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Scoliosis: A case study in an adolescent boy

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10482-02_ON2603-Napierkowski.qxd 5/15/07 5:18 PM Page 147
Scoliosis
A Case Study in an Adolescent Boy
Daria Beth Napierkowski
A normal spine when viewed form the posterior is straight.
However, if the spine has a lateral curvature, it is defined as
having a scoliotic curvature. Screening is performed on the
adolescent around the age of 10 and again around 13. The
condition is more common in girls and is commonly diag-
nosed as idiopathic. The advent of the MRI has helped to dis-
cover other causes of scoliosis, particularly in boys. Our expe-
rience started with an abnormal scoliosis screening. After my
son’s surgery, I researched the literature to discover the
cause of his rare neurological condition.
The experience began with a notification from the
school. The school nurse identified an abnormal
scoliosis screening. My son’s physical examination
performed only 6 months prior, was normal. I pre-
sumed that scoliosis occurred primarily in girls. I
returned to my textbooks to review the medical in-
formation regarding scoliosis but my real education
was yet to come.
Definition
A normal spine when viewed from the posterior is
straight and the trunk is symmetrical with all of the ver-
tebrae facing forward. From the side, the normal spine
has a slightly rounded kyphotic contour (20–40 degrees)
of the thoracic spine and a lordotic curve that faces the
opposite direction, like a backward “C,” in both the neck
and the lumbar spine (see Figure 1).
Scoliosis is a descriptive term that describes a lateral
deviation of the normal vertical line of the spine, which
when measured by x-ray is greater than 10 degrees. The
spine curves to one side or the other often in the thoracic
or lumbar areas. The primary definition of scoliosis is
the lateral curvature, S shape, plus rotation of the ver-
tebrae within the curve. Further physical findings
depend on the patient’s deformity location and magni-
tude. Shoulder heights may be uneven, and there may be
an increased space between the elbow and trunk because
of trunk deviation (see Figure 2). Prominence of a “hip,”
pelvis, or breast may also be seen.
Until recently, school-wide screening for scoliosis has
been standard policy in many schools. Annual school
screening programs are done using the Adams’s Bend
test, also known as the forward bend test. The child
bends forward dangling the arms, with the feet together
and the knees straight. This position makes the structural
Orthopaedic Nursing
curve more apparent, and the amount of rotational asym-
metry present (the degree to which one side of the body is
more prominent than the other) is evaluated. The Adams
test is quick and acceptable to most children and teens.
Abnormal findings result in the referral of the child to a
primary care provider or specialist.
Screening is performed during peak adolescent
growth, and nearly all significant curvatures can be found
on physical examination at about age 10 (Bunnell,
2005). The risk of progression of curvature in females
decreases significantly after menarche, so therefore the
female adolescent should be screened by age 10. Because
males mature later than females, it would seem prudent
to assess males at age 10 and again at age 14. In this case,
it was the school nurse who initially identified an abnor-
mality at age 13. The benefit of early screening creates the
opportunity for conservative medical treatment without
the need for spinal fusion.
Although scoliosis screening has been practiced for
over 30 years, current evidence has raised concerns over
unnecessary costs from false referrals (Bunnell, 2005).
Such costs include medical exams, x-rays, and braces for
minimal curves, as well as the costs of parental time off
from work and travel expenses.
To make recommendations for scoliosis screening,
the U.S. Preventive Services Task Force for Screening for
Idiopathic Scoliosis in Adolescents (2005) examined data
relevant to the question, “How valid and accurate are
screening tests for adolescents with idiopathic scoliosis?”
Three large cohort studies (one retrospective and two
prospective) provided insufficient evidence to support
efficacy of screening. However, scoliosis screening is
mandated in 22 states, recommended in 14, and prac-
ticed on a volunteer level in most other states and many
other countries.
Diagnosis
Positive screening calls for follow-up evaluation with a pri-
mary care provider. Prior or concurrent with the appoint-
ment, x-ray films should be ordered to support a diagnosis
and determine the extent of the deformity.
