Spinal Column Deformities

Musculoskeletal Disorders Part 5: Spinal Column Deformities

M A R I A C A R M E L A L . D O M O C M A T , R N , M S N

I N S T R U C T O R

S C H O O L O F N U R S I N G

N O R T H E R N L U Z O N A D V E N T I S T C O L L E G E

A R T A C H O , S I S O N , P A N G A S I N A N

Overview 2

� Part 1: Degenerative & Metabolic bone disorders:

� Part 2: Bone infections

� Part 3: Muscular disorders

� Part 4: Disorders of the hand

� Part 5: Spinal column deformities

3/5/2012Maria Carmela L. Domocmat, RN, MSN

� Part 5: Spinal column deformities� Scoliosis

� Kyphosis

� Lordosis

� Osteogenesis imperfecta (OI)

� Part 6 : Disorders of foot

� Part 7: Sports Injuries

Spinal column deformities3

� Scoliosis

� Kyphosis

� Lordosis

� Osteogenesis imperfecta (OI)


Scoliosis

Scoliosis 5

� AKA

� Spinal curvature

� Infantile scoliosis

� Juvenile scoliosis


Scoliosis7

� is an abnormal curving of the spine.

� But people with scoliosis have a spine that curves too much. The spine might look like the letter “C” or “S.”


Causes, incidence, and risk factors

� idiopathic scoliosis� most common type. It is grouped by age.� In children age 3 and younger--infantile scoliosis.� In kids age 4 - 10--juvenile scoliosis.� In older kids age 11 – 18 --adolescent scoliosis.� most often affects girls.

Curving generally gets worse during a growth spurt.� Curving generally gets worse during a growth spurt.

� Congenital scoliosis� This type of scoliosis is present at birth. It occurs when the baby’s

ribs or spine bones do not form properly.

� Neuromuscular scoliosis� This type is caused by a nervous system problem that affects your

muscles, such as cerebral palsy, muscular dystrophy, spina bifida, and polio.

Symptoms12

� Usually there are no symptoms. But symptoms can include:

� Backache or low-back pain

� Tired feeling in the spine after sitting or standing for a long time


time

� Uneven hips or shoulders (one shoulder may be higher than the other)

� Spine curves more to one side

� Kyphoscoliosis is another type of abnormal curving of the spine.

Dx exams13

� PE: One shoulder is higher than the other, pelvis is tilted

� X-rays of the spine

� Spinal curve measurement (scoliometer screening)


� MRI of the spine

Scoliometer screening14


Treatment15

� Treatment depends on many things:� The cause of scoliosis

� Where the curve is in your spine

� How big the curve is

� If body is still growing

� Most people with idiopathic scoliosis do not need


� Most people with idiopathic scoliosis do not need treatment. However, should be checked by a doctor about every 6 months.

� If still growing --back brace. � A back brace prevents further curving. There are many different

types of braces. Back braces can be adjusted as you grow.

� Back braces work best in people over age 10. Braces do not work for those with congenital or neuromuscular scoliosis.

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� Scoliosis surgery involves correcting the curve as much as possible.

� The spine bones are held in place with one or two metal rods, which are held down with hooks and screws until the bone heals together.


heals together.

� Surgery may be done with a cut through the back, belly area, or beneath the ribs.

� After surgery, you may need to wear a brace for a little while to keep the spine still.

� if the spine curve is severe or getting worse very quickly. The surgeon may want to wait until all your bones stop growing, but this isn’t always possible.

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� Scoliosis treatment may also include:

� Emotional support. Some kids, especially teens, may be self-conscious when using a back brace

� Physical therapy and other specialists to help explain the treatments and make sure the brace fits correctly.


treatments and make sure the brace fits correctly.

Expectations (prognosis)18

� depends on the type, cause, and severity of the curve. The more severe the curving, the more likely it will get worse after stop growing.

� People with mild scoliosis do very well with braces. They usually do not have long-term problems. However, scoliosis can make more likely to have back pain when get older.

� The outlook for those with neuromuscular or congenital scoliosis


� The outlook for those with neuromuscular or congenital scoliosis varies.

� Patients with neuromuscular scoliosis have another serious disorder (like cerebral palsy or muscular dystrophy) so their goals are much different.

� Often the goal of surgery is simply to allow a child to be able to sit upright in a wheelchair.

� Congenital scoliosis is difficult to treat and usually requires many surgeries.

Complications19

� Breathing problems (in severe scoliosis)

� Low back pain

� Lower self-esteem

� Persistent pain if there is wear and tear of the spine


� Persistent pain if there is wear and tear of the spine bones

� Spinal infection after surgery

� Spine or nerve damage from an uncorrected curve or spinal surgery

Prevention20

� Routine scoliosis screening is now done in middle and junior high schools.

