Scoliosis

Scoliosis, a lateral curvature of the spine, may be found 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 often associated with kyphosis (humpback) and lordosis (swayback).

Causes

Scoliosis may be functional or structural. Functional (postural) scoliosis usually results from poor posture or a discrepancy in leg lengths, not fixed deformity of the spinal column. In structural scoliosis, curvature results from a deformity of the vertebral bodies.

Structural scoliosis may be one of three types:

❑ Congenital scoliosis is usually related to a congenital defect, such as wedge vertebrae, fused ribs or vertebrae, or hemivertebrae.

❑ Paralytic or musculoskeletal scoliosis develops several months after asymmetrical paralysis of the trunk muscles from polio, cerebral palsy, or muscular dystrophy.

❑ Idiopathic scoliosis (the most common form) may be transmitted as an autosomal dominant or multifactoral trait. This form appears in a previously straight spine during the growing years.

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. 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

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. (See Cobb method for measuring angle of curvature.) A scoliometer can also be used to measure the angle of trunk rotation.

A 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

The severity of the deformity and potential spine growth determine appropriate treatment, which may include such noninvasive measures as close observation, exercise, or a brace. For more serious deformity, surgery or a combination of methods may be needed. To be most effective, treatment should begin early, when spinal deformity is still subtle.

Noninvasive measures

A curve of less than 25 degrees is mild and can be monitored by X-rays and an examination every 3 months. An exercise program that includes sit-ups, pelvic tilts, spine hyperextension, push-ups, and breathing exercises may strengthen torso muscles and prevent curve progression. A heel lift also may help.

A curve of 25 to 39 degrees requires management with spinal exercises and a brace. (Transcutaneous electrical nerve stimulation may be used as an alternative.)

A brace halts progression in most patients but doesn’t reverse the established curvature. Such devices passively strengthen the patient’s spine by applying asymmetric pressure to skin, muscles, and ribs. Braces can be adjusted as the patient grows and can be worn until bone growth is complete.

Surgery

A curve of 40 degrees or more requires surgery (spinal fusion with instrumentation) because a lateral curve continues to progress at the rate of 1 degree a year even after skeletal maturity.

CLINICAL TIP: Some surgeons may prescribe Cotrel dynamic traction for 7 to 10 days for preoperative preparation. This traction consists of a belt-pulley-weight system. While in traction, the patient should exercise for 10 minutes every hour, increasing muscle strength while keeping the vertebral column immobile.

Surgery corrects lateral curvature by posterior spinal fusion and internal stabilization with a Harrington rod or other fixation devices. 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 with instrumentation, 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

❑ Keep in mind that scoliosis affects many adolescent girls, who are likely to find activity limitations and treatment with orthopedic appliances distressing. Therefore, provide emotional support, along with meticulous skin and cast care, and patient teaching.

If the patient needs a brace:

❑ Enlist the help of a physical therapist, a social worker, and an orthotist (orthopedic appliance specialist). 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 a day and to remove it only for bathing and exercise. Encourage the patient to lie down and rest several times a day while still adjusting to the brace.

❑ 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 comes in contact with the skin. Instead, suggest using rubbing alcohol or tincture of benzoin to toughen the skin. Advise the patient 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 to avoid strenuous sports. Emphasize the importance of conscientiously performing prescribed exercises. Recommend swimming during the 1 hour out of the brace, but strongly warn against diving.

❑ Instruct the patient to turn the whole body, instead of just the head, when looking to the side. To make reading easier, advise holding the reading matter to look straight ahead at it instead of down. If this proves difficult, suggest prism glasses as an alternative.

If the patient needs traction or a cast before surgery:

❑ Explain these procedures to the patient and 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” (padded). Warn the patient not to insert anything under the cast or let anything get under it and to immediately report cracks in the cast, pain, burning, skin breakdown, numbness, or odor.

❑ Before surgery, assure the patient and her family that she’ll have adequate pain control after the surgery. Check sensation, movement, color, and blood supply in all extremities to detect neurovascular deficit, a serious complication following spinal surgery.

After corrective surgery:

❑ Check neurovascular status every 2 to 4 hours for the first 48 hours, then several times a day. Logroll the patient often.

❑ Measure intake, output, and urine specific gravity to monitor effects of blood loss, which is often substantial.

❑ Monitor abdominal distention and bowel sounds.

❑ Encourage deep-breathing exercises to avoid pulmonary complications.

❑ Give an analgesic as needed, especially before any activity.

❑ Promote active range-of-motion (ROM) 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 ROM exercises of ankles and feet.

❑ Watch for skin breakdown and signs of cast syndrome. Teach the patient how to recognize these signs.

❑ Remove antiembolism stockings for at least 30 minutes each day.

❑ Offer emotional support to help prevent depression, which 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 Harrington rod and cast and must have bed rest, arrange for a social worker and a visiting nurse to provide home care. Before discharge, make sure the patient understands activity limitations.

❑ If you work in a school, screen children routinely for scoliosis during physical examinations.

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Book Source Details

• Book Title: Handbook of Diseases
• Author(s): Springhouse
• Year of Publication: 2003
• Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.

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