SPINAL CORD INJURIES

Submitted by:Cardinoza, Czarina

Castro, Nia Caroline

Catugas, Kalvin Paul

Cayetano, Jennilyn Joy

Cayetano, Pia Romilda

Cepe, Ina Mariel

Chan, James Jester

Ching, Angela Nicole

Chua, Robeley May

Chutani, Sagar

Clavito, Sherwin

IIINUR-2 RLE 2

Case Scenario:CAA age 20 has a compression fracture at C5 to C6 who was admitted to UST Hospital Emergency Room as result of diving from a bridge into a river and hitting a submerged rock. Fortunately, a companion who had training as lifeguard rescues him and tried to minimize any secondary damage. Upon arrival on the ER, CAA could not move her limbs or sense touch and lacked reflexes in her limbs. Surgery was performed to relieve pressure and stabilize the fracture site. Several weeks later, routine examination indicated that some spinal reflexes were returning in the lower extremities. 1. Why is caution needed when handling a person with possible spinal cord injury2. Describe a compression fracture3. Explain why reflexes are absent in CCA at this early stage. What type of paralysis is present4. What manifestation are present among clients who has spinal cord injury5. What complication may develop from a spinal cord injury6. Explain how the dermatomes can assist in detecting functional areas

SPINAL CORD INJURY Occurs in the following situations: Falls, Diving, and Vehicular Accident. SCI results to the following effects below level of lesion: Paralysis Loss of Reflexes Loss of sensory function Loss of motor function Autonomic dysfunction

DIAGNOSTIC STUDIES: CT Scan: gold standard in diagnosing stability of the injury, location, and degree of bone injury and spinal compromise Cervical x-ray MRI: to assess soft tissue and neural changers Neurologic examination (comprehensive exam) Physical assessment (head, chest, abdomen for additional injuries or trauma) Vertebral angiography: to rule out vertebral artery damageCLINICAL MANIFESTATION:

Respiratory system: Inflammation may extend upward to the level of C3 to C5 Injury at C2 and C3 usually fatal Injury above the level of C4: total respiratory muscle function Injury below the level of C4: respiratory insufficiency Respiratory muscle paralysis Impairment of intercostal muscle Paralysis of abdominal muscle Pulmonary edema

Cardiovascular system Bradycardia Hypotension Hypovolemia

Urinary system Urinary retention

Gastrointestinal system Injury above the level of T5: hypomotility Injury at the level of T12 or below: areflexic bowel aand decreased sphincter tone Paralytic ileus Gastric distention Development of stress ulcers Intra abdominal bleeding Neurogenic bowel

Integumentary system Potential of skin breakdown over bony prominences since client is potential for lack of movement

Thermoregulation Poikilothermism: the adjustment of the body temperature to the room Decrease ability to sweat or shiver

Specific effects of permanent damage depend on the level at which the spinal cord trauma occurred. Men may have neurogenic reflex erection Men with high level cord injury are infertile Women can bear child with close monitoring during pregnancy Vaginal delivery may be difficultINTERVENTIONS (PER CASE): Collaborative management for the client with SCI are as follows: FIRST PRIORITY: promotion of respiratory function especially in cervical SCI Immobilize in a flat, firm surface. To prevent further injury Apply cervical collar especially if cervical injury is suspected Transport client as a unit. Do not attempt to realign body parts.

Monitor and manage potential complications of SCI SPINAL SHOCK (Neural Shock, Areflexia) Period of flaccid paralysis and a complete loss of all reflexes occur. Clinical Manifestations: Absence of sweating below the level of lesion. Bowel and bladder retention Hypotension, bradycardia. If the lumbosacral segments are under damaged, spinal shock wears off in 2 to 3 weeks. The first sign of resolution of spinal shock is contraction of the quadriceps (hamstring) muscles and flexion or extension of toes on plantar stimulation The other signs of resolution of spinal shock are reflexive emptying of the bladder, reflex defecation and return of sweating.

AUTONOMIC HYPERREFLEXIA (Dysreflexia) It occurs in clients with SCI above T6; most often in cervical injuries. It causes hyperstimulation of the sympathetic nervous system (SNS) It is caused by visceral distention like bladder distention, fecal impaction and skin stimulation like pressure sore below the level of lesion CLINICAL MANIFESTATIONS: Severe headache Blurring of vision Nasal congestion Hypertension, bradycardia Sweating above the lesion; pilomotor spasm (goose flesh) below the lesion.

The most dangerous effect of autonomic dysreflexia is severe hypertension. This may lead to blindness and CVA. COLLABORATIVE MANAGEMENT: Place the client in sitting position. To lower BP by gravity Check bladder distention. Catheterize client as indicated. Check fecal impaction. Perform manual extraction as indicated. Turn the client to sides at regular intervals. To prevent pressure sore. Pharmacotherapy: Hexamethonium Chloride (a ganglionic blocking agent) Nitroprusside (Vasodilator)

WHIPLASH INJURY It is caused by violent hyperextension and flexion of the neck. It usually results from vehicular accident. There is damaged to muscles, disks, ligaments and nervous tissues of the cervical spine. CLINICAL MANIFESTATIONS: Pallor Weakness Gait disturbance Dizziness Nausea and Vomiting Occipital Headache Nuchal rigidity COLLABORATIVE CARE: Promote bed rest. Apply cervical collar as needed Apply hot packs to the neck as indicated Administer analgesic and muscle relaxant as prescribed.

DermatomeEach spinal nerve conducts impulses from a specific area of the skin which is called the dermatome. Dermatome can be used to test for areas of sensory loss or pain sensation and thus determine the site of damage following spinal cord injuries. This can be drawn on a map of the body surface. Assessment of sensory awareness using the dermatome maps can be a useful tool in determining the level of damage to the spinal cord.