I remember looking at the x-ray. The physician
turned on the light box, placed the x-ray on it and
Daria Beth Napierkowski, MSN, RN, APN, C, Clinical Instructor,
University of Medicine and Dentistry of New Jersey.
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FIGURE 1. Illustration of normal spine anatomy in the PA and lateral projection.
(Image provided by Medtronic.)
started to explain it. The x-ray looked classic, like a
page from one of my medical surgical books. The
physician continued to explain how one arrives at
these curvatures. But I really wasn’t listening, anxi-
ety started to take over. This wasn’t one of my pa-
tients. This was an x-ray of the spine of my 13-year-
old son. How did I miss this?
Although scoliosis is considered a common problem in
children, it is clinically significant in less than 1 in 1,000
children aged 6–14 years of age (Oxborrow, 2000). The
severity of the scoliosis is determined by the extent of
spinal curvature and by the angle of the trunk rotation.
The Cobb method is the standard technique for measure-
ment of curvature of the spine and spinal deformities
from the spine x-ray. The magnitude of the Cobb angle is
the angle between lines drawn along the upper border of
the most tilted vertebrae above the curve’s apex and the
lower border of the most tilted vertebrae below the apex
(Oxborrow, 2005). This is illustrated in Figure 3. A scoli-
otic curve exists when the angle measures at least 10 de-
grees. Curves between 10–25 degrees are considered mild
and are monitored until the skeleton has reached skeletal
148 Orthopaedic Nursing • May/June 2007 • Volume 26
Page 148
maturity. Most curves over 25 degrees are considered sig-
nificant, with curves between 25–40 degrees treated with
bracing. There are a variety of braces available to prevent
further progression of the scoliotic curve. The thoracic
lumbar sacral orthesis (TLSO) is one example of such a
brace (see Figure 4). The type of brace that is used is
based on location of the curve and physician preference.
If the curvature progresses rapidly (10 or more de-
grees over a few months) or the curvature is greater than
40 degrees, surgical intervention is considered. Surgery
with rod placement and stabilization of the spine with
bone grafting achieve partial or complete correction in
adolescents with a curvature over 45 degrees (Taft &
Francis, 2003).
Further x-ray evaluation to determine the extent of
his curvature was done. I remember looking at the
x-ray. I recalled it looked bizarre. Within 4 months
my son had grown four inches to the right and not
straight upward. His Cobb angle was 18 degrees of
the thoracic angle and 39 degrees of the lumbar
spine. My son was less concerned with the angle and
more concerned with the deformity. Thinking back
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FIGURE 3. Illustration demonstrating the Cobb

FIGURE 2. Adolescent boy with a right thoracolumbar scoliosis. method of measuring a scoliotic curve.
(Image provided by Medtronic.)

I realized it was in the last 4 months he was wearing

his clothes bigger and being private with his body
appearance.
Physical findings associated with scoliosis include asym-
metry of the shoulders, the scapula, or the waist. Adole-
scents may notice that clothing does not fit correctly.
The female might notice a hemline being askew. Tho-
racic rib prominence or paravertebral muscle promi-
nence on forward bend may be present. A patient may
complain of headache and neck pain. Neurological signs
may include sensory losses and absent unilateral super-
ficial abdominal reflexes (Inoue et al., 2003). Any evi-
dence of muscle weakness, gait defects, or abnormal or
absent reflexes should be investigated (Maher, Salmond,
& Pellino, 2002).
Upon physical examination my son was discovered
to have an absent abdominal reflex on his left side.
X-ray findings and physical findings suggested that
his problem was not idiopathic scoliosis. An MRI
was ordered.

Idiopathic Scoliosis
Idiopathic scoliosis is a lateral curvature that is struc-
tural in nature and present in otherwise healthy adoles-
cent individuals. Approximately 80% of patients have
“idiopathic” scoliosis in which the cause is not known.
