together,
with the arms dangling down

Most of the time scoliosis does not cause pain in children or teens. When back pain is present
with scoliosis, it may be because the curve in the spineis causing stress and pressure on the spinal
discs, nerves, muscles, ligaments, or facet joints. It is not usually caused by the curve itself. Pain
in a teen who has scoliosis may indicate another problem, such as a bone or spinal tumor. If your

child has pain associated with scoliosis, it is very important that he or she see a doctor to find out
what is causing the pain.
Adults who have scoliosis may or may not have back pain. In most cases where back pain is
present, it is hard to know whether scoliosis is the cause. But if scoliosis in an adult gets worse
and becomes severe, it can cause back pain and difficulty breathing.
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 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 intra thoracic 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 Procedures
o Frequently, a scoliosis curve in the spine is first diagnosed in school exams or during a
regular checkup with a pediatrician. Most students are given the Adam's Forward Bend
Test routinely in school when they are in fifth and/or sixth grade to determine whether or
not they may have scoliosis. The test involves the student bending forward with arms
stretched downward toward the floor and knees straight, while being observed by a
healthcare professional. This angle most clearly shows any scoliosis symptoms which
present as asymmetry in the spine and/or trunk of the adolescent's body.
The forward bend test, however, is not sensitive to abnormalities in thelower back, a very
common site for scoliosis. Because the test misses about 15% of scoliosis cases, many experts do
not recommend it as the sole method for screening for scoliosis.
o Other Physical Tests.
-

The patient walks on the toes, then the heels, and then jumps up and down
on one foot. Such activities indicate leg strength and balance.

The doctor will check leg length and look for tight tendons in the back of
the leg, which may cause an uneven leg length or other back problems.

The doctor will also check for neurological impairment by testing reflexes,
nerve sensation, and muscle function.

Because a scoliosis curvature is usually in the thoracic or thoracolumbar spine (upper back or
mid back), if a rib hump or asymmetry of the lumbar spine is found, or if the shoulders are
different heights, it is possible that the individual has scoliosis. If this is the case, follow-up with
a physician for a clinical evaluation and an X-ray is the next step.
o Physician's exam. The clinical evaluation with the physician will usually include a
physical exam, during which the physician will also test to make sure that there are no
neurological deficits. Neurological deficits due to scoliosis are uncommon but necessary
to check for because there are rare causes of scoliosis that may have spinal cord
involvement.
o Inclinometer (Scoliometer). An inclinometer, also known as a scoliometer, measures
distortions of the torso. The procedure is as follows:

The patient bends over, arms dangling and palms pressed together, until a
curve can be observed in the upper back (thoracic area). The Scoliometer
is placed on the back and measures the apex (the highest point) of the
upper back curve. The patient continues bending until the curve can be
seen in the lowerback (lumbar area). The apex of this curve is also
measured. Measurements are repeated twice, with the patient returning to
a standing position between repetitions. If results show a deformity, the
patient will probably need x-rays to determine the extent of the problem.

Some experts believe the scoliometer would make a useful device for widespread screening.
Scoliometers, however, indicate rib cage distortions in more than half of children who turn out to
have very minor or no sideways curves. They are therefore not accurate enough to guide
treatment.
o Imaging Tests
Currently, x-rays are the most cost-effective method for diagnosing scoliosis. Experts hope that
accurate, noninvasive diagnostic techniques will eventually be developed to replace some of the
x-rays used to monitor the progression of scoliosis. To date, imaging techniques under
investigation appear to be fairly accurate for detecting scoliosis in the upper back (the thoracic
region), but not scoliosis in the lower back (the lumbar region).

X-Rays. If screening indicates scoliosis, the child may be sent to a specialist who takes
an initial x-ray and monitors the child every few months using repeated x-rays. X-rays
are essential for an accurate diagnosis of scoliosis:
-

They reveal the degree and severity of scoliosis.