� Screening has helped detect early scoliosis in many kids.


References26

� http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002221/

� Hedequist DJ. Surgical treatment of congenital scoliosis. Orthop Clin North Am. 2007;38:497-509, vi. [PubMed]


vi. [PubMed]

� Lonner BS. Emerging minimally invasive technologies for the management of scoliosis. Orthop Clin North Am. 2007;38:431-440. [PubMed]

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Kyphosis

Maria Carmela L. Domocmat, RN, MSN 3/5/2012

Kyphosis28

� AKA

� Scheuermann's disease;

� Roundback;

� Hunchback;

� Postural kyphosis


� Postural kyphosis

Kyphosis29

� is a curving of the spine that causes a bowing or rounding of the back, which leads to a hunchback or slouching posture.


Causes, incidence, and risk factors30

� Kyphosis can occur at any age, although it is rare at birth.

� Adolescent kyphosis, also known as Scheuermann'sdisease, is caused by the wedging together of several bones of the spine (vertebrae) in a row. The cause of Scheuermann's disease is unknown.

In adults, kyphosis can be caused by:


� In adults, kyphosis can be caused by:� Degenerative diseases of the spine (such as arthritis or disk

degeneration)

� Fractures caused by osteoporosis (osteoporotic compression fractures)

� Injury (trauma)

� Slipping of one vertebra forward on another (spondylolisthesis)

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� Other causes of kyphosis include:

� Certain endocrine diseases

� Connective tissue disorders

� Infection (such as tuberculosis)

� Muscular dystrophy


� Muscular dystrophy

� Neurofibromatosis

� Paget's disease

� Polio

� Spina bifida

� Tumors

congenital kyphosis32

� Clinical photograph and MRI scan of a child with an abrupt congenital kyphosis in the thoracic spine. The MRI scan shows a posteriorly

3/5/2012http://orthoinfo.aaos.org/figures/A00423F02.jpg

shows a posteriorlylocated hemivertebracausing impingement on the spinal cord.

� (Courtesy of Texas Scottish Rite Hospital for Children)

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� Kyphosis can also be seen with scoliosis. Each cause has its own risk factors.


Symptoms34

� Difficulty breathing (in severe cases)

� Fatigue

� Mild back pain

� Round back appearance


� Round back appearance

� Tenderness and stiffness in the spine

Dx exams 35

� Physical examination by a health care provider confirms the abnormal curve of the spine. The doctor will also look for any nervous system (neurological) changes (weakness, paralysis, or changes in sensation) below the curve.


sensation) below the curve.

Dx exams 36

� Spine x-ray

� Pulmonary function tests (if kyphosis affects breathing)

� MRI (if there may be a tumor, infection, or neurological symptoms)


neurological symptoms)

Treatment37

� Treatment depends on the cause of the disorder:

� Congenital kyphosis requires corrective surgery at an early age.

� Scheuermann's disease is treated with a brace and physical therapy. Occasionally surgery is needed for large (greater than 60 degrees), painful curves.


60 degrees), painful curves.

Treatment38

� Treatment depends on the cause of the disorder:

� Multiple compression fractures from osteoporosis can be left alone if there are no nervous system problems or pain. However, the osteoporosis needs to be treated to help prevent future fractures. For debilitating deformity or pain, surgery is an option.


an option.

� Kyphosis caused by infection or tumor needs to be treated more aggressively, often with surgery and medications.

� Treatment for other types of kyphosis depends on the cause. Surgery may be necessary if neurological symptoms or persistent pain develop.

Expectations (prognosis)39

� Adolescents with Scheuermann's disease tend to do well even if they need surgery, and the disease stops once they stop growing.

� If the kyphosis is due to degenerative joint disease or multiple compression fractures, surgery is needed to


multiple compression fractures, surgery is needed to correct the defect and improve pain.

Complications40

� Decreased lung capacity

� Disabling back pain

� Neurological symptoms including leg weakness or paralysis


� Round back deformity

Prevention41

� Treating and preventing osteoporosis can prevent many cases of kyphosis in the elderly.

� Early diagnosis and bracing of Scheuermann'sdisease can reduce the need for surgery, but there is no way to prevent the disease.


no way to prevent the disease.

References42

� Spiegel DA, Hosalkar HS, Dormans JP. The spine. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 678.

� Freeman BL III. Scoliosis and kyphosis. In: Canale


� Freeman BL III. Scoliosis and kyphosis. In: CanaleST, Beaty JH, eds. Campbell's Operative Orthopaedics. 11th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 38.


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Lordosis

Maria Carmela L. Domocmat, RN, MSN 3/5/2012

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� Lordosis is an increased curving of the spine.

� AKA: Swayback


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� The spine has three types of curves:

� Kyphotic curves refer to the outward curve of the thoracic spine (at the level of the ribs).