Idiopathic scoliosis commonly manifests during the FIGURE 4. Thoracic lumbar sacral orthosis (TLSO).

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growth spurt right before and during adolescence. Mild
curvatures (less than 20 degrees) occur equally in boys
and girls, but curve progression is 10 times more likely
to occur in girls. For boys, the risk of progression is
greater when there is a larger curvature at the time of
diagnosis. The peak age that scoliosis is first found in
boys is 14, while it is often discovered in girls at age 11
(Karol, Johnston, Browne, & Madison, 1993). The num-
ber of females requiring treatment is estimated to be
1.0%, while treatment in males is 0.1%.
The true causes of idiopathic scoliosis are believed to
be multifactorial. The role of genetic or hereditary factors
is generally accepted. Clinical studies have indicated a
higher prevalence of the disorder in relatives of the af-
fected individual than in the general population. The
exact method of inheritance is unknown at this time, and
specific curve patterns do not exist within families (Miller
et al., 2001). Structural deformities and a disturbance of
the growth of the paravertebral muscles have been dis-
cussed as a possible cause but also could result from the
effect of the deformity. Problems with coordination, ab-
normalities in the central nervous system, and other bio-
logical factors have been considered as causative factors.
Idiopathic-Like Scoliosis
In the assessment of the patient presenting with scoliosis,
it is essential to seek the cause of the deformity. Only
when all causes of the deformity have been ruled out can
the case be considered “idiopathic.” Scoliosis may result
from various conditions that affect bones and muscles
associated with the spinal column. This may include
neuromuscular diseases, for example, cerebral palsy,
muscular dystrophy, tumors, rheumatic disease, myelo-
meningocele, and spinal muscular atrophy. Tumors,
growths, or other small abnormalities on the spinal col-
umn are now believed to play a larger role in causing
some cases of scoliosis. These neurological abnormali-
ties, such as Chiari I malformation (CMI) and syringo-
myelia, can exist despite no prior abnormalities on the
history or physical examination. The combination of
clinical findings, and atypical curvature patterns, includ-
ing left thoracic, double thoracic, triple, and a long right
thoracic curve suggest the need to further explore neu-
rologic abnormalities as the cause of the skeletal defor-
mity (Spiegel et al., 2003). Inoue et al. (2003) suggests
further evaluation for patients who present with juvenile
onset of scoliosis, abnormal neurological signs, and re-
ports of headache or neck pain. Further evaluation is
done with a MRI.
My husband and I went away for the weekend for
our 20th anniversary. On Monday we returned to
find a message from our son’s orthopaedic physician
to see a neurologist. The neurologist sent our son to
have an MRI, and within days we had a diagnosis of
Chiari I malformation with syringomyelia.
Chiari I Malformation
and Syringomyelia
The advent of the MRI has led to increased awareness of
neurological abnormalities associated with spinal defor-
mity (Flynn et al., 2004) and as a result of diagnostic
150 Orthopaedic Nursing • May/June 2007 • Volume 26
Page 150
MRI, CMI can be diagnosed. As in the case of my son, the
spinal deformity was the first sign of an underlying neuro-
logical defect.
The CMI is a caudal displacement of the cerebellar
tonsils into the cervical spinal canal. It is generally de-
fined as herniation more than 5 mm below the plane of
the foramen magnum (Cohen, 2001). Why CMI occurs
congenitally is unknown; however, it seems to be caused
by a disparity between the volume of the posterior fossa
neural elements and the posterior fossa cranial content.
The normal cerebrospinal fluid flow within the spine is
prevented (Alden, Ojemann, & Park, 2001).