Upper Body Test PonitsC2 - Occipital ProtuberanceC3 - Supraclavicular FossaC4 - Acromioclavicular JointC5 - Lateral Antecubital FossaC6 - ThumbC7 - Middle FingerC8 - Little FingerT1 - Medial Antecubital FossaT2 - Apex of AxillaLower Body Test PointsL1 - Upper Anterior ThighL2 - Mid Anterior Thigh

L3 - Medial Femoral CondyleL4 - Medial MalleolusL5 - Dorsum 3rd MTP JointS1 - Lateral HeelS2 - Popliteal FossaS3 - Ischial TuberosityS5 - Perianal AreaV1 - Ophthalmic Division of Trigeminal Nerve (Upper Face)V2 - Maxillary Division of Trigeminal Nerve (Mid Face)V3 - Mandibular Division of Trigeminal Nerve (Lower Face)

Case Scenario: Jester Chan, a 14-year old school boy goes to school every day carrying a backpack full of books and a shoulder bag for his clubs files. One night, Jester felt a sudden pain in his lower-back after a long day of standing in a school event that his club hosted. Following that night, his parents decided to take him to a doctor to check his back. Upon assessment, the doctor noticed that his shoulders are asymmetrical showing an elevation of the right shoulder. The x-ray showed an abnormal curvature of the spine. Jester Chan was diagnosed with scoliosis. 1. What causes scoliosis?2. What are the risk factors for scoliosis?3. What are its most common manifestations?4. What are the ways to assess for scoliosis?5. Enumerate some interventions.6. Is a surgery required for patients with scoliosis?

SCOLIOSIS

Scoliosis is an abnormal curvature of the spine most often occurs during growth spurt just before puberty. It causes a sideway curve of the spine. The curves are often S-shaped or C-shaped. It is a spinal deformity in which there is a lateral curvature greater than 10 degrees. The primary deformity in scoliosis is lateral flexion plus rotation of the involved vertebrae around a vertical axis. Scoliosis is classified as nonstructural and structural according to magnitude, location, direction, and cause. Every spine naturally curves a bit but people with scoliosis has spine that curves too much. It is most common in late childhood and early teens and girls are more likely to have it then boys. Scoliosis can be caused by conditions such as cerebral palsy and muscular dystrophy but most of the causes of scoliosis cases is unknown.Most cases of scoliosis are mild, but some children develop spine deformities that continue to get more severe as they grow. Severe scoliosis can be disabling. An especially severe spinal curve can reduce the amount of space within the chest which makes the lungs to function improperly.

TYPES OF SCOLIOSIS1. Nonstructural scoliosis. Also known as functional scoliosis, this involves a spine that is structurally normal yet appears curved. This is a temporary curve that changes, and is caused by an underlying condition such as difference in leg length, muscle spasms or inflammatory conditions such as appendicitis. Physicians usually treat this type of scoliosis by addressing the underlying condition. The term nonstructural scoliosis has also been used to describe cases involving a sidetoside curvature.

2. Structural scoliosis. This is a fixed curve that is treated individually according to its cause. Some cases of structural scoliosis are the result of disease, such as the inherited connective tissue disorder known as Marfans syndrome. In other cases, the curve occurs on its own. Other causes include neuromuscular diseases (such as cerebral palsy, poliomyelitis or muscular dystrophy), birth defects, injury, infection, tumors, metabolic diseases, rheumatic diseases or unknown factors. The term structural scoliosis has also been used to describe cases involving a twisting of the spine in three dimensions rather than a sideways curvature.

ASSESSMENT The newborn may display signs of spinal dysraphismcutaneous sinuses, midline hairy patches, or other cutaneous lesions. The examination of the older child begins with a general inspection of the back in the standing position. Obvious asymmetries are noted along the contour of the back: elevation of a shoulder, prominence of a scapula, uneven waistline, or a rib hump. Truncal asymmetries, often caused by congenital deformities, can be detected in the first few years of life. Shoulder levels are measured from the floor to the acromioclavicular joints. The difference between the height of the high shoulder and that of the low shoulder is noted in centimeters. Levels of the anterior superior or posterior superior iliac spines are also compared, and the difference is noted in centimeters. The head should align directly over the sacrum, and any deviation from midline may reflect a spinal deformity. The orthopedic surgeon can detect deformity by dropping a plumb line from the spinous process of C7 down to the level of the gluteal cleft. The number of centimeters of the plumb line from the gluteal cleft is noted. The anterior chest is examined for deformity, pectus excavatum, or pectus carinatum. By viewing the patient from the side, the sagittal curve can be noted between the occiput and sacrum. A normal cervical lordosis, thoracic kyphosis, and lumbar lordosis generally maintain a proper balance of the head and trunk over the pelvic girdle. Range of motion is assessed by viewing the spine in flexion, extension, and side-bending. Passive side-bending is often necessary to visualize the maximal amount of flexibility in a curve. When pain is present, it is important to note the exact location in the standing, sitting, and prone position. Restriction of spinal range of motion should be documented. Multiple markers of maturity are important to the clinical assessment. The orthopedic surgeon will determine the level of skeletal maturity by assessing the epiphyseal status on wrist radiographs, assigning a Risser grade, assessing Tanner stages, progressive sitting and standing height measurements, and age at menarche. If Tanner staging or age at menarche is not consistent with the Risser grade, curve progression may proceed at a different rate. Height measurements of the patient sitting and standing should be taken every 3-4 months. Frequently documenting height measurements helps to determine the onset of the adolescent growth spurt and the potential rapid progression of the spinal curve. Changes in sitting height, which can be less than changes in standing height, give a better estimation of truncal growth rates. Caf-au-lait spots (>5 in number) and subcutaneous skin nodules are associated with neurofibromatosis. In patients with paralytic conditions or severe deformities, a traction evaluation is applied by lifting the individual. Traditionally, the Adam's forward bending test with a level plane and ruler or scoliometer (a device specifically designed for the assessment of the angle of trunk rotation, which represents one of the components of clinical scoliotic deformity) was used as a screening test for scoliosis. The measurements obtained from the Adam's forward bending test, however, are difficult to standardize and should only be obtained when they will affect management decisions for an individual or to reassure the patient and family. Poor posture, uneven shoulder height. One hip more prominent than the other. Scapular prominence. Uneven waist line or hemline Spinal curve observable or palpable on both upright and bent forward. Back pain may be present but is not a routine finding in idiopathic scoliosis. Leg length discrepancy.

MANIFESTATIONSWithout anX-ray of the spine, there are several common physical symptoms that may indicate scoliosis. One of the most common tests for detecting scoliosis is called the Adam's Forward Bend Test, in which the individual bends from the waist as if touching the toes. Usually there are no manifestations but the medical professional then observes for one or more of the following signs of scoliosis: One shoulder is higher than the other One shoulder blade sticks out more than the other One side of the rib cage appears higher than the other One hip appears higher or more prominent than the other The waist appears uneven The body tilts to one side One leg may appear shorter than the other Backache or low-back pain Tired feeling in the spine after sitting or standing for a long timeAny type of back pain is not usually considered a scoliosis symptom.

