Musculoskeletal Disorders Part 5:: Spinal Column Deformities

Musculoskeletal Disorders Part 5:
Spinal Column Deformities
MARIA CARMELA L. DOMOCMAT, RN, MSN

INSTRUCTOR
SCHOOL OF NURSING
NORTHERN LUZON ADVENTIST COLLEGE
ARTACHO, SISON, PANGASINAN
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
Scoliosis
Kyphosis
Lordosis
Osteogenesis imperfecta (OI)
Part 6 : Disorders of foot
Part 7: Sports Injuries
Maria Carmela L. Domocmat, RN, MSN 3/5/2012

Spinal column deformities
3
Scoliosis
Kyphosis
Lordosis

Scoliosis
Scoliosis
5
AKA
Spinal curvature
Infantile scoliosis
Juvenile scoliosis

Scoliosis
7
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.
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.
Symptoms
12
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
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 exams
13
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 screening
14

Treatment
15
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
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.

16
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.
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.

17
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.

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
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.

Complications
19
Breathing problems (in severe scoliosis)

Low back pain
Lower self-esteem
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

Prevention
20
Routine scoliosis screening is now done in middle

and junior high schools.
Screening has helped detect early scoliosis in many
kids.

References
26
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0
002221/
Hedequist DJ. Surgical treatment of congenital
scoliosis. Orthop Clin North Am. 2007;38:497-509,
vi. [PubMed]
Lonner BS. Emerging minimally invasive
technologies for the management of scoliosis.
Orthop Clin North Am. 2007;38:431-440. [PubMed]

Kyphosis
27

Kyphosis
28
AKA
Scheuermann's disease;
Roundback;
Hunchback;
Postural kyphosis

Kyphosis
29
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 factors
30
Kyphosis can occur at any age, although it is rare at birth.

Adolescent kyphosis, also known as Scheuermann's
disease, 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:
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)

31
Other causes of kyphosis include:

Certain endocrine diseases
Connective tissue disorders
Infection (such as tuberculosis)
Muscular dystrophy
Neurofibromatosis
Paget's disease
Polio
Spina bifida
Tumors

congenital kyphosis
32
Clinical photograph and
MRI scan of a child with
an abrupt congenital
kyphosis in the thoracic
spine. The MRI scan
shows a posteriorly
located hemivertebra
causing impingement on
the spinal cord.
(Courtesy of Texas
Scottish Rite Hospital for
Children)
http://orthoinfo.aaos.org/figures/A00423F02.jpg 3/5/2012
33
Kyphosis can also be seen with scoliosis. Each cause

has its own risk factors.

Symptoms
34
Difficulty breathing (in severe cases)

Fatigue
Mild back pain
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.

Dx exams
36
Spine x-ray
Pulmonary function tests (if kyphosis affects
breathing)
MRI (if there may be a tumor, infection, or
neurological symptoms)

Treatment
37
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.

Treatment
38
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.
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.

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
correct the defect and improve pain.

Complications
40
Decreased lung capacity

Disabling back pain
Neurological symptoms including leg weakness or
paralysis
Round back deformity

Prevention
41
Treating and preventing osteoporosis can prevent

many cases of kyphosis in the elderly.
Early diagnosis and bracing of Scheuermann's
disease can reduce the need for surgery, but there is
no way to prevent the disease.

References
42
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
ST, Beaty JH, eds. Campbell's Operative
Orthopaedics. 11th ed. Philadelphia, Pa: Mosby
Elsevier; 2007:chap 38.
002220/

Lordosis
43

44
Lordosis is an increased curving of the spine.

AKA: Swayback

45
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).
Scoliotic curving is a sideways curvature of the spine and is
always abnormal.

46
A small degree of both kyphotic and lordotic

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

47
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
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.

Causes
48
Achondroplasia
Benign juvenile lordosis (not medically significant)
Spondylolisthesis

49
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
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.

50
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
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 Care
51
If the back is flexible, lordosis is usually not treated

and will not progress or cause problems.