Syringomyelia often occurs with CMI, and it is un-
common for syringomyelia to be idiopathic. Syringo-
myelia is an accumulation of spinal fluid inside the
spinal cord resulting from blockage of cerebrospinal
fluid (CSF) flow. It has been suggested that the CSF flow
to and from the spinal area that occurs during the car-
diac cycle is obstructed. This results in increased CSF
pressure in the spinal area during systole and fluid is
forced into the cord through its surface (Alden et al.,
2001). It is also referred to as a syrinx. A syrinx is a cyst
filled with CSF within the spinal cord. This rare condition
is potentially dangerous to the patient. In some cases if
left untreated, it can lead to loss of function, respiratory
compromise, and death. Because CMI causes herniation
of the cerebellar tonsils into the cervical spinal canal, it
commonly leads to a syrinx. The lesion often expands in
the adolescent, and scoliosis is commonly the presenting
symptom. The cause of a syrinx is unknown at this time.
The syrinx presses on the spinal cord from within. It can
occur anywhere within the spinal cord and mainly affects
the nerves that carry pain and temperature sensation. As
it extends it can cause muscle weakness, spasms, and
eventually muscle atrophy (www.merck.com).
Limited research exists concerning CMI and syringo-
myelia (CMI/S), however clinical studies suggest the
prevalence is no greater than 0.24% (Speer, George,
Enterline, Franklin, Wolpert, Milhorat, 2000). Speer et
al. found familial clustering of patient’s families when the
patient was diagnosed with CMI/S. Familial clustering
does not establish a genetic basis for a CMI/S because en-
vironmental exposure is common to family members.
However, the evidence suggested that CMI/S may have a
basis as a primary mesodermal disorder involving the
mesoderm at the base of the cranium and craniovertebral
junction. Current studies are still recruiting patients and
family members to study the possible genetic link of CMI.
The diagnosis of syringomyelia-associated scoliosis
is usually suspected with the presence of left-sided tho-
racic curves and male gender. Symptoms of pain or neu-
rological problems are often not found or are slight
(Ouellet et al., 2003). Ouellet and colleagues found sta-
tistically significant differences with respect to gender
with males having a predisposition to syringomyelia.
Patients with syringomyelia-associated thoracic scolio-
sis had a statistically significant difference in their
curvature. Those with syringomyelia-associated tho-
racic scoliosis did not have the apical lordosis on lat-
eral x-rays that the typical patient with idiopathic scol-
iosis demonstrates. Consequently, when apical lordosis
is not present in patients with thoracic scoliosis, the
presence of syringomyelia should be suspected and an
MRI should be performed (Ouellet et al., 2003).
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Now instead of one problem, scoliosis, my son was
diagnosed with another problem and the probable
underlying cause of his spinal deformity. The Chiari
I malformation would need to be surgically decom-
pressed before we could address the scoliosis issue.
Finding a pediatric neurosurgeon in our insurance
plan was impossible. After several phone calls to the
insurance company they agreed to pay out of net-
work because they did not have a specialist within
the network who operated on children with Chiari I
malformation.
CMI and Syringomyelia
Surgical Treatment
The CMI is considered the mildest form of the more
extensive hindbrain abnormalities that are seen with
spinal bifida and other brainstem and structural abnor-
malities. In addition, there is risk of progression and
damage to the spinal cord due to the associated syringo-
myelia, which occurs in 50%–70% of patients (Alzate,
Kothbauer, Jallo, & Epstein, 2001). The literature sug-
gests that decompression surgery leads to stabilization
or improvement of neurological symptoms. Neuro-
logical drainage can also delay scoliosis progression.
Approximately 50% of patients require spinal fusion after
decompression surgery, and they tended to have been
older at presentation and with large double curves (Flynn
et al., 2004).
The pediatric neurosurgeon put the MRI on the light
box and proceeded to explain the surgery and showed
us the syrinx that was present in my son’s spine. It
would have been fascinating if it was a nameless pa-
tient but this was my 13-year-old son who in one
week was to undergo brain surgery.