INTERVENTIONS The primary goal of treating any type of scoliosis is prevention of the progression of the curve magnitude and preservation of pulmonary and cardiac function. Radiographs should only be considered when a patient has a curve that might require treatment or could progress to a stage requiring treatment (usually 40 degrees). This determination is done by the Orthopedic Surgeon and any patient of concern should be referred. Management of congenital scoliosis consists of serial radiographs to determine whether the deformity is worsening. If worsening of 5-10 degrees or more is documented, surgical fusion is necessary regardless of child's age. Controversy surrounds indications for bracing. Trends over the past 20 years have moved towards bracing only the more significant curves (20-50 degrees). Surgery, rod placement, and bone grafting may be necessary to achieve partial or complete correction in adolescents with curves >45 degrees. Treatment of neuromuscular scoliosis is aimed at preserving pulmonary functionthe ability to sit upright. There is debate whether surgical stabilization of the deformity improves pulmonary function. Surgery may not be recommended if the child's life expectancy is less than 2 years. Treatment of paralytic scoliosis consists of surgically correcting the deformity after the curve exceeds 40 degrees. If a curve progresses rapidly, the cord should be screened for the development of a posttraumatic syrinx (PTS). PTS refers to the development of a cyst filled with cerebrospinal fluid within the spinal cord. PTS is a relatively infrequent, but potentially devastating, complication following traumatic spinal cord injury. If left untreated, PTS can result in loss of function, chronic pain, respiratory failure, or death. Treatment of scoliosis secondary to neurofibromatosis consists of early aggressive surgical intervention. Bracing is ineffective for short angulated dystrophic curves.

NURSING INTERVENTIONS Prepare the child for casting or immobilization procedure by showing materials to be used and describing procedure in age-appropriate terms. Promote comfort with proper fit of brace or cast. Provide opportunity for the child to express fears and ask questions about deformity and brace wear. Assess skin integrity under and around the brace or cast frequently. Providegood skin careto prevent breakdown around any pressure areas. Instruct the patient to examine brace daily for signs of loosening or breakage. Instruct patient to wear cotton shirt under brace to avoid rubbing. Instruct about which previous activities can be continued in the brace. Provide a peer support person when possible so the child can associate positive outcomes and experiences from others.

PATHOPHYSIOLOGY1. Idiopathic scoliosis exact etiology is unknown. Accounts for 65% of cases. Possible causes include genetic factors, vertebral growth abnormality. Classified into three groups based on age at time of diagnosis. Infantile birth to age 3. Juvenile presentation between age 11 and 17.Congenital scoliosis exact etiology unknown; represented as malformation of one or more vertebral bodies that results in asymmetric growth. Type I failure of vertebral body formation e.g. isolated hemivertebra, wedged vertebra, multiple wedged vertebrae, and multiple hemivertebrae. Type II failure of segmentation e.g. unilateral unsegmented bar, bilateral block vertebra. Commonly associated with other congenital anomalies.Paralytic or musculoskeletal scoliosis develops several months after symmetrical paralysis of the trunk muscles from polio, cerebral palsy, or muscular dystrophy.Neuromascular scoliosis child has a definite neuromascular condition that directly contributes to the deformity.Additional but less common causes of scoliosis are osteopathic conditions, such as fractures, bone disease, arthritic conditions, and infections.Miscellaneous factors that can cause scoliosis include spinal irradiation, endocrine disoders, postthoracotomy, and nerve root irritation.As the deformity progresses, changes in the thoracic cage increase. Respiratory and cardiovascular compromise can occur in cases of severe progression.

Case Scenario:Sherlin Clavit, a 29-year-old woman, suddenly felt severe headache that won't be relieved by rest and taking of pain medications. This continued for a few more days accompanied by cold sensations of her left and right hands going up to both of her arms. This led to her consultation. Upon examination, Ms. Clavit seems to have limited range-of-motion in her cervical area and muscle weakness in her extremities. The doctor advised Ms. Clavit to take an X-ray examination. The results showed a tumor at C2 and C3 and left vertebral artery occlusion. Ms. Clavit was diagnosed with Spinal Tumor.1. What is a Spinal Tumor?2. What are the causes of Spinal Tumors?3. What are the types of Spinal Tumors?4. What are the symptoms of Spinal Tumors?5. What are the interventions used in Spinal Tumors?6. What are the treatments used in Spinal Tumors?

SPINAL TUMOR

A spinal tumor is a growth that develops within the spinal cord or within the bones of the spine. It may be cancerous or noncancerous.

Spinal cord tumors or growths of any kind can lead to pain, neurological problems and sometimes paralysis. Whether cancerous or not, a spinal cord tumor can be life-threatening and cause permanent disability.

The outcome varies depending on the tumor. Early diagnosis and treatment usually leads to a better outcome.

Nerve damage often continues, even after surgery. Although some amount of permanent disability is likely, treatment may delay major disability and death.

