Diseases and Conditions: Scoliosis, pediatric

Scoliosis, pediatric
Revised: April 5, 2019

Overview
Lateral curvature of the spine that deviates from a normal vertical alignment, measures greater than 10
degrees of curvature, and is associated with vertebral rotation
Classified as nonstructural/functional (flexible spinal curve, with temporary straightening when child leans
sideways) or structural (fixed deformity)
Types: idiopathic, congenital, or neuromuscular
Early onset scoliosis can occur before the age of 10 years

Pathophysiology
The vertebrae rotate, forming the convex part of the curve.
The rotation causes rib prominence along the thoracic spine and waistline asymmetry in the lumbar spine.
Severity of spinal deformity dictates physiologic impairment.
If severe, the rib cage may press against the lungs and heart, interfering with breathing and cardiac pumping.
In neuromuscular disorders, scoliosis can occur as a side effect of muscular weakness and the inability of the
musculature to support the spine.

Causes
Idiopathic; may be genetic
Secondary to injury, musculoskeletal disease or neurological disease

Idiopathic Scoliosis
Accounts for 80% to 85% of cases
Diagnosis of exclusion, made after underlying disease processes have been ruled out
Divided into three groups:
infantile (up to age 3)
juvenile (age 4 to 9)
adolescent (age 10 until end of growth)
Greater than 80% of cases fall into the adolescent group

Congenital Scoliosis
Curvature of the spine resulting from abnormalities or abnormally developed vertebrae
May result in sagittal plane abnormalities (kyphosis or lordosis), coronal plane abnormalities (scoliosis), or
both sagittal and coronal plane abnormalities
Occurs in utero around 4 to 6 weeks' gestation
Male-to-female ratio is 1:1.4
Related to a higher incidence of abnormalities in other organ systems
10% incidence of cardiac abnormalities
25% incidence of genitourinary abnormalities
40% incidence of intraspinal anomalies

Secondary Causes of Scoliosis

Neuromuscular Scoliosis
Occurs secondarily in children with a traumatic spinal injury or neurologic or muscular disease, including:
Muscular dystrophy
Polio
Cerebral palsy
 Rheumatic diseases
Connective tissue disorders
Spinal muscular atrophy
Posttraumatic encephalopathy
Myopathies
Myelomeningocele

Nonstructural Scoliosis
Acute disk disease
Leg length discrepancies
Paraspinal inflammation
Poor posture

Structural Scoliosis
No known cause

Traumatic Scoliosis
Vertebral fractures
Disk disease

Risk Factors
Congenital or neuromuscular problem
Aging process
Sex (females are at a greater risk for curve worsening during adolescence)
Family history
May accompany other conditions noted above

Incidence
Fewer than 1% of school-age children are affected.
The disorder is most commonly seen at growth spurts with onset at the start of puberty.
Infantile scoliosis is most common in boys ages 1 to 3.
Juvenile scoliosis affects children aged 4 to 10, with girls and boys about equally affected.
Adolescent scoliosis occurs after age 10 and is more common among girls.

Complications
Back pain
Severe deformity
If there is continued development of curvature that is uncorrected, reduced pulmonary function can result,
especially if the thoracic curve exceeds 60 degrees. There can also be an increased risk of cor pulmonale in
middle age, especially if the thoracic curve exceeds 80 degrees.
Decreased pulmonary function
Disturbed self-image

Assessment

History
Family history
Often detected during community or school scoliosis screenings
Hemlines look uneven
Pant legs appear unequal in length
One shoulder or hip higher than the other
Backache, fatigue, and dyspnea
Physical Findings
The child may be asymptomatic at the initial physical exam or on general inspection.
Signs of scoliosis might only be identified with specific examination. (See Testing for scoliosis.)
Back pain and all spinal curves should be investigated for other spinal diseases, such as a tumor.