The goals of surgery are to make a roomier posterior
fossa and regulate flow of CSF. The operation consists of
a suboccipital craniectomy, laminectomy of C1 and C2,
and lysis of adhesions between the prolapsed cerebellar
tonsils and the floor of the fourth ventricle. Bone is re-
moved to make an enlarged foramen magnum. Care is
taken to not remove too much bone so that cerebellar
slump does not occur (Ellenbogen, Armonda, Shaw, &
Winn, 2000).
Following surgery my son stayed in the pediatric in-
tensive care unit for 3 days and was monitored
closely. On the third postoperative day he was sta-
ble and moved to the pediatric floor. He was dis-
charged on the fifth postoperative day without
neurological deficit. He returned to school in Sep-
tember, and continuous observations were performed
by the orthopaedic surgeon and the neurosurgeon.
Eight months later the lumbar curve increased to
50 degrees and surgery was advised by his ortho-
paedic surgeon. In March of the following year
he underwent spinal fusion using Cotrel-Dubousset
instrumentation.
Surgical Treatment for Scoliosis
Scoliosis surgery is not deemed necessary unless the cur-
vature has progressed significantly. A scoliotic curve that
Orthopaedic Nursing
is more than 40 degrees will potentially progress until the
patient stops growing (LaMontagne, Hepworth, Cohen, &
Salisbury, 2004). If it is left untreated, it can cause respi-
ratory problems and chronic back pain, as well as psychi-
atric problems from the impact of skeletal deformity.
The goals of spinal surgery for scoliosis are to
straighten the spine and balance the torso and pelvic
areas. This is accomplished by performing a spinal fu-
sion along the curve and supporting the fused bones
with instrumentation.
Spinal fusion to correct scoliosis is one of the most in-
vasive orthopaedic surgeries performed on adolescents
and children. The Harrington rod, the first instrumenta-
tion used, was developed in the 1950s by Paul Harrington.
At the time it was a major advance in the treatment of
scoliosis. The distraction forces provided by the rod held
the spine in a corrected position while the underlying
spine fusion is completed (www.jdryerscoliosis.com/
Harrington_Rod). The Harrington instrumentation was
effective to correct scoliotic curves in the frontal plane;
however, deviations in axial rotation and lordosis
were not corrected. The Cotrel-Dubousset instrumenta-
tion (CDI), introduced in the early 1980s, facilitates a
3-dimensional correction in scoliosis surgery. It pro-
vides multiple points of fixation to the spine and allows
compression and distraction on the same rod.
When patients underwent Harrington instrumenta-
tion, the lumbar spine lordosis was flattened, causing de-
generative changes later in life. The development of the
CDI achieves a balanced frontal plane and corrects ver-
tebral rotation. Perez-Grueso, Fernandez-Baillo, Arauz
de Robles, and Fernandez (1999) found that half of the
patients who underwent scoliosis surgery with CDI had
degenerative changes on MRI 10 years after surgery. He
concluded that the general population has evidence of
the same changes, and these factors were normal aging
alterations and not changes from the scoliosis surgery
with CDI.
CDI appears to achieve correction in the frontal plane
and provides some correction of the rotation seen with
scoliosis. Patients report improved cosmetic results. Cor-
rection loss is less than 2%, and the patient does not re-
quire immobilization after surgery (Woolf, 2002).
On a follow up visit to the orthopaedic surgeon, he
informed us that the lumbar curve had progressed
another 10 degrees to 50 degrees and advised
surgery. Our hopes were daunted that the brain
surgery would stop the progression of the curvature,
which had progressed and surgery could not be
avoided.
Short-Term Psychosocial Issues
Adolescents and their families experience significant anx-
iety regarding the impending surgery and the recovery
period. Parental anxiety also can affect the adolescent’s
anxiety level, causing the adolescent more emotional dis-
tress. During the operative phase, attention to anxiety
and pain management is the priority.
