Scoliosis Nursing Care Management and Study Guide

Scoliosis is lateral curvature and rotation of the vertebral column. Most of what you do is catch it early, track whether the curve is progressing, and carry the child through long-term bracing or surgery without letting skin breakdown, immobility, or a wrecked body image derail the plan. The curve is the medical problem. Compliance over years of growth is the nursing problem.

What is Scoliosis?

The term comes from the Greek skolios ("twisted") and describes a sideward curve in the spine, often an "S" or "C" shape. It is not a simple one-plane bend but a three-dimensional deformity that usually develops in childhood. It can occur at any age but is most often diagnosed in adolescence. Mild curves may cause no symptoms; severe scoliosis leads to back pain, difficulty breathing, and postural change.

Naming tracks the age of onset: infantile scoliosis is curvature in children younger than 3 years, juvenile is 4 to 9 years, and adolescent is 10 to 18 years. The curve comes in two forms, structural and functional (postural).

Types

Structural scoliosis involves rotated and malformed vertebrae. Functional scoliosis is the more common type and stems from poor posture, muscle spasm after trauma, or unequal leg length.

Pathophysiology

Most structural scoliosis is idiopathic; a few cases trace to congenital deformity or infection. Most curves develop during the first year of life, and there is a strong correlation between an infant's nursing posture and curve development. It is less common in the United States than in Europe, where babies are nursed supine. Infants tend to turn toward the right, and because of the plasticity of the infant axial skeleton this can produce plagiocephaly, bat ear on the right, and curvature of the spine toward the left.

Statistics and Incidences

Many states require routine scoliosis screening starting in the fifth or sixth grade. Idiopathic scoliosis accounts for fewer than 1% of cases in North America; in Europe the rate is 4%. Males make up 60% of early-onset cases; 90% of early-onset cases resolve spontaneously, but the remaining 10% progress to severe, disabling deformity. Females constitute 90% of late-onset cases and need close monitoring so intervention happens at the right time. Idiopathic scoliosis appears in school-age children 10 years and older. Mild curves are as common in boys as girls, but scoliosis requiring treatment occurs eight times more often in girls.

Causes

The exact cause is unknown; hypotheses rest on epidemiologic evidence. One theory holds that mechanical factors during intrauterine life drive the higher same-side incidence of plagiocephaly, developmental dysplasia of the hip, and scoliosis. A second proposes multifactorial causes: genetic predisposition facilitated or inhibited by external factors such as defective motor development, collagen disorders, joint laxity, and infant nursing posture. Other associations include older mothers from poorer families, breech presentation, and premature, male, low-birth-weight infants.

Clinical Manifestations

Infantile scoliosis is usually caught in the first year of life by parents or by the pediatrician on routine exam. Expect a single long thoracic curve to the left; a thoracic and lumbar double curve is less common. Look for asymmetry of the shoulders, shoulder blades, or hips, and an unequal distance between the arms and the waist.

Assessment and Diagnostic Findings

Diagnosis is made on screening exam. Spine radiographs in infants are taken with the child held up by the arms; severity is established by the rib-vertebral angle difference (RVAD). CT gives a detailed picture of the curve. MRI is necessary in moderate-to-severe scoliosis because the reported frequency of neural axis abnormalities is high (21 to 50% in some sources).

Medical Management

Treatment depends on many factors and is either nonsurgical or surgical.

Nonsurgical Management

Treatment is long-term and often lasts through the rest of the child's growth cycle. Electrical stimulation is an alternative to bracing for mild-to-moderate curves: applied at night during sleep, electrodes on the skin stimulate muscles on the convex side of the curve to contract, straightening the spine. The Boston or TLSO brace is the common choice; it is worn constantly except during bathing and swimming, fitted and monitored closely, and worn over a T-shirt or undershirt to protect the skin. Because of instrumentation advances, pedicle screw instrumentation can be used in children with further growth potential; a growing rod here carries fewer complications than fixation with L-rods. For severe spinal curvature or cervical instability, halo traction may be used to reduce the curve and straighten the spine.

Surgical Management

Whether to operate depends on many factors. Growing rods without fusion are preferred until combined posterior and anterior fusion can be done; growing-rod systems (for example, pediatric Isola instrumentation) prevent curve progression, with extensions needed every 6 months to keep pace with growth until the child has adequate trunk length, usually between ages 11 and 15 years. A localizer cast holds the curve and prevents progression: applied to the trunk under general anesthesia with traction to the head and neck via a sling across the mandible and occiput and countertraction to the pelvis through another sling; the plaster jacket stops just below the iliac wings to allow hip movement and goes around the axillae superiorly, leaving the arms and shoulders free. The pediatric Isola spine system uses screws with washers applied posterior to anterior, horizontal to the frontal plane of the vertebral body and parallel to the apex of the curve; screws may be placed through staples, rods are inserted to prevent progression, and the rods are extended every 6 months to keep pace with growth.

Nursing Management

Nurses are central to managing the child with scoliosis, especially postoperatively.

Nursing Assessment

Reassess a child with scoliosis every 4 to 6 months. Document the degree of curvature and related impairments. Provide privacy and protect the child's modesty. Stay sensitive to the emotional state of the child; family caregivers may be upset too but hide it for the child's sake.

Nursing Diagnoses

Based on assessment data, the major nursing diagnoses are:

• Impaired physical mobility related to restricted movement.
• Risk for injury related to decreased mobility.
• Risk for impaired skin integrity related to brace irritation.
• Risk for disturbed body image related to wearing a brace continuously.
• Risk for noncompliance related to long-term treatment.

Nursing Care Planning and Goals

The major goals are to minimize disruption of activities, prevent injury, maintain skin integrity and self-image, and support compliance with long-term care.

Nursing Interventions

Practice and perform prescribed exercises as directed; this minimizes the risks of immobility and supports self-esteem. After the brace is applied, evaluate the child's environment and take precautions to prevent injury, help the child practice moving about safely, and have caregivers ask school personnel to provide comfortable, supportive seating. Check the child regularly for proper brace fit, watch for rubbing, discomfort, or irritation and adjust as needed, massage the skin under the pads daily, and bathe daily. Involve the child in all care planning and give them room to talk about their feelings; help them pick clothing that fits current styles but is loose enough to hide the brace. The child wears the brace for years until spinal growth is complete, so caregivers and child need ongoing emotional support; teach them about the complications of spinal instability and further deformity if correction fails, which reinforces compliance.

Evaluation

Goals are met when activity disruption is minimized, injury is prevented, skin integrity and self-image are maintained, and the child complies with long-term care.

Documentation Guidelines

Document individual findings (factors affecting the child, interactions, nature of social exchanges, specifics of behavior), cultural and religious beliefs and expectations, the plan of care, the teaching plan, responses to interventions and teaching, and attainment or progress toward the desired outcome.