Testing for scoliosis

When assessing a child for an abnormal spinal curve, use this screening test for scoliosis. Have the
child remove top clothing and stand as straight as possible, facing away from you. Instruct the child
to distribute weight evenly on each foot. Then observe both sides of the back from the neck to the
buttocks. Look for these signs:

Uneven shoulder height and shoulder blade prominence

Unequal distance between the arms and body
Asymmetrical waistline
Uneven hip height
Sideways lean
One scapula higher than the other and more prominent

With the child's back still facing you, ask the child to do the Adam's forward bend test, in which the
child places the palms together and slowly bends forward, beginning at the waist until the back
comes into a horizontal plane, keeping the head down, with both feet together. Then, check for
these signs:

Asymmetrical thoracic spine or prominent rib cage (rib hump) on either side
Asymmetrical waistline.
Diagnostic Test Results

Imaging
Initial radiography is used to measure the Cobb angle formed by the intersection of two lines. The Cobb
angle measurement is completed by the radiologist and reported on the final X-ray report. The greater the
Cobb angle, the greater the degree of scoliosis.
A single standing posteroanterior X-ray should be taken of the entire spine from C7 to the sacrum. Spinal X-
ray studies confirm scoliosis and determine the degree of curvature and flexibility of the spine; they also
determine skeletal maturity, predict remaining bone growth, and differentiate nonstructural from structural
scoliosis.

Other
Bone growth studies may help determine skeletal maturity.

Treatment

General
Primary goal of treatment: Preventing progression of the curve
Secondary goal: Achieve curve correction
Treatment usually not required for mild idiopathic scoliosis with a curve angle of less than 10 degrees,
which is unlikely to progress
Close observation with radiographic follow-up every 6 to 8 months until growth is complete
Possibly, bracing and surgery when scoliosis causes significant pain, balance or gait disturbances,
impaired respiratory function, or severe contractures
Brace (thoraco-lumbar-sacral orthosis [Boston brace or TLSO brace]; cervico-thoraco-lumbar-sacral
orthosis [Milwaukee brace])
Functional strengthening program with physical therapy
Traction, in rare cases, for young children with spinal disorders

Activity
Gradually increased activity
No vigorous sports
Prescribed exercise regimen
Swimming, but no diving

Surgery
Surgery based on curve degree and location, typically indicated for a thoracic curve that will be 50 degrees
or more at spinal maturity
Posterior segmental fixation instrumentation
Posterior spinal fusion with instrumentation and bone grafting
Anterior spinal fusion with solid rods
Serial casting with plaster casts (casts are changed three times, with each cast brace worn for one month;
casts can be applied up until the age of 5 years)
In severe scoliosis, a variety of novel instrumentation techniques, including hybrid constructs, pedicle
screws, and clamps to correct or partially correct curvature and improve self-image and quality of life
For EOS, magnetically controlled implanted growing rods may be placed that allow for lengthening
approximately every 3 to 4 months via magnets, as opposed to surgical lengthening
For neuromuscular scoliosis, studies have not shown clinically significant benefit to surgery and have
shown a higher complication rate compared with idiopathic scoliosis; surgery individualized according to
condition, risks, and benefits

Medications
Narcotic analgesics (IV, PO, intrathecal, epidural or PCA) for severe postoperative pain (short-term use in
the hospital)
 Nonsteroidal anti-inflammatory drugs to reduce pain, inflammation, fever and improve postoperative
ambulation (usually started 3 days after surgery and continued for 3 or more days)
Acetaminophen to reduce pain

Nursing Considerations

Nursing Interventions
Encourage a gradual increase in activity; promote self-care while allowing adequate time for completion of
tasks.
Encourage frequent rest periods to prevent overtiring.
Allow the child and family to verbalize their feelings and concerns related to the child's condition and
planned treatment, including concerns about body image and wearing a brace. Provide clear explanations
about care and treatment measures. Provide emotional support.
Encourage deep-breathing exercises and incentive spirometry, as appropriate.
Assist with application of the brace; ensure padding of the brace edges to minimize the risk of skin
irritation and breakdown.
Inspect the skin around and under the brace; provide suggestions for appropriate skin care.
Reinforce the plan for use of the brace, including the number of hours per day that the child needs to wear
it.
Provide suggestions to the child about clothing and use of the brace.
Encourage the child's participation in care and decision making; point out the child's positive aspects and
provide positive reinforcement.
Promote active ROM arm exercises.
Prepare the child and family for possible surgery; explain possible activity restrictions after surgery and the
use of pain-relief measures, including patient-controlled analgesia, if appropriate.
Provide postoperative care, as ordered, including appropriate logrolling, neurovascular checks, and care of
the surgical site.