ETIOLOGYSpinal cord tumors can be primary or metastatic. These tumors are identified by the location of the origin of the mass: Extradural: Lesions located outside the dura mater in either the epidural space or the bones of the spinal column or paraspinal tissue. Extradural tumors are mostly metastatic tumors that can originate from breast, lung, kidney and prostate. Other extradural tumors are from lymphomas, myelomas and neurofibromas. Intradural: Lesions located within or under the dura mater of the meninges. Intradural tumours are classified as intradural extramedullary (arising inside the dura but outside the spinal cord) and intradural intramedullary (arising within the spinal cord). Intradural intramedullary tumours are primary cord tumours, because they arise within the spinaltumor; Intramedullary: Intradural lesions arising within the substance of the spinal cord, within the tracts and central gray matter. Intradural extramedullary tumors include schwannomas, meningiomas and a range of other rare benign tumors. Extramedullary: Lesions arising outside of the spinal cord in the meninges, nerve roots, or vertebral bodies. Intradural extramedullary tumors include schwannomas, meningiomas and a range of other rare benign tumours. Neurilemomas: Neurilemomas are the most common intradural primary tumors of the spinal cord and are classified as schwannomas, or neurofibromas. They arise from the nerve root sheaths and are therefore found in the spinal, cranial, and peripheral nervous systems. Most commonly they are extramedullary. The majority of these nerve sheath tumors arise in the dorsal nerve root. They tend to involve the spinal can cranial nerves. The tumors are neurofibromatosis, or von Recklinghausen's disease, are of the neurilemoma type. Meningiomas: Meningiomas are well-circumscribed intradural or extramedullary primary tumors that arise from the arachnoid cells. They occur most often in the thoracic area and are more prevalent in women than in men. They are usually loosely attached to the dura, which permits easy surgical removal. They may also erode into bony structures. Astrocytomas: Astrocytomas are most often intradural and intramedullary. They are the common type of intramedullary spinal cord tumor in adults and children. They occur most often through the fifth decades of life an are more common in males than in females. Similar to the classification of brain tumors, astrocytomas occur along a continuum of grades I to IV. The majority of spinal cord astrocytomas are grade I, with 75% being low-grade gliomas. Grade II tumors contain a number of anaplastic cells, and grade III and grade IV tumors are considered malignant. A malignant astrocytoma may quickly lead to rapid neurologic deterioration and death. Ependymomas: Ependymomas can be found throughout the spinal cord and tend to be intradural and intramedullary. More than half occur in the fourth and fifth decades of life, and approximately one third of them involve an increased number of anaplastic cells. Unlike astrocytomas, ependymomas tend not to invade normal tissue. They can therefore be debulked with minimal morbidity. The 10-year survival rate is greater than 90% without further treatment. Radiation is indicated only in those with anaplastic cells. Sarcomas: Sarcomas are malignant tumors that arise from mesenchymal tissue and have very little connective tissue. Examples are fibrosarcomas and liposarcomas. Sarcomas account for approximately 10% of all intradural extramedullary spinal cord tumors.

Spinal cord tumors are rare in terms of overall central nervous system tumors. Presenting symptoms depend on location of the lesion as well as the cell type. Metastatic extradural tumors causing epidural spinal cord compression are most commonly a result of lung tumors in men and breast tumors in women.

PATHOPHYSIOLOGY The pathophysiology of a spinal cord tumor also depends on the cell type. The histologic types of intradural spinal cord tumors are neurilemomas (schwannomas, neurofibromas), meningiomas, astrocytomas, ependymomas, and sarcomas.

A small number of spinal tumors occur in the nerves of the spinal cord itself. Most often these are ependymomas and other gliomas.

Tumors that start in spinal tissue are called primary spinal tumors. Tumors that spread to the spine from some other place (metastasis) are called secondary spinal tumors. Tumors may spread to the spine from the breast, prostate, lung, and other areas.

The cause of primary spinal tumors is unknown. Some primary spinal tumors occur with genetic defects.

As it grows, the tumor can affect the: Blood vessels Bones of the spine Meninges Nerve roots Spinal cord cells

The tumor may press on the spinal cord or nerve roots, causing damage. With time, the damage may become permanent.

SYMPTOMSThe symptoms depend on the location, type of tumor, and persons general health. Tumors that have spread to the spine from another site (metastatic tumors) often progress quickly. Primary tumors often progress slowly over weeks to years.

Tumors in the spinal cord usually cause symptoms, sometimes over large portions of the body. Tumors outside the spinal cord may grow for a long time before causing nerve damage.

Symptoms may include: Abnormal sensations or loss of sensation: Especially in the legs (may be in the knee or ankle, with or without shooting pain down the leg) Cold sensation of the legs, cool fingers or hands, or coolness of other areas Back pain: Gets worse over time In any area -- middle or low back are most common Is usually severe and not relieved by pain medication Is worse when lying down Is worse with strain, cough, sneeze May extend to the hip, leg, or feet (or arms), or all extremities Fecal incontinence Inability to keep from leaking urine (urinary incontinence) Muscle contractions, twitches, or spasms (fasciculations) Muscle function loss

Possible complications are: Life-threatening spinal cord compression Loss of sensation Paralysis Permanent damage to nerves, disability from nerve damage Muscle weakness (decreased muscle strength not due to exercise): Causes falls Especially in the legs Makes walking difficult May get worse (progressive)

ASSESSMENTMany factors must be included in the assessment and history of the patient with a spinal cord tumor. Often, a complete neurologic exam can locate the level of the lesion, allowing accurate diagnostic imaging and work up to begin. These factors include:

Pain: Many spinal cord tumors present with pain as the initial symptom. The pain is thought to be caused by compression, invasion of the spinal tracts, tension on the nerve roots, or attachment to the dura. Extramedullary and extradural spinal cord tumors can cause severe local pain and tenderness. Intramedullary tumors can cause pain, but this is usually less severe. Radicular pain runs through the distribution of the nerve root that is affected. Pain caused by a spinal cord tumor is aggravated by bedrest and is therefore worse at night (remember that pain from a herniated disk is usually improved by rest).

Sensory impairment: Sensory disturbances depend on the degree to which ascending fibers of the spinal cord are affected. Affected dorsal columns produce impairments of light touch, joint and position sense, vibration, two-point discrimination, and stereognosis. When the fibers of the anterolateral columns are affected, impairment of pain and temperature discrimination results.

Motor impairment: In general, motor weakness is a late symptom of a spinal cord tumor. Weakness is due to the involvement of the pyramidal or corticospinal tract. The degree of motor impairment may range from clumsiness to complete quadriplegia. Myelopathy may be evident with central spinal cord tumors, resulting in spasticity, paresis, hyperactive reflexes, Babinski's sign. Some patients may develop a syrinx, which is a fluid filled area in the center of the spinal cord caused by pressure on the cord from a tumor, trauma, or after surgery. Diffuse motor deficits may be noted in those with a syrinx. These symptoms can be unilateral or bilateral, and are usually slow to develop.

Sphincter control: Disturbances of sphincter control, with a loss of bladder and bowel control, can occur as late symptoms of a spinal tumor. When the tumor causes pressure on the second or third sacral nerve roots, micturition is affected and there is paralysis of bladder contractions, bladder distention, and retention of urine with overflow incontinence. Urinary incontinence is often associated with a syrinx when the lesion causes disruption of the sacral pathways. Sexual dysfunction may also occur in association with loss of sphincter control.

Lesion levels: Along with a baseline assessment of pain, sensory impairment, motor impairment, and sphincter control, the clinician must ascertain whether the lesion is at the cervical, thoracic, or lumbar level of the spinal cord.

