SCOLIOSIS

• Scoliosis

  Lateral curvature of the spine that deviates from a normal vertical alignment, measures greater than 10 degrees of curvature, and is associated with vertebral rotation
• Types of scoliosis


  • Nonstructural/functional
  • Structural
  • Traumatic
• Subtypes of scoliosis


  • Idiopathic
  • Congenital
  • Neuromuscular
• Early onset scoliosis (EOS)


  Scoliosis that occurs before age 10
• Late onset scoliosis


  Scoliosis that occurs after age 10
• Idiopathic scoliosis


  • Accounts for 80% to 85% of cases
  • Diagnosis of exclusion, made after ruling out underlying disease processes
  • Divided into infantile, juvenile, and adolescent
• Congenital scoliosis


  • Results from abnormally developed vertebrae
  • May result in sagittal plane, coronal plane, or both sagittal and coronal plane abnormalities
  • Occurs in utero at approximately 4 to 6 weeks' gestation
  • Most common spinal deformity that affects newborns
  • Has a female-to-male ratio of 1.4:1
  • Manifests before 10 years of age
  • Has a high prevalence in children who undergo surgery for treatment of congenital heart disease during the first year of life
  • Is related to abnormalities in other organ systems
• Neuromuscular scoliosis


  • Occurs secondarily in children who experience a traumatic spinal injury or have a neurologic or muscular disease
• Nonstructural scoliosis


  Occurs secondary to acute disk disease, leg length discrepancies, paraspinal inflammation, or poor posture
• Structural scoliosis


  Occurs secondary to infection, tumor, or may have no cause
• Traumatic scoliosis


  Occurs secondary to vertebral fractures or disk disease
• Pathophysiology of scoliosis


  1. The vertebrae rotate, forming the convex part of the curve

  2. The rotation causes rib prominence along the thoracic spine and waistline asymmetry in the lumbar spine

  3. If severe, the rib cage may press against the lungs and heart, interfering with breathing and cardiac pumping

  4. In neuromuscular disorders, scoliosis can occur as a side effect of muscular weakness and an inability of the musculature to support the spine

  5. Thoracic curvatures to the left are often associated with nonidiopathic causes, requiring additional evaluation
• Causes of scoliosis


  • Idiopathic (80%)
  • Possible genetic component
  • Hormones
  • Secondary to injury, musculoskeletal disease, neurological disease, or tumor
• Risk factors for scoliosis

  • Congenital or neuromuscular problem
  • Sex (females are at greater risk for curve worsening during adolescence)
  • Family history
• Incidence of scoliosis


  • Affects 2% to 5.2% of children and adolescents
  • Males account for most early-onset scoliosis cases
  • Females account for most late-onset scoliosis cases
  • Infantile scoliosis is rare and accounts for less than 1% of cases in North America and Europe
• Complications of scoliosis


  • Back pain
  • Severe deformity
  • Reduced pulmonary function if thoracic curve exceeds 60 degrees
  • Increased risk of cor pulmonale in middle age if thoracic curve exceeds 80 degrees
  • Disturbed self-image
• Assessment of scoliosis


  1. History taking (family history, uneven hemlines, unequal appearance of length of pant legs, unequal shoulder or hip height, backache, fatigue, dyspnea)

  2. Physical examination (signs of scoliosis identified with specific examination)

  3. Testing for scoliosis (Adam's forward bend test, using a scoliometer)
• Scoliometer


  A tool used to determine if a child may need radiography to further identify a potential spinal curvature
• Diagnostic tests for scoliosis

  1. Spinal radiography (to confirm scoliosis, determine degree of curvature and flexibility of spine, determine skeletal maturity, predict remaining bone growth, differentiate nonstructural from structural scoliosis, identify soft tissue abnormalities)

  2. Magnetic resonance imaging (to provide more-detailed imaging of the neurologic system)

  3. Bone growth studies (to determine skeletal maturity)
• Treatment goals for scoliosis

  • Prevent progression of the curve
  • Achieve curve correction
  • Prevent long-term disability
  • Improve cosmetic appearance
• Treatment for mild idiopathic scoliosis

  Close observation with radiographic follow-up every 6 to 8 months until growth is complete
• Treatment options for scoliosis

  • Bracing (thoraco-lumbar-sacral orthosis or cervico-thoraco-lumbar-sacral orthosis)
  • Functional strengthening program with physical therapy
  • Traction (in rare cases)
  • Surgery (posterior segmental fixation instrumentation, posterior spinal fusion with instrumentation and bone grafting, anterior spinal fusion with solid rods, serial casting, novel instrumentation techniques, magnetically controlled implanted growing rods, individualized for neuromuscular scoliosis, vertical expandable prosthetic titanium rib for congenital scoliosis with fused ribs)
• Medications for scoliosis


  • Narcotic analgesics (for severe postoperative pain)
  • Nonsteroidal anti-inflammatory drugs (to reduce pain, inflammation, and fever and improve postoperative ambulation)
  • Acetaminophen (to reduce pain)
  • Gabapentin (for neuropathic pain)
• Nursing considerations for scoliosis

  • Administer prescribed medications and monitor their effect
  • Assess the child's pain level and reassess after each intervention
  • Utilize nonpharmacological measures to treat pain and discomfort
  • Complete a pediatric fall risk assessment and implement necessary precautions
  • Cluster nursing activities to minimize energy expenditure and provide frequent uninterrupted rest periods
  • Encourage the use of energy-conservation measures
  • Promote a safe environment and institute safety measures
  • Provide clear explanations about care and treatment measures
  • Collaborate with respiratory therapy to encourage coughing and deep-breathing exercises
  • Collaborate with occupational therapy to assist with activities of daily living and use of the brace
  • Reinforce the plan for use of the brace
  • Collaborate with physical therapy to promote active range-of-motion exercises, mobility, and ambulation
• Utilize nonpharmacological measures to treat pain and discomfort


  As appropriate
• Complete a pediatric fall risk assessment using an approved screening tool

  Implement necessary precautions
• Cluster nursing activities


  1. Minimize energy expenditure

  2. Provide frequent uninterrupted rest periods
• Promote a safe environment

  Institute safety measures according to facility policy
• Collaborate with respiratory therapy

  Encourage coughing and deep-breathing exercises to help prevent respiratory illness
• Collaborate with occupational therapy

  1. Assist with activities of daily living

  2. Use of the brace
• Reinforce the plan for use of the brace

  Including the number of hours per day the child needs to wear it
• Collaborate with physical therapy

  1. Promote active range-of-motion exercises

  2. Mobility

  3. Ambulation
• Encourage a gradual increase in activity


  Promote self-care while allowing adequate time for completion of tasks
• Encourage the child and family (as appropriate) to participate in care activities and decision making

  To foster feelings of self-esteem and control
• Offer support and encouragement to the child and family

  Assist with the use of positive coping strategies
• Provide meticulous skin care


  Keep the child's skin clean and dry
• Reposition the child


  Apply skin protection under bony prominences and medical devices to prevent skin breakdown
• Collaborate with nutrition services

  Provide a well-balanced diet while maintaining any dietary restrictions, as appropriate
• Adhere to standard precautions

  Perform meticulous hand hygiene to minimize infection risk
• Encourage the child and family (as appropriate) to verbalize questions, feelings, and concerns

  Actively listen and answer questions honestly