� Lordotic curves refer to the inward curve of the lumbar spine (just above the buttocks).


(just above the buttocks).

� Scoliotic curving is a sideways curvature of the spine and is always abnormal.

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� A small degree of both kyphotic and lordoticcurvature is normal.

� Too much kyphotic curving causes round shoulders or hunched shoulders (Scheuermann's disease).


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� Too much lordotic curving is called swayback (lordosis). Lordosis tends to make the buttocks appear more prominent. Children with significant lordosis will have a significant space beneath their lower back when lying on their back on a hard


lower back when lying on their back on a hard surface.

� If the lordotic curve is flexible (when the child bends forward the curve reverses itself), it is generally not a concern. If the curve does not move, medical evaluation and treatment are needed.

Causes48

� Achondroplasia

� Benign juvenile lordosis (not medically significant)

� Spondylolisthesis


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� Achondroplasia is a disorder of bone growth that causes the most common type of dwarfism.

� Achondroplasia is one of a group of disorders called chondrodystrophies or osteochondrodysplasias.

� Achondroplasia may be inherited as an autosomal dominant trait, which means that if a child gets the defective gene from


trait, which means that if a child gets the defective gene from one parent, the child will have the disorder. If one parent has achondroplasia, the infant has a 50% chance of inheriting the disorder. If both parents have the condition, the infant's chances of being affected increase to 75%.

� However, most cases appear as spontaneous mutations. This means that two parents without achondroplasia may give birth to a baby with the condition.

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� Spondylolisthesis is a condition in which a bone (vertebra) in the lower part of the spine slips out of the proper position onto the bone below it.

� In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum (pelvis) area. It is often due to a birth defect in that area of the spine or sudden injury (acute trauma).

� In adults, the most common cause is degenerative disease (such as arthritis). The slip usually occurs between the fourth and fifth lumbar


arthritis). The slip usually occurs between the fourth and fifth lumbar vertebrae.

� Other causes of spondylolisthesis include bone diseases, traumatic fractures, and stress fractures (commonly seen in gymnasts). Certain sport activities, such as gymnastics, weight lifting, and football, put a great deal of stress on the bones in the lower back. They also require that the athlete constantly overstretch (hyperextend) the spine. This can lead to a stress fracture on one or both sides of the vertebra. A stress fracture can cause a spinal bone to become weak and shift out of place.

Home Care51

� If the back is flexible, lordosis is usually not treated and will not progress or cause problems.


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� Call health care provider if notice that child has an exaggerated posture or a curve in the back.

� The condition should be evaluated to determine if there is a medical problem.


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� physical exam. The child may be asked to bend forward, to the side, and to lie flat on a table so that the spine can be examined in a variety of positions.


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� In some cases, particularly if the curve seems "fixed" (not bendable), the following or other diagnostic tests may be recommended:

� Lumbosacral spine x-ray

� Spine x-ray


� Spine x-ray

� Other tests to rule out suspected disorders causing the condition

Treatment55

� Specific treatment for lordosis will be determined by child's physician based on:

� your child's age, overall health, and medical history

� the extent of the condition

� child's tolerance for specific medications, procedures, or


� child's tolerance for specific medications, procedures, or therapies

� expectations for the course of the condition

� Paretn’s opinion or preference

http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/orthopaedics/lordosis.html

Treatment56

� Observation

� physical therapy

� bracing.

� most severe cases require surgery


� most severe cases require surgery

Treatment57

� The goal of treatment is to stop the progression of the curve and prevent deformity.

� Management of lordosis will depend upon the cause of the lordosis.

Simple exercises may be sufficient if lordosis is


� 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.

http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/orthopaedics/lordosis.html

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References59

� Spiegel DA, Dormans JP. The spine.In: KliegmanRM,Behrman RE, Jenson HB, Stanton BF, eds.Nelson Textbook of Pediatrics.19th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 671.


� http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/orthopaedics/lordosis.html

Osteogenesis imperfecta (OI)

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http://www.oif.org/images/content/pagebuilder/94682.jpg

Maria Carmela L. Domocmat, RN, MSN

Osteogenesis imperfecta (OI)

• AKA: Brittle bone disease• rare genetic disorder in which bone are fragile and

fracture easily resulting in bone deformity• anautosomal dominantdisease

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• anautosomal dominantdisease

• A person with OI has a 50% chance of passing on the gene and the disease to their children.

• involves errors in synthesis of collagen, a connective tissue


Types according to Silence classification system

o has four types based on inheritance as autosomal dominant or autosomal recessive and clinical findings of each type

o Types I and IV – more mild manifestations of disease;

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can persist into adulthoodo Types II and III – more severe and can result in fracture

in utero, during the birthing process, or in early childhood; associated with high mortality rate


Type 1 osteogenesis

� most common.

