Scoliosis
Scoliosis: Excerpt from Professional Guide to Diseases (Eighth Edition)
Scoliosis is a lateral curvature of the spine that may occur in the thoracic, lumbar, or thoracolumbar spinal segment. The curve may be convex to the right (more common in thoracic curves) or to the left (more common in lumbar curves). Rotation of the vertebral column around its axis occurs and may cause rib cage deformity. Scoliosis is commonly associated with kyphosis (roundback) and lordosis (swayback).
Causes and incidence
Scoliosis may be functional, structural, or idiopathic. Functional (postural) scoliosis usually results from a discrepancy in leg lengths rather than from a fixed deformity of the spinal column; it corrects when the patient bends toward the convex side. Structural scoliosis results from a deformity of the vertebral bodies, and it doesn’t correct when the patient bends to the side. Structural scoliosis may be:
❑ congenital: usually related to a congenital defect, such as wedge vertebrae, fused ribs or vertebrae, or hemivertebrae; may result from trauma to zygote or embryo
❑ paralytic or musculoskeletal: develops several months after asymmetrical paralysis of the trunk muscles due to polio, cerebral palsy, or muscular dystrophy
❑ idiopathic (the most common form): may be transmitted as an autosomal dominant or multifactorial trait. This form appears in a previously straight spine during the growing years. Brain stem dysfunction, possibly due to a lesion of the posterior columns or the inner ear, may be the cause.
Idiopathic scoliosis can be classified as infantile, which affects mostly male infants between birth and age 3 and causes left thoracic and right lumbar curves; juvenile, which affects both sexes between ages 4 and 10 and causes varying types of curvature; or adolescent, which generally affects girls between age 10 and achievement of skeletal maturity and causes varying types of curvature.
Signs and symptoms
The most common curve in functional or structural scoliosis arises in the thoracic segment, with convexity to the right, and compensatory curves (S curves) in the cervical segment above and the lumbar segment below, both with convexity to the left. (See Cobb method for measuring angle of curvature.) As the spine curves laterally, compensatory curves develop to maintain body balance and mark the deformity. Scoliosis rarely produces subjective symptoms until it’s well established; when symptoms do occur, they include backache, fatigue, and dyspnea. Because many teenagers are shy about their bodies, their parents suspect that something is wrong only after they notice uneven hemlines, pant legs that appear unequal in length, or subtle physical signs like one hip appearing higher than the other. Untreated scoliosis may result in pulmonary insufficiency (curvature may decrease lung capacity), back pain, degenerative arthritis of the spine, disk disease, and sciatica.
Diagnosis
CONFIRMING DIAGNOSIS Anterior, posterior, and lateral spinal X-rays, taken with the patient standing upright and bending, confirm scoliosis and determine the degree of curvature (Cobb method) and flexibility of the spine.
A scoliometer can also be used to measure the angle of trunk rotation. Physical examination reveals unequal shoulder heights, elbow levels, and heights of the iliac crests. Muscles on the convex side of the curve may be rounded; those on the concave side, flattened, producing asymmetry of paraspinal muscles.
Treatment
Only two treatments effectively treat scoliosis: spinal bracing and surgery. If monitored closely, a properly constructed and fitted brace can successfully halt progression of a curve in approximately 70% of cooperative patients. Most braces should be worn over a long T-shirt or similar article of clothing for 23 hours a day. However, mild curvatures may require less. Exercises must be done daily both in and out of the brace to maintain muscle strength. Patients should be seen for follow-up and brace adjustment every 3 months. Radiographs should be repeated at 6-month intervals. As the skeleton matures, as seen radiographically, brace wear should be gradually decreased until it’s worn only at night.
The primary indications for surgery are relentless curve progression (usually curves over 40°) or significant curve progression despite bracing. Surgery corrects lateral curvature by posterior spinal fusion and internal stabilization with metal rods. A distraction rod on the concave side of the curve “jacks” the spine into a straight position and provides an internal splint. An alternative procedure, anterior spinal fusion, corrects curvature with vertebral staples and an anterior stabilizing cable. Some spinal fusions may require postoperative immobilization in a brace. Postoperatively, periodic checkups are required for several months to monitor stability of the correction.
Special considerations
It’s important to provide emotional support in addition to meticulous skin care and patient teaching.
If the patient needs a brace:
❑ Enlist the help of a physical therapist, a social worker, and an orthotist. Before the patient goes home, explain what the brace does and how to care for it (how to check the screws for tightness and pad the uprights to prevent excessive wear on clothing). Suggest that loose-fitting, oversized clothes be worn for greater comfort.
❑ Tell the patient to wear the brace 23 hours per day and to remove it only for bathing and exercise. While he’s still adjusting to the brace, tell him to lie down and rest several times per day.
❑ Suggest a soft mattress if a firm one is uncomfortable.
❑ To prevent skin breakdown, advise the patient not to use lotions, ointments, or powders on areas where the brace contacts the skin. Tell him to keep the skin dry and clean and to wear a snug T-shirt under the brace.
❑ Advise the patient to increase activities gradually and avoid vigorous sports. Emphasize the importance of conscientiously performing prescribed exercises.
❑ Instruct the patient to turn his whole body, instead of just his head, when looking to the side. To make reading easier, tell him to hold the book so he can look straight ahead at it instead of down. If he finds this difficult, help him to obtain prism glasses.
If the patient needs traction or a cast before surgery:
❑ Explain these procedures to the patient and her family. Remember that application of a body cast can be traumatic because it’s done on a special frame and the patient’s head and face are covered throughout the procedure.
❑ Check the skin around the cast edge daily. Keep the cast clean and dry and the edges of the cast petaled. Warn the patient not to insert or let anything get under the cast and to immediately report cracks in the cast, pain, burning, skin breakdown, numbness, or odor.
After corrective surgery:
❑ Check sensation, movement, color, and blood supply in all extremities every 2 to 4 hours for the first 48 hours and then several times a day, for signs of neurovascular deficit, a serious complication following spinal surgery. Logroll the patient often.
❑ Measure intake, output, and urine specific gravity to monitor effects of blood loss, which is usually substantial.
❑ Monitor abdominal distention and bowel sounds.
❑ Encourage deep-breathing exercises to avoid pulmonary complications.
❑ Medicate for pain, especially before any activity.
❑ Promote active range-of-motion arm exercises to help maintain muscle strength. Remember that any exercise, even brushing the hair or teeth, is helpful. Encourage the patient to perform quadriceps-setting, calf-pumping, and active range-of-motion exercises of the ankles and feet.
❑ Watch for skin breakdown and signs of cast syndrome. Teach the patient how to recognize these signs. (See Cast syndrome.)
❑ Offer emotional support to help prevent depression that may result from altered body image and immobility. Encourage the patient to wear her own clothes, wash her hair, and use makeup.
❑ If the patient is being discharged with a rod and cast and must have bed rest, arrange for a social worker and a visiting nurse to provide home care. Before discharge, check with the surgeon about activity limitations, and make sure the patient understands them.
❑ If you work in a school, screen children routinely for scoliosis during physical examinations.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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