Monitoring
Pain level and relief
Respiratory status
Activity and mobility level
Skin integrity (with brace use)
Postoperative skin integrity
Body image
Sensation, movement, color, and pulses
Postoperative status

Associated Nursing Procedures

Ambulation, progressive
Hospital bed preparation, pediatric
Incentive spirometry, pediatric
Indwelling urinary catheter (Foley) removal, pediatric
Pain assessment, pediatric
Pain management
Passive range-of-motion exercises, pediatric
Patient-controlled analgesia
Postoperative care
Preoperative care, pediatric
Pulse assessment, pediatric
Pulse oximetry, pediatric
Respiratory assessment, pediatric
Sequential compression therapy

Patient and Family Teaching

 General
Include the child's family or caregiver in your teaching, when appropriate. Be sure to cover:
the disorder, diagnosis, and treatment, including possible surgery, if appropriate
that the prognosis is good and that the risk of progression is low if the curvature is less than 20 degrees
the proper application and care of the brace, including the number of hours to wear the brace during the
day, the proposed duration of treatment with the brace, and how to inspect the brace daily for fit or
breakage
skin care measures, including wearing a cotton shirt under the brace
ways to minimize the appearance of the brace, such as wearing loose clothing
safe body mechanics
relaxation techniques
strengthening exercises
postoperative activity restrictions, as appropriate
the importance of adhering to recommended follow-up care, especially if observation is the mode of
treatment.

Discharge Planning
Participate as part of a multidisciplinary team to coordinate discharge planning efforts. The team may
include a bedside nurse, care manager, nutritionist, surgeon, physical therapist and primary care
practitioner.
Assess the understanding of the diagnosis, treatment, follow-up, and warning signs for which to seek
medical attention. Assess the child's, family members', and/or guardian's understanding, as appropriate.
Use the teach-back method, when possible.
Explain the importance of scheduling and attending all follow-up appointments.
Confirm arrangements for transportation to initial follow-ups.
Ensure that the parents understand the treatment regimen, including dosage, administration, expected
results, duration, and possible adverse effects of the prescribed medication.
Ensure that the parents or caregivers (or whoever has been designated as the responsible party) are able to
obtain medications.
Ensure the parents or caregivers understand how to perform dressing changes and/or care for surgical
site.
Ensure the parents or caregivers know how to perform personal hygiene and bathing after surgery at home.
Ensure that the child and caregivers have been given the proper medical contact information.
Document the discharge planning evaluation in the patient's clinical record, including who was present and
involved in discharge planning and teaching and their understanding of the teaching provided.

Resources
American Academy of Orthopaedic Surgeons: www.aaos.org
The American College of Obstetricians and Gynecologists: www.acog.org
National Scoliosis Foundation: www.scoliosis.org
Scoliosis Research Society: www.srs.org

Selected References
1. Bajwa, S. J., & Haldar, R. (2015). Pain management following spinal surgeries: An appraisal of the available
options. Journal of Craniovertebral Junction & Spine, 6(3), 105-110. Accessed March 2019 via the Web at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530508/
2. Honeyman, C. (2014). Raising awareness of scoliosis among children's nurses. Nursing Children & Young
People, 26(5), 30-37.
 3. Horne, J. P., et al. (2014). Adolescent idiopathic scoliosis: Diagnosis and management. American Family
Physician, 89(3), 193-198. Accessed March 2019 via the Web at
http://www.aafp.org/afp/2014/0201/p193.html
4. Hresko, M. T., et al. (2016). Early detection of idiopathic scoliosis in adolescents. Journal of Bone & Joint
Surgery, 98(16), e67.
5. Johnson, J., et al. (2016). Referral for adolescent idiopathic scoliosis by pediatric primary care providers.
Clinical Pediatrics, 56(1), 20-25. (Level VI)
6. Lee, M. C. (2017). “Congenital spinal deformity” [Online]. Accessed March 2019 via the Web at
https://emedicine.medscape.com/article/1260442-overview
7. Mehlman, C. T. (2017). “Idiopathic scoliosis” [Online]. Accessed March 2019 via the Web at
https://emedicine.medscape.com/article/1265794-overview
8. Physiopedia. (n.d). Adam's forward bend test. Accessed March 2019 via the Web at https://www.physio-
pedia.com/Adam's_forward_bend_test
9. Ridderbusch K, et al. (2018). Strategies for treating scoliosis in early childhood. Deutsches Aerzteblatt
International (115), 371-6.
10. Scherl, S. A. (2018). Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis. In: UpToDate,
Phillips, W. (Ed.).