� People who have type 1 disease generally reach normal height and have few obvious skeletal deformities.

typically causes more fractures during childhood

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� typically causes more fractures during childhood than in adulthood.

� Hearing loss is pronounced and begins early in childhood.


Type 2 osteogenesis imperfecta

� most rare and the most severe.

� produces numerous deformities of the skeleton

� often is fatal in infancy.

� abnormal collagen formation also profoundly affects

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� abnormal collagen formation also profoundly affects the lungs, causing significant breathing problems.



� more severe than type 1 but less severe than type 3.

� Fractures are most common before puberty.

� Hearing loss begins in early childhood and is often profound

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� produces obvious skeletal deformities. Fractures before birth are common;

� UTZ can detect them in the fetus.

� also affects the lungs and muscles.

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� Hearing loss begins in early childhood and often becomes complete by adolescence.

http://www.beltina.org/health-dictionary/osteogenesis-imperfecta-types-treatment.html


s/s

� All people with OI have weak bones, which makes them susceptible to fractures.

� Persons with OI are usually below average height (short stature).

� However, the severity of the disease varies greatly

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s/s

� The classic symptoms include:

� osteoporosis

� history of multiple fractures

� bone deformity

� poor skeletal development

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� poor skeletal development

� soft brownish teeth

� hearing loss

� Blue tint to the whites of their eyes (blue sclera)

� Because type I collagen is also found in ligaments, persons with OI often have loose joints (hypermobility) and flat feet.


s/s

� Symptoms of more severe forms of OI may include:

� Bowed legs and arms

� Kyphosis

� Scoliosis (S-curve spine)

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bone deformity 71


blue sclerae72

http://www.thachers.org/images/Osteogenesis_imperfecta_blue_sclera.JPG

http://cnx.org/content/m15020/latest/Cases_40_41_42-pres1-1.jpg


soft brownish teeth; bone deformity 73

http://jorthod.maneyjournals.org/content/vol30/issue4/images/large/Kind.f1c.jpeg

http://www.beltina.org/pics/osteogenesis_imperfecta.jpg


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This baby's extremities are positioned oddly because there have been multiple fractures due to osteogenesis imperfecta (OI). This disease leads to multiple fractures. The basic problem is a defect in the formation of type 1 collagen that forms bone matrix. There are several types of OI with different inheritance patterns.

http://medgen.genetics.utah.edu/photographs/diseases/high/peri021.jpg


Dx:

� serum alkaline phosphatase – increased

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Treatment

� Treatment for fracture - generally conservative� targeting a balance between immobilizing the fracture long enough

for it to heal and allowing normal muscle function as quickly as possible.

� Physical activity � helps strengthen muscles and bone, which in turn minimizes

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� helps strengthen muscles and bone, which in turn minimizes fractures.

� The most numerous fractures occur during childhood when the bones are growing and thus have lower mineral content.

� The risk for fracture is lifelong, however, and may increase in women after menopause when bone density naturally declines.


Treatment

o palliativeo steroidso calcium o vit Co sodium fluoride

PT

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o PTo castingo bracing o telescoping intramedullary rods – to maintain mobility and

promote ambulation o research ongoing – Biphophonates


Expectations (prognosis)

� How well a person does depends on the type of OI they have.

� Type I, or mild OI, is the most common form. Persons with this type can live a normal lifespan.

Type II is a severe form that is usually leads to death

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� Type II is a severe form that is usually leads to death in the first year of life.

� Type III is also called severe OI. Persons with this type have many fractures starting very early in life and can have severe bone deformities. Many become wheelchair bound and usually have a somewhat shortened life expectancy.


Expectations (prognosis)

� Type IV, or moderately severe OI, is similar to type I, although persons with type IV often need braces or crutches to walk. Life expectancy is normal or near normal.

� There are other types of OI, but they occur very infrequently and most are considered subtypes of the moderately severe form

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most are considered subtypes of the moderately severe form (type IV).


Complications

� Complications are largely based on the type of OI present. They are often directly related to the problems with weak bones and multiple fractures.

� Hearing loss (common in type I and type III)

� Heart failure (type II)

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� Heart failure (type II)

� Respiratory problems and pneumonias due to chest wall deformities

� Spinal cord or brain stem problems

� Permanent deformity


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http://jorthod.maneyjournals.org/content/vol30/issue4/images/large/Kind.f1c.jpeg


Resources

� Ignatavicius and Workman (2006). Medical surgical nursing [5th ed]. Singapore: Elsevier.


http://www.beltina.org/health-

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� http://www.beltina.org/health-dictionary/osteogenesis-imperfecta-types-treatment.html

� http://www.oif.org/site/PageServer

� http://www.umm.edu/ency/article/001573.htm


Health & Medicine

Spinal Column Deformities