They show other spinal abnormalities, including kyphosis (hunchback) and

hyperlordosis (swayback).

X-rays help the doctor determine whether skeletal growth has reached maturity.

X-rays taken when patients are bending forward can also help differentiate
between structural and nonstructural scoliosis. Structural curves persist when a
person bends over, and nonstructural curves tend to disappear. (Muscle spasms or
spinal growths may sometimes cause nonstructural scoliosis that shows a curve on
bending.)

Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) is an advanced

imaging procedure that does not use radiation, as x-rays do. It is expensive, however, and
not generally used for an initial diagnosis. MRI can, nevertheless, identify spinal cord and
brain stem abnormalities, which some studies indicate may be more prevalent than
previously believed in children with idiopathic scoliosis. It also may be particularly
useful before surgery for detecting defects that could lead to potential complications.

o Determining The Extent Of The Curve

There are various methods for determining and classifying the extent of the curve.
o Cobb Method. The technique known as the Cobb method nearly always calculates the
degree of the curve.
-

On an x-ray of the spine, the examiner draws two lines: One line extends out and
up from the edge of the top vertebrae of the curve. The second line extends out
and down from the bottom vertebrae.

The technician then draws a perpendicular line between the two lines.

Measuring the intersecting angle determines the degree of curvature.

The Cobb method is limited because it cannot fully determine the flexibility or the threedimensional aspect of the spine. It is not as effective, then, in defining spinal rotation or
kyphosis. It also tends to over-estimate the curve.
o Classifying the Curve

Classification of the curve allows the doctor to identify patterns that can help determine
treatments, particularly specific surgical techniques. The following are examples:
o King Classification. The King classification classifies scoliosis curves as one of five
patterns, which can help determine surgical treatments. It has limitations, however, and is
not very useful for advanced surgical techniques.
o Lenke Classification. Lenke classification takes more features of the curve into
consideration and is proving to be more reliable. It includes six curve patterns plus
additional factors that modify each of these curves.
o

Three-Dimensional Modeling Techniques. Advanced computer modeling techniques are

able to create three dimensional images using x-rays or other two-dimensional images. They
allow doctors to observe the spinal distortions. Eventually, they could reduce the number of
x-rays needed to monitor scoliosis and help surgeons determine the best surgical procedures.
Treatment
o Physical therapy
A physical therapist helps those who have experienced an injury or illness regain or maintain the
ability to participate in everyday activities. For those with scoliosis, a physical therapist can
provide assistance through assessment, intervention, and ongoing evaluation of the condition.
This helps them manage physical symptoms so they can participate in daily activities like selfcare, productivity, and leisure.

Exercise. A spinal muscle exercise performed by laying in the prone position and
performing alternating shoulder flexions and hip extensions. Strengthening
spinal muscles is a crucial preventative measure. This is because the muscles in the back
are essential when it comes to supporting the spinal column and maintaining the spine's
proper shape. Exercises that will help improve the strength of the muscles in the back
include rows and leg and arm extensions. Elastic resistance exercise may also be able to
sustain the progression of spinal curvature. This type of exercise is able to sustain
progression by equalizing the strength of the torso muscles found on each side of the
body.

Self-care. Disability caused by scoliosis, as well as physical limitations during recovery

from treatment-related surgery, often affects an individuals ability to perform selfcare activities. One of the first treatments of scoliosis is the attempt to prevent further
curvature of the spine. Depending on the size of the curvature, this is typically done in
one of three ways: bracing, surgery, or postural positioning through customized
cushioning. Stopping the progression of the scoliosis can prevent the loss of function in
many activities of daily living by maintaining range of motion, preventing deformity of
the rib cage, and reducing pain during activities such as bending or lifting.