Cervical lesionsLesions at the level of the foramen magnum (the upper cervical segments) can be complicated. Patients may hold their head stiffly and have difficulty with shoulder elevation. Lesions at the C4 level can be particularly dangerous because of the phrenic nerve (which controls the diaphragm). With lesions involving the unilateral cord, the patient may experience respiratory difficulty and bilateral respiratory failure. High cervical lesions also produce quadriplegia, occipital headaches, stiff neck, and downbeat nystagmus.Lesions below the C4 level are less life threatening because the phrenic nerve is spared. Pain and muscle weakness follow patterns according to root distribution.Horner's syndrome may occur with lesions at the cervicothoracic junction (C8) as a result of automatic nervous system dysfunction. Horner's syndrome includes ptosis of the eyelid with pupillary constriction (miosis) and anhydrosis on the affected side. This can occur unilaterally or bilaterally.

Thoracic lesionsMetastatic lesions from the lung tend to spread to the thoracic area. Whether metastatic or primary, lesions of the thoracic region are more difficult to localize than are cervical or lumbar lesions. Pain and sensory changes usually precede muscle weakness. Sensory changes are relatively easy to identify because of the regular bandlike distribution of the dermatomes at this level.Beevor's sign maybe present with a lesion at the T10 level. When a patient sits up or raises the head from a recumbent position, the umbilicus is displaced toward the head. This is a late sign and occurs secondary to paralysis of the interior portion of the rectus abdominal muscle.

Lumbar lesionsPatients with cancer of the lung, breast, prostate, and kidney may have metastases to the lumbar or cauda equina region. Whether metastatic or primary, lesions of the lumbar and cauda equina region are characterized by pain, paresis, and a loss of strength in the lower extremity muscles. The pain can be very severe, and early loss of sphincter control is not uncommon.

Cauda equina syndrome is the compression (or injury) of any of the lumbosacral nerve roots within the neural canal below the level of L1. The patient may experience an areflexic bladder and bowel with varying degrees of motor/sensory impairment depending on the level and severity of compression. As peripheral nerves are able to regenerate, recovery is often possible in this situation.

Conus medullaris syndrome occurs with damage to the gray matter in the lower lumbar and sacral portion of the spinal cord and may also include nerve roots within the spinal canal. Again, the patient may experience areflexic bladder and bowel with varying degrees of motor/sensory impairment. Unfortunately, conus injuries have much less chance of return of function compared to cauda equina injuries

DIAGNOSTICS AND LABORATORY FINDINGSDiagnostic studies are used in the initial evaluation of spinal cord tumors. Understanding the probable pathology based on comprehensive examination is important in ordering the appropriate imaging study or lab test. In current cost-driven health care markets, the choice of studies is based on availability, perceived accuracy of the test, patient tolerance, and physician familiarity and comfort with the study.Myelography: Useful in obtaining information about the characteristics, location, and spatial relationships among spinal structures. Can demonstrate the level of a lesion, widening of the cord, and blockage of CSF.CT Scan: Beneficial in diagnosing lesions affecting the vertebral column. Useful in assessing bony defects and invading tumors.MRI: Provides the most detail of the pathologic condition of the spinal cord and surrounding soft tissue.SPECT (Single Photon Emission Computer Tomography): Useful for localizing metastatic lesions. Can define the site of the lesion within a given vertebra (pedicle vs. facet).Plain x-rays: While helpful in imaging spinal tumors, they do not image the spinal cord. Should be used in conjunction with an MRI.

TREATMENTThe goal of treatment is to reduce or prevent nerve damage from pressure on (compression of) the spinal cord.

Treatment should be given quickly. The more quickly symptoms develop, the sooner treatment is needed to prevent permanent injury. Any new or unexplained back pain in a patient with cancer should be thoroughly investigated.

Treatments include: Corticosteroids (dexamethasone) may be given to reduce inflammation and swelling around the spinal cord.

Surgery may be needed to relieve compression on the spinal cord. Some tumors can be completely removed. In other cases, part of the tumor may be removed to relieve pressure on the spinal cord. Surgery is generally the first treatment option for patients with primary spinal cord tumours because it allows the cord to be decompressed, thus relieving the symptoms of spinal cord compression. The surgeon will locate the tumour and remove as much as possible, at the same time obtaining tissue for histological diagnosis. As primary cord tumours are tumours of the cord itself, complete surgical excision may be very difficult. Before surgery, the surgeon will discuss with the patient the potential risks of the procedure, such as infection, worsening of existing deficits and, in some instances, the possibility of death. Radiation therapy may be used with, or instead of, surgery. Chemotherapy has not been proven effective against most spinal tumors, but it may be recommended in some cases. Physical therapy may be needed to improve muscle strength and the ability to function independently.

Case Scenario:Hillary, 25 years old, is complaining for two months of progressive low back pain and severe, radiating pain in the right lower extremity (sciatica). At the time of presentation, she reported associated numbness and weakness in her right lower extremity, particularly in her calf muscle. Her ability to ambulate and perform usual activities was severely impaired.

On examination, she was found to have reduced range of motion of her lumbar spine, positive sciatic nerve stretch testing, and measurable weakness in her calf muscle on the right side. Her gait was impaired, and she walked with a limp.Her MRI revealed a large right-sided L5-S1 extrudeddisc herniationwith superior migration up to the level of the L5 vertebral body. 1. What are some of the common manifestations of Herniated Intervertebral Disc Disease?2. Enumerate some of the causes of Herniated Intervertebral Disc Disease.3. What are some of the considerations in managing Herniated Intervertebral Disc Disease?4. Give some ways on how to diagnose Herniated Intervertebral Disc Disease.5. Enumerate some of the interventions done in managing Herniated Intervertebral Disc Disease.