52
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.

53
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.

54
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
Other tests to rule out suspected disorders causing the
condition

Treatment
55
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
therapies
expectations for the course of the condition
Paretn’s opinion or preference
http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/orthopaedics/
lordosis.html

Treatment
56
Observation
physical therapy
bracing.
most severe cases require surgery

Treatment
57
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
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

58

References
59
Spiegel DA, Dormans JP. The spine.In: Kliegman

RM,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/HealthLibr
ary/orthopaedics/lordosis.html

61
http://www.oif.org/images/content/pagebuilder/94682.jpg
Maria Carmela L. Domocmat, RN, MSN

Osteogenesis62imperfecta (OI)
• AKA: Brittle bone disease
• rare genetic disorder in which bone are fragile and
fracture easily resulting in bone deformity
• an autosomal dominant disease
• 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
63
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;
can persist into adulthood
o 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
64
most common.
People who have type 1 disease generally reach
normal height and have few obvious skeletal
deformities.
typically causes more fractures during childhood
than in adulthood.
Hearing loss is pronounced and begins early in
childhood.

Type 2 osteogenesis imperfecta
65
most rare and the most severe.

produces numerous deformities of the skeleton
often is fatal in infancy.
abnormal collagen formation also profoundly affects
the lungs, causing significant breathing problems.

66
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

67
produces obvious skeletal deformities. Fractures

before birth are common;
UTZ can detect them in the fetus.
also affects the lungs and muscles.
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
68
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

s/s
69
The classic symptoms include:

osteoporosis
history of multiple fractures
bone deformity
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
70
Symptoms of more severe forms of OI may include:

Bowed legs and arms
Kyphosis
Scoliosis (S-curve spine)

bone deformity
71

blue sclerae
72
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/Ki
nd.f1c.jpeg
http://www.beltina.org/pics/osteogenesis_imperfecta.j
pg

74
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:
75
serum alkaline phosphatase – increased

Treatment
76
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
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
77
o palliative
o steroids
o calcium
o vit C
o sodium fluoride
o PT
o casting
o bracing
o telescoping intramedullary rods – to maintain mobility and
promote ambulation
o research ongoing – Biphophonates

78
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
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.

79
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
(type IV).

Complications
80
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)
Respiratory problems and pneumonias due to chest
wall deformities
Spinal cord or brain stem problems
Permanent deformity

81
http://jorthod.maneyjournals.org/content/vol30/issue4/images/large/Ki
nd.f1c.jpeg

Resources
82
Ignatavicius and Workman (2006). Medical surgical

nursing [5th ed]. Singapore: Elsevier.
002540/
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

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Musculoskeletal Disorders Part 5:

Spinal Column Deformities

MARIA CARMELA L. DOMOCMAT, RN, MSN

Part 1: Degenerative & Metabolic bone disorders:

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

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

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

is an abnormal curving of the spine.

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

Usually there are no symptoms. But symptoms can

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

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

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

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

Treatment depends on many things:

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

Scoliosis surgery involves correcting the curve as

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

Scoliosis treatment may also include:

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

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

Breathing problems (in severe scoliosis)

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

Routine scoliosis screening is now done in middle

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

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

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

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

is a curving of the spine that causes a bowing or

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

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

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

Other causes of kyphosis include:

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

Kyphosis can also be seen with scoliosis. Each cause

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

Difficulty breathing (in severe cases)

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

Physical examination by a health care provider

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

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

Treatment depends on the cause of the disorder:

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

Treatment depends on the cause of the disorder:

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

Adolescents with Scheuermann's disease tend to do

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

Decreased lung capacity

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

Treating and preventing osteoporosis can prevent

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

Spiegel DA, Hosalkar HS, Dormans JP. The spine.

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

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

Lordosis is an increased curving of the spine.

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

The spine has three types of curves:

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

A small degree of both kyphotic and lordotic

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

Too much lordotic curving is called swayback

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

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