Productive activities include paid or unpaid work, household chores, school, work, and
play. Recent studies in healthcare have led to the development of a variety of treatments
to assist in the management of scoliosis thereby maximizing productivity for people of all
ages. Assistive technology has undergone dramatic changes over the past 20 years; the
availability and quality of the technology has improved greatly. As a result of using
assistive technology, functional changes may range from improvements in abilities,
performance in daily activities, participation levels, and quality of life.

o Bracing
Bracing is normally done when the patient has bone growth remaining and is, in general,
implemented to hold the curve and prevent it from progressing to the point where surgery is
recommended. In some cases with juveniles, bracing has reduced curves significantly, going
from a 40 degrees out of the brace to 18 degrees in it. Braces are sometimes prescribed for adults
to relieve pain related to scoliosis. Bracing involves fitting the patient with a device that covers
the torso; in some cases, it extends to the neck. The most commonly used brace is a TLSO, such

as a Boston brace, a corset-like appliance that fits from armpits to hips and is custom-made from
fiberglass or plastic. It is sometimes worn 2223 hours a day, depending on the doctor's
prescription, and applies pressure on the curves in the spine. The effectiveness of the brace
depends not only on brace design and orthotist skill but on patient compliance and amount of
wear per day. The typical use of braces is for idiopathic curves that are not grave enough to
warrant surgery, but they may also be used to prevent the progression of more severe curves in
young children, to buy the child time to grow before performing surgery, which would prevent
further growth in the part of the spine affected.
o Casting
In progressive infantile and sometimes juvenile scoliosis, a plaster jacket applied early may be
used instead of a brace. It has been proven possible to permanently correct cases of infantile
idiopathic scoliosis by applying a series of plaster casts (EDF: elongation, derotation, flexion) on
a specialized frame under corrective traction, which helps to "mould" the infant's soft bones and
work with their growth spurts. EDF casting is now the only clinically known nonsurgical method
of complete correction in progressive infantile scoliosis. Complete correction may be obtained
for curves less than 50 if the treatment begins before the second year of life.
o Surgery
Surgery is usually recommended by orthopedists for curves with a high likelihood of progression
(i.e., greater than 45 to 50 of 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.
Surgery for scoliosis is performed by a surgeon specializing in spine surgery. For various
reasons, it is usually impossible to completely straighten a scoliotic spine, but in most cases,
significant corrections are achieved.
The two main types of surgery are:

Anterior fusion: This surgical approach is through an incision at the side of the chest
wall.

Posterior fusion: This surgical approach is through an incision on the back and involves
the use of metal instrumentation to correct the curve.

Nursing Responsibilities
o Teach the child and family about the course of the disease, its signs and symptoms, and
treatment. Provide appropriate handouts. Encourage the child and parents to ask
questions.
Rationale: Understanding and involvement increase motivation and compliance while
reducing fear.
o Determine whether client is experiencing pain at the time of the initial interview. If so,
intervene at that time to provide pain relief.
Rationale: The intensity, character, onset, duration, and aggravating and relieving factors of
pain should be assessed and documented during the initial evaluation of the patient.
o Assess the level of pain and initiate pain management strategies as soon as possible. Use
patient controlled analgesia if ordered.
Rationale: Adequate pain management allows for faster healing and a more cooperative
patient. Patient controlled analgesics may be effective.
o Reposition the child every 2 hours using the log-roll technique. Support the back, feet,
and knees with pillows.
Rationale: Proper positioning prevents twisting or turning the spine.

o Teach cast or brace care as appropriate. Provide oral and written instructions and a list of
activity limitations.
Rationale: Providing education decreases anxiety and increases compliance with treatment
plan. Demonstration reinforces the learning process.

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Freeman III, BL. Scoliosis and Kyphosis. In: Canale ST, Beatty JH. (eds.) Campbell's Operative
Orthopaedics. 11th ed. Philadelphia, Pa: Mosby Elsevier; 2007.
Spiegel DA, Dormans JP. The spine.In: Kliegman RM,Behrman RE, Jenson HB, Stanton BF,
eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2011.
Kaneshiro,
N.
2012.
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