HERNIATED INTERVERTEBRAL DISC

The vertebral column (backbone) is made up of 33 vertebrae separated by spongy disks and classified into four distinct areas. The cervical area consists of seven bony parts in the neck; the thoracic spine consists of 12 bony parts in the back area; the lumbar spine consists of five bony segments in the lower back area; five sacral bones (fused into one bone, the sacrum); and four coccygeal bones (fused into one bone, the coccyx).Between each vertebra is a fibrous disc with a jelly-like core. These cushions of cartilage allow the body to accept and dissipate load across multiple levels in the spine and still allow for the flexibility required for performing normal activities of daily living. As the body twists, bends, flexes and extends, the intervertebral discs are constantly changing their shape.CAUSESWhen discs degenerate, becoming less supple due to age or back strain, the disc may prolapse squeezing out some of the soft core. This loss of cushioning may cause pressure on local nerves and cause back or neck pain, numbness or tingling in the arms, or searing pain down one or both legs. If the prolapse is severe it can damage the spinal cord. As a part of the aging process the discs lose their high water content and their ability to cushion the vertebrae. This is called degenerative disc disease. As the discs deteriorate, the spine can initially become less stable. Bony spurs can develop as a result of this instability and can cause pressure on nearby nerves leading to leg or arm pain. Narrowing of the neural canal by these bony spurs is known as degenerative spinal stenosis. In some patients, this disc degeneration can be nearly asymptomatic; in others, disc degeneration can lead to intractable back pain. The outer layer of the discs themselves can also tear. When this occurs, the inner, gelatinous layer can herniate out (a herniated or ruptured disc) and also cause pressure on an adjacent nerve. If the herniation occurs in the neck and causes pressure there, it can cause pain that radiates into the shoulder and arm; if it occurs in the lower back, the pain produced can radiate down into the hip and leg.PATHOPHYSIOLOGYThe spine is made up of different parts. The backbone, also called the vertebral column, provides support and protection. It consists of 33 vertebrae (bones). There are discs between each of the vertebra that act like pads or shock absorbers. Each disc is made up of a tire-like outer band called the annulus fibrosus and a gel-like inner substance called the nucleus pulposus. The vertebrae and the discs provide a protective tunnel (the spinal canal) to house the spinal cord and spinal nerves. These nerves run down the center of the vertebrae and exit to the various parts of the body.

The spine also has muscles, ligaments, tendons and blood vessels. Muscles are strands of tissues that act as the source of power for movement. Ligaments are the strong, flexible bands of fibrous tissue that link the bones together and tendons connect muscles to bones and discs. Blood vessels provide nourishment. These parts all work together to help the body move.

A herniated disc most often occurs in the lumbar region (low back). This is because the lumbar spine carries most of the bodys weight. Sometimes the herniation can press on a nerve, causing pain that spreads or radiates to other parts of the body. The amount of pain associated with a disc rupture often depends upon the amount of material that breaks through the annulus fibrosus and whether it compresses a nerve.

Pain from a herniated disc is often the result of daily wear and tear on the spine. However, it may also be caused by an injury. Pain is sometimes the result of pinched nerves that are crowded by the leaking nucleus pulposus. A herniated disc can occur slowly over time, taking weeks or months to reach the point when medical attention is needed. Pain may also occur suddenly from incorrect lifting or twisting that aggravates a weak disc.

There are four stages to the formation of a herniated disc:

1. Disc Degeneration: During the first stage, the nucleus pulposus weakens due to chemical changes in the disc associated with age. At this state no bulging (herniation) occurs. 2. Prolapse: During prolapse, the form or position of the disc changes. A slight bulge or protrusion begins to form, which might begin to crowd the spinal cord. 3. Extrusion: During extrusion, the gel-like nucleus pulposus breaks through the tire-like wall of the annulus fibrosus but still remains within the disc. 4. Sequestration: During the last stage, the nucleus pulposus breaks through the anulus fibrosus and even moves outside the disc in the spinal canal.

SYMPTOMSPatients with disc disease in the cervical, thoracic, or lumbar spine experience variable symptoms depending on where the disc has herniated and what nerve root it is pushing on. The following are the most common symptoms of lumbar disc disease: Intermittent or continuous back pain (this may be made worse by movement, coughing, sneezing, or standing for long periods of time) Spasm of the back muscles Sciatica pain that starts near the back or buttock and travels down the leg to the calf or into the foot. Muscle weakness in the legs Numbness in the leg or foot Decreased reflexes at the knee or ankle Changes in bladder or bowel functionIn rare cases, patients with large disc herniation may experience weakness in an extremity or signs of spinal cord compression such as difficulty with gait, incoordination, or loss of bowel/bladder control.EXAMS & TESTS During physical examination, the following will be done: observation of ones posture, range of motion, and physical condition both standing and lying down. Movement that causes pain will be noted. A Lasgue test, also known as the Straight-Leg Raising test, may be done. The patient will be asked to lie down and extend his/her knee with the hip bent. If it produces pain, this may indicate disc herniation.

With disc herniation, the patient may feel stiff and may have lost normal spinal curvature due to muscle spasm. The doctor will feel the patients spine, note its curvature and alignment and feel for tightness.

A neurological exam will also be done. This is to test the reflexes, muscle strength, other nerve changes and spread of pain. Radicular pain (inflammation of a spinal nerve) may increase when pressure is applied directly to the affected area.DIAGNOSTIC STUDIES Spine x-raysare commonly taken after a neck injury in order to rule out a fracture, dislocation or instability. If the x-rays show degenerative changes right after the injury, then we assume they were present prior to the injury. Cervical spine x-rays may reveal congenital narrowing of the cervical spinal canal when present. Thoracic and lumbar x-rays may also show evidence of degenerative disease such as bone spurs and disc space narrowing. CT scanof the spine is valuable in assessing bone injury, such as fracture and/or dislocation. Bulging or herniated discs may or may not be visible on CT scan, and may or may not be related to the patients symptoms. CT scan is most useful in showing bone structures, and is not as good as MRI in showing spinal cord, nerve roots or discs. CT scan does not show torn ligaments or minor tears of discs. MR scanning (MRI)of the spine is the best method of imaging the spinal cord and nerve roots, the intervertebral discs, and the ligaments. However, MRI findings can only be of value when they are interpreted together with and in the light of the entire clinical picture, and exactly match the clinical findings. Cervical myelographyconsists of x-rays taken after the injection of radio-opaque contrast material into the spinal fluid via a lumbar puncture, and is followed by post-myelogram CT scan of the spine (myelo-CT). It may provide useful images of the interior of the spinal canal, and can reveal indentations of the spinal fluid sac caused by bulging or herniated discs or bone spurs that might be pressing on the spinal cord or nerves. MRI provides superior images of the spinal cord, nerve roots and discs. Electrodiagnostic studies(EMG and nerve-conduction velocities)are useful in evaluating weakness of hand and arm or leg muscles, and can indicate whether the weakness is due to abnormality or compression of a nerve root, or to some other cause.Additional tests:

Discogram or discography: A sterile procedure in which dye is injected into one of the vertebral disc and viewed under special conditions (fluoroscopy). The goal is to pinpoint which disc(s) may be causing the pain. Bone scan: This technique creates computer or film images of bones. A very small amount of radioactive material is injected into a blood vessel then throughout the blood stream. It collects in the bones and can be detected by a scanner. This procedure helps doctors detect spinal problems such as arthritis, a fracture, tumor, or infection.

