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
injury
2. Describe a compression fracture
3. Explain why reflexes are absent in CCA at this early stage. What type of
paralysis is present
4. What manifestation are present among clients who has spinal cord injury
5. What complication may develop from a spinal cord injury
6. 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:
o Paralysis
o Loss of Reflexes
o Loss of sensory function
o Loss of motor function
o 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 damage
CLINICAL MANIFESTATION:
Respiratory system:

o
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o
o
o
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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
o Bradycardia
o Hypotension
o Hypovolemia
Urinary system
o Urinary retention
Gastrointestinal system
o Injury above the level of T5: hypomotility
o Injury at the level of T12 or below: areflexic bowel aand decreased
sphincter tone
o Paralytic ileus
o Gastric distention
o Development of stress ulcers
o Intra abdominal bleeding
o Neurogenic bowel
Integumentary system
Potential of skin breakdown over bony prominences since client is
potential for lack of movement
Thermoregulation
o Poikilothermism: the adjustment of the body temperature to the room
o 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 difficult

INTERVENTIONS (PER CASE):
Collaborative management for the client with SCI are as follows:
o FIRST PRIORITY: promotion of respiratory function especially in cervical
SCI
o Immobilize in a flat, firm surface. To prevent further injury
o Apply cervical collar especially if cervical injury is suspected
o Transport client as a unit.
o Do not attempt to realign body parts.

Monitor and manage potential complications of SCI

o 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.
o 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:
o Severe headache
o Blurring of vision
o Nasal congestion
o Hypertension, bradycardia
o 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:
o Place the client in sitting position. To lower BP by gravity
o Check bladder distention. Catheterize client as indicated.
o Check fecal impaction. Perform manual extraction as
indicated.
o Turn the client to sides at regular intervals. To prevent
pressure sore.
o Pharmacotherapy:
Hexamethonium Chloride (a ganglionic blocking
agent)
Nitroprusside (Vasodilator)

o 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:
o Pallor
o Weakness
o Gait disturbance
o Dizziness
o Nausea and Vomiting
o Occipital Headache
o Nuchal rigidity
COLLABORATIVE CARE:
o Promote bed rest.
o Apply cervical collar as needed
o Apply hot packs to the neck as indicated
o Administer analgesic and muscle relaxant as prescribed.
Dermatome
Each 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 Ponits
C8 - Little Finger
C2 - Occipital Protuberance
T1 - Medial Antecubital Fossa
C3 - Supraclavicular Fossa
T2 - Apex of Axilla
C4 - Acromioclavicular Joint
Lower Body Test Points
C5 - Lateral Antecubital Fossa
L1 - Upper Anterior Thigh
C6 - Thumb
L2 - Mid Anterior Thigh
C7 - Middle Finger

L3 - Medial Femoral Condyle

L4 - Medial Malleolus
L5 - Dorsum 3rd MTP Joint
S1 - Lateral Heel
S2 - Popliteal Fossa
S3 - Ischial Tuberosity
S5 - Perianal Area

V1 - 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 SCOLIOSIS
1. 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 sidebending 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.

MANIFESTATIONS
Without an X-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 time

Any 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.

Provide good skin care to 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.

PATHOPHYSIOLOGY
1. 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.

2 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.

3 Paralytic or musculoskeletal scoliosis develops several months after

symmetrical paralysis of the trunk muscles from polio, cerebral palsy, or
muscular dystrophy.
4 Neuromascular scoliosis child has a definite neuromascular condition
that directly contributes to the deformity.
5 Additional but less common causes of scoliosis are osteopathic
conditions, such as fractures, bone disease, arthritic conditions, and
infections.
6 Miscellaneous factors that can cause scoliosis include spinal irradiation,
endocrine disoders, postthoracotomy, and nerve root irritation.
7 As the deformity progresses, changes in the thoracic cage increase.
Respiratory and cardiovascular compromise can occur in cases of severe
progression.
8
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.
ETIOLOGY
Spinal 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.
SYMPTOMS
The 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:
o Especially in the legs (may be in the knee or ankle, with or without
shooting pain down the leg)
o Cold sensation of the legs, cool fingers or hands, or coolness of
other areas
Back pain:
o Gets worse over time
o In any area -- middle or low back are most common
o Is usually severe and not relieved by pain medication
o Is worse when lying down
o Is worse with strain, cough, sneeze
o 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):
o Causes falls
o Especially in the legs
o Makes walking difficult
o May get worse (progressive)
ASSESSMENT

Many 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 lesions
Lesions 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 lesions
Metastatic 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 lesions
Patients 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 FINDINGS
Diagnostic 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 costdriven 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.
TREATMENT
The 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 extruded disc herniation with
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.
CAUSES

When 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.
PATHOPHYSIOLOGY
The 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.

SYMPTOMS
Patients 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 function

In 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-rays are 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 scan of 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 myelography consists of x-rays taken after the injection of radioopaque 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 programs
Weight 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 position
3. Use logroll (board) during a change of position
4. Auxiliary mounting brace or corset
5. Limit the activity of the patient during the acute phase according to the
needs
6. Teach relaxation techniques
7. 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 active
2. Assist patient in ambulation activity progressively

3. 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 immobilizing
5. Demonstrate the use of auxiliary equipment such as a cane
6. 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 mechanics
3. Suggest to use the board or a small pillow under the neck
4. Avoid the use of heaters in a long time
5. 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?
LORDOSIS
Lordosis, 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 preference

Management: 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 xray 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 not cause 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 position

abnormal development of the spine in the womb congenital kyphosis if

something disrupts the spine's normal development, two or more
vertebrae sometimes fuse together.

COMPLICATIONS

Body 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 TEST

X-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 DRUGS
MEDICATIONS

Pain 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.

THERAPY
Exercise 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 PROCEDURES

If 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.