Chapter 68 Scoliosis
PATHOPHYSIOLOGY
Scoliosis, a frequently occurring orthopedic problem, is the lateral curvature of the spine with a Cobb angle of more than 10 degrees accompanied by vertebral rotation. It can occur anywhere along the spine. Curvatures in the thoracic area are the most common, although curvatures of the cervical and lumbar areas are the most deforming. There are two basic forms of scoliosis: functional and structural. Functional scoliosis is secondary to a preexisting problem such as poor posture or unequal leg length. This form of scoliosis can be corrected through exercises or the use of shoe lifts. Structural scoliosis results from the congenital deformity of the spinal column. This condition often occurs in children with myelomeningocele and muscular dystrophy. Scoliosis is also seen in children with cerebral palsy and osteogenesis imperfecta. The structural form of scoliosis can be classified into three basic types: (1) infantile, which occurs during the first year of life (more than 20% of affected children have spontaneous resolution); (2) juvenile, which occurs between 5 and 6 years of age (bracing is used for management); and (3) adolescent, which is not evident until 11 years of age (when skeletal maturation occurs). Management of scoliosis may include nonsurgical and/or surgical methods. Most spinal curvatures do not progress more than 20%. The curvature is flexible initially and becomes rigid with age.
CLINICAL MANIFESTATIONS
LABORATORY AND DIAGNOSTIC TESTS
Refer to Appendix D for normal values and/or ranges of laboratory and diagnostic tests.
1. Forward bending test, or Adam’s position—to assess inequality of flank and ribs (screening test)
2. Cobb diagnostic method—to assess angle of curvature on radiographic studies
3. Anteroposterior and lateral radiographic studies of spine—to evaluate curvature of spine
4. Three-dimensional computed tomography—to assess for axial rotation of the spine
5. Magnetic resonance imaging—to assess for intraspinal pathology
Preoperative Tests
1. Complete blood count—to assess for anemia
2. Blood chemistry analysis—to assess for electrolyte imbalances
3. Type and cross-match for blood transfusions
4. Coagulation studies—to assess for deficiency in clotting factors
5. Radiography of skull—to assess for area of spinal curvature
6. Pulmonary function tests—to assess for pulmonary complications.
7. Arterial blood gas values—to assess for pulmonary complications
MEDICAL AND SURGICAL MANAGEMENT
Curves of less than 20 degrees require evaluation every 3 to 12 months. If the curve progresses, several corrective devices can be used to stop its progression. The Milwaukee brace is used for treatment of lateral curvature of 20 to 40 degrees; the brace consists of neck ring and pelvic girdle, and it must be worn 23 hours a day until curvature is corrected. The thoracolumbar-sacral orthosis (TLSO, or the Boston brace) is a molded plastic jacket that comes up to beneath the underarms and is worn 20 hours a day. A Cheneau orthosis can also be used. The Charleston bending brace is worn at night.
Surgical Management
A posterior spinal fusion is the treatment of choice for a spinal curvature greater than 40 degrees or for a curve that progressively worsens in spite of nonsurgical treatment. Spinal fusion provides a permanent method of halting the progressive worsening of the spinal curvature. Several different types of instrumentation are used to stabilize the spine internally, including the Harrington rod, the Luque rod (segmental spinal instrumentation), and Dwyer cables. Use of the Luque rod instrumentation is a more recent and preferred technique in the surgical correction of scoliosis. During the surgery, bone chips from the posterior iliac crest are positioned on top of the spine. External immobilization with the use of a body cast is then not needed, because greater internal immobilization is achieved with this technique.
Anterior thoracic discectomy procedures with endplate ablations and posterior spinal fusions are recommended for individuals with severe scoliosis. Video-assisted thoracoscopic surgery is used in some institutions to release the anterior spine of these individuals.
NURSING INTERVENTIONS
Preoperative Care
1. Prepare child or adolescent and family before preoperative and operative procedures for sequence of events and sensations that will be experienced.
2. Prepare child or adolescent for surgery (see the Preparation for Procedures or Surgery section in Appendix F).
3. Orient child or adolescent to intensive care unit and treatment procedures used postoperatively (e.g., blow gloves and spirometer).
Postoperative Care
1. Monitor for signs and symptoms of potential complications.
2. Promote proper body alignment.
3. Promote pulmonary ventilation.
4. Monitor fluid and electrolyte balance.
5. Provide pain relief measures as necessary (may have epidural catheter and/or patient-controlled anesthesia) (see Appendix I).
Discharge Planning and Home Care
Postoperative Care
1. Instruct child or adolescent and family about various aspects of care (which vary according to procedure).
2. Encourage child or adolescent and family to express fears and body image concerns.
3. Refer to community resources (public health nurse, home health nurses) (see Appendix G).
4. Encourage adherence to follow-up care regimen (clinic visits for 6 to 12 months postoperatively).
Nonsurgical Interventions
1. Instruct child or adolescent and parents in use of Milwaukee brace or Orthoplast jacket, Charleston brace, or Boston Brace.
2. Instruct child or adolescent and parents in use of exercises, and reinforce instruction.
3. Instruct child or adolescent and parents about participation in sports and recreational activities.
4. Encourage child or adolescent to express feelings of concern and inadequacy concerning brace.
5. Emphasize that compliance with brace regimen leads to better results than noncompliance.
CLIENT OUTCOMES
1. Child will maintain proper body alignment.
2. Child will have minimal pain during first 72 hours postoperatively.
3. Child and family will adhere to various aspects of postoperative home care.
4. Child will experience sense of mastery about the hospitalization and surgical experience.
5. Child will integrate positive body image of him- or herself following the recovery period.
6. Child will resume usual daily activities with minimal amount of disruption.
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