Lab tests: Typically blood is drawn (venipuncture) and tested to determine if the blood cells are normal or abnormal. Chemical changes in the blood may indicate a metabolic disorder, which could be contributing to the back pain.

INTERVENTIONS

The following are considerations for managing herniated intervertebral disc: The history and severity of their pain Whether or not they have had prior treatments for this problem and how effective they have been and Whether or not there is any evidence of neurologic damage such as weakness of an extremity or the loss of reflexes

Some of the treatments used include: Activity modification Patient education on proper body mechanics (to help decrease the chance of worsening pain or damage to the disc) Physical therapy, which may include ultrasound, massage, conditioning, and exercise programsWeight control Medications (to control pain and/or to relax muscles)

Surgery for patients with disc disorders of the spine is usually reserved for those who have failed exhaustive attempts at conservative treatment over a period of 6-12 weeks. An exception to this is the patient with a neurologic deficit; in this patient, it is wise to consider early surgical decompression to maximize the likelihood of neurologic recovery.Surgery is done under general anaesthesia. An incision is placed in the lower back over the area where the disc is herniated. Some bone from the back of the spine is removed to gain access to the area where the disc is located. Typically, the herniated part of the disc and any extra loose pieces of disc are removed from the disc space.After surgery, restrictions may be placed on the patients activities for several weeks while healing is taking place to prevent another disc herniation from occurring.

NURSING INTERVENTIONS

A. Acute pain related to nerve compression, muscle spasm

1. Assess complaints of pain, location, duration of attacks, precipitating factors, which aggravate. 2. Maintain bed rest, semi- Fowler position to the spinal bones, hips and knees in a scale of flexion, supine position3. Use logroll (board) during a change of position4. Auxiliary mounting brace or corset5. Limit the activity of the patient during the acute phase according to the needs6. Teach relaxation techniques7. Collaborative care: analgesics, traction, physiotherapy

B. Impaired physical mobility related to pain, muscle spasms and damage to neuromuscular restrictive therapy

1. Give aids to perform passive range of motion exercises and active2. Assist patient in ambulation activity progressively3. Provide good skin care, massage point pressure after reap change of position. Check state of the skin under the brace with specific time period.4. Note the emotional responses or behaviors in immobilizing5. Demonstrate the use of auxiliary equipment such as a cane6. Collaborative care: analgesic

C. Knowledge deficient related to the lack of information about the condition, prognosis

1. Explain the process of disease and prognosis and restrictions on activities.2. Give information about body mechanics3. Suggest to use the board or a small pillow under the neck4. Avoid the use of heaters in a long time5. Give information about the signs that need attention such as puncture pain, loss of sensation or ability to walk

Case Scenario:Pia Cayetano is a well-known Victorias Secret model. She started modeling at the age of 18. After 3 years of modeling, she experienced lower back pain but did not go for a check-up. 2 years after, the pain is now accompanied with tingling and numbness. She then consulted her private physician at the UST Hospital, and was later found that she has Lordosis.1. What are ways to assess the patient?2. What diagnostic tests can be done to diagnose Lordosis?3. What are the possible treatments? 4. Is a surgery needed? Why or why not?5. What are possible complications if left untreated? And after surgery?6. As a nurse, what suggestions can you give the patient in managing her condition?

LORDOSISLordosis, also known as swayback, is the exaggerated forward curve of the lumbar spine.

COMMON CHARACTERISTICS OF LORDOSIS Anterior tilt of pelvis Hyperextended knees Upper body is shifted backwards Lordosis tends to make the buttocks appear more prominent. Individuals with significant lordosis will have a significant space beneath their lower back when lying on their back on a hard surface.

SYMPTOMS Severe lower back pain Exaggerated posture 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 Problems in moving in certain ways

CAUSES Genetic predispositions Weak abdominals, gluteals, and hamstrings Poor posture Tight lower back muscles Secondary to other spinal deformities Muscular dystrophy Obesity Flexion contracture of hip Congenital dislocation of hip High heels shortening of Achilles tendon, sudden discontinuation of wearing high heels can increase lumbar lordosis even further

ASSESSMENT Physical Exam The patient may be asked to bend forward, to the side, and to lie flat on a table so that spine can be examined in a variety of positions.In some cases, particularly if the curve seems fixed (not bendable), the following or other diagnostic tests may be recommended: Lumbosacral spine x-ray MRI/CT Scan Other tests to rule out suspected disorders causing the condition

INTERVENTIONS If the lordotic curve is flexible or when the individual bends forward, the curve reverses itself, it is generally not a concern. But if the curve does not move, medical evaluation and treatment are needed. Usually not treated and will not progress or cause problems. Call health care provider if notice that individual has an exaggerated posture or a curve in the back. The condition should be evaluated to determine if there is a medical problem.

TREATMENT Specific treatment for lordosis will be determined by patients physician based on: Patients age, overall health, and medical history Extent of the condition Patients tolerance for specific medications, procedures, or therapies Expectations for the course of the condition Parent/patients opinion or preferenceManagement: Depend upon the cause of the lordosis.

Goal of treatment: Stop the progression of the curve and prevent deformity. Observation Physical Therapy (to help build strength in the core muscles, improve posture) Bracing Medication to reduce pain and swelling (NSAID) Yoga (to increase body awareness, strength, flexibility, and range of motion) Weight loss Most severe cases require surgery

Simple exercises may be sufficient if lordosis is associated with poor posture.

However, lordosis occurring as a result of a hip problem may be treated as a part of the hip problem.

SURGERIES Discectomy Removes the herniated or affected disc Incision down the center of the back, muscles and nerves moved aside and problematic disc is removed and device is implanted Suture or metal staples are used to close

Corpectomy Removes multiple vertebrae, more invasive Device implanted in the removed area Suture or metal staples are used to close

Recovery after Surgery Most patients go home 1-2 days (disectomy) or 4-5 days (corpectomy) later Recovery time: 1-4 weeks 8-12 weeks recovery needed for more labor intensive jobs Surgical tape to affix suture, keep wound dry and clean Narcotic medication may be taken for pain 2-4 weeks Physical therapy recommended Do not sit for long periods of time or drive for the first 2-4 weeks

POSSIBLE COMPLICATIONS Osteoporosis patients may encounter problems with device fixation Obesity (too much stress) Potential Complications of Surgery Hematoma Skin necrosis outside operation region Deep infection around implantation Thrombosis

DESIRED OUTCOMES Better sitting posture Improved sagittal balance Reduced pain Optimized fusion environment

TEACHING TIPS Provide exercises to (a) stretch lower back muscles, (b) strengthen abdominals, and (c) realign pelvic tilt. Encourage the patient to consciously think about reestablishing proper pelvic alignment in normal daily activities. Inform the patient that all stretching should be done pain-free. Collaborate with the adapted physical educator/physical therapist/occupational therapist to assist with the students physical and motor development

Case Scenario:Client L.C., a 16 years old 510 male Dota player who plays 6-8 hours a day, was brought to the emergency department due to difficulty of breathing. Assessment was done and no crackles or adventitious sounds were heard but a rounding of the back was noticed. He had a history of intermittent back pain for 3 weeks already which is sometimes relieved by topical pain relievers. A chest x-ray was done and showed normal findings. Client was then given inhalation therapy to sooth difficulty of breathing. After a week, client had an x-ray for schools medical examination and showed an increase in the convexity of thoracic spine. Client L.C. was then diagnosed with kyphosis.1. Why did client L.C. experienced difficulty breathing in the first place?2. Aside from difficulty of breathing, what are the other manifestations of kyphosis?3. What caused client L.C.s kyphosis?4. What nursing interventions can be done in order to prevent further complication?5. What treatment will be done to Client L.C.?6. What are the complications if Client L.C. wasnt diagnosed early?

KYPHOSIS

Kyphosis , usually referred to as the exaggerated rounding of the back or hunchback, is the increase in the convexity of the thoracic spine. While kyphosis can occur at any age, it's most common in older women.

Kyphosis often develops in mature adults secondary to disorders such as osteoporosis and tuberculosis. Age-related kyphosis often occurs after osteoporosis which weakens spinal bones to the point that they crack and compress. Other types of kyphosis are seen in infants or teens due to malformation of the spine or wedging of the spinal bones over time. Kyphosis during adolescence often occurs due to frequent hunching over or poor posture due to tall height or self consciousness. A curve of more than 60 degrees is considered a sign of kyphosis.Kyphosis causes few problems, but severe cases can cause pain and be disfiguring. Sometimes kyphosis does notcause any symptoms other than the back appearing abnormally curved or hunched.

SYMPTOMS Back pain Stiffness Tenderness of the spine Tiredness Numbness Difficulty of breathing Appearance of round back

CAUSES Osteoporosis. This bone-thinning disorder can result in crushed vertebrae (compression fractures). Osteoporosis is most common in older adults, particularly women, and in people who have taken high doses of corticosteroids for long periods of time.Disk degeneration. Soft, circular disks act as cushions between spinal vertebrae. With age, these disks dry out and shrink, which often worsens kyphosis.Scheuermann's disease. Also called Scheuermann's kyphosis, this disease typically begins during the growth spurt that occurs before puberty. Boys are affected more often than are girls. The rounding of the back may worsen as the child finishes growing.Birth defects. If a baby's spinal column doesn't develop properly in the womb, the spinal bones may not form properly, causing kyphosis.Syndromes. Kyphosis in children can also be associated with certain syndromes, such as Marfan syndrome or Prader-Willi disease.Cancer and cancer treatments. Cancer in the spine can weaken vertebrae and make them more prone to compression fractures, as can chemotherapy and radiation cancer treatments.Poor posture (postural kyphosis) slouching, leaning back in chairs and carrying heavy bags can stretch supporting muscles and ligaments, which can pull the thoracic vertebrae out of their normal positionabnormal development of the spine in the womb congenital kyphosis if something disrupts the spine's normal development, two or more vertebrae sometimes fuse together.

COMPLICATIONSBody image problems. Adolescents especially may develop a poor body image from having a rounded back or from wearing a brace to correct the condition.Back pain. In some cases, the misalignment of the spine can lead to pain, which can become severe and disabling.Decreased appetite. In severe cases, the curve may cause the abdomen to be compressed and lead to decreased appetite.

DIAGNOSTIC TESTX-rays. Plain X-rays are used to determine the degree of curvature and can detect deformities of the vertebrae, which helps identify the type of kyphosis.Computerized tomography (CT scan). If more detail is required, your doctor might order a CT scan which takes X-ray images from many different angles and then combines them to form cross-sectional images of internal structures.Magnetic resonance imaging (MRI). If your doctor suspects a tumor or infection, he or she may request an MRI of your spine. MRI uses radio waves and a very strong magnet to produce detailed images of both bone and soft tissues.If you are experiencing any numbness or muscle weakness, your doctor may recommend several tests that can determine how well nerve impulses are traveling between your spinal cord and your extremities.TREATMENT AND DRUGSMEDICATIONSPain relievers. If over-the-counter medicines such as acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve) aren't enough, stronger pain medications are available by prescription.Osteoporosis drugs. In many older people, kyphosis is the first clue that they have osteoporosis. Bone-strengthening drugs may help prevent additional spinal fractures that would cause your kyphosis to worsen.

THERAPYExercise and postural change can reverse mild kyphosis, but severe deformities require surgery or brace for correction.Exercises. Stretching exercises can improve spinal flexibility and relieve back pain. Exercises that strengthen the abdominal muscles may help improve posture.Bracing. Children who have Scheuermann's disease may be able to stop the progression of kyphosis by wearing a body brace while their bones are still growing.

Healthy lifestyle. Maintaining a healthy body weight and regular physical activity will help prevent back pain and relieve back symptoms from kyphosis.Maintaining good bone density. Proper diet with calcium and vitamin D and screening for low bone density, particularly if there is a family history of osteoporosis or history of previous fracture, may help older adults avoid weak bones, compression fractures and subsequent kyphosis.

SURGICAL AND OTHER PROCEDURESIf the kyphosis curve is very severe or if the curve is pinching the spinal cord or nerve roots, your doctor might suggest surgery to reduce the degree of curvature.The most common procedure, called spinal fusion, connects two or more of the affected vertebrae permanently. Surgeons insert pieces of bone between the vertebrae and then fasten the vertebrae together with metal rods and screws until the spine heals together in a corrected position.

NURSING INTERVENTIONS Teach client on the importance of sitting upright. Teach client how to properly use the bracing equipment. Encourage client to exercise frequently. Refer client to a proper therapist.