The nurse plays a significant role in reducing anxiety
and managing the intense pain experienced in the imme-
diate postoperative period. Higher levels of anxiety are
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associated with higher levels of pain. Findings from a
study by LaMontagne, Hepworth, Cohen, and Salisbury
(2003) examined the effectiveness of different nursing in-
terventions on anxiety and pain in children with scolio-
sis. The study found that providing concrete instruction
about the surgery and aftermath and information on cop-
ing methods had the greatest impact on reducing post-
operative anxiety and pain after spinal fusion surgery.
Teaching the adolescent and the parent about the amount
of pain to expect after surgery and how to deal with it is a
critical nursing intervention.
Pain medication was offered to my son via a
patient-controlled analgesia pump. The nurses ex-
plained how to use the pump, but they did not seem
to connect with him. One nurse told my son that he
had an attitude when he yelled at her as she turned
him. She later apologized. Additional coping meth-
ods were not offered to him.
Support of the patient in the postoperative period
goes beyond providing pain medication and how to in-
terpret the pain scale. Adolescents feel that their privacy
is invaded in the postoperative period after major spine
surgery and that they would like others to be more sen-
sitive to their needs (Gauvin, Vandal, Mercier, & Bradet,
2002). This is further compounded by the fact that the
male adolescent often does not have the social skills to
express his needs. The amygdala is developing in the
early adolescent and controls the emotional processes
of the brain (Herrman, 2005). Emotions in the adolescent
period can be intense as the brain matures. Interpreting
emotions is developed as the adolescent matures and
continues into the 20s. Nurses caring for teens should
be aware of the heightened emotional response as the
adolescent attempts to understand his or her chronic ill-
ness. The nurse needs to look at the adolescent and his
or her situation from the teen’s perspective, not the adult
perspective.
As the teen moves away from the primary family unit,
he or she seeks approval and acceptance from other au-
thority figures and therefore the nurse can use his or her
position of authority in a positive and therapeutic man-
ner (Slote, 2002). Because the adolescent can problem
solve and be more independent than the school-age
child, it would be helpful for the nurse to empower the
adolescent. This can be accomplished by having the ado-
lescent participate in his or her care and healthcare de-
cisions. The patient that can participate in simple tasks
and decisions helps to lessen his or her anxiety. I found
that if my son could make simple decisions, such as
when to get out of bed, he appeared less anxious.
An empathetic response is essential for maintaining a
therapeutic nursing relationship with the patient (Slote,
2002). When the nurse came back to apologize for “scold-
ing” my son, she stated: “I know that this surgery can be
very painful.” This simple acknowledgment calmed
my son, and he stopped yelling when he was moved in
the bed.
As the parent and a nurse, myself, I felt a great amount
to guilt concerning my son’s condition. I felt helpless in
relieving my son’s pain and responsible for the verbal
hostility my son exhibited. Understanding these feelings
can enhance the nurse-parent relationship. Empowering
152 Orthopaedic Nursing • May/June 2007 • Volume 26
Page 152
the parent along with the adolescent to make simple de-
cisions in the care of their child facilitates a successful
outcome. Advise the parent not to touch the patient-
controlled pump (PCA) while the adolescent is sleeping
so he or she understands that awakening is a good sign of
arousability and the patient is not receiving excess med-
ication (Slote, 2002). This was difficult for me to restrain
myself from touching the equipment, especially when I
was familiar with it. I had my own personal conflict with
being a nurse and a parent.
Cosmetic results and correction of the curve are
outcomes of surgery. Although this is a positive
benefit there is tremendous anxiety. I could not help
but wonder about the long-term psychological ef-
fects of having major spine surgery at a time when
one is trying to find independence. My son returned
to school 8 weeks after surgery and tried to resume a
normal adolescent life. Activities were restricted for
a year, and contact sports are prohibited for life.
Long-Term Psychosocial Issues
Empirical data suggests that social impairment sec-
ondary to mobility restriction and altered body image re-
main as stressors for years after surgical intervention.
The level of psychosocial stress is not correlated with the
magnitude of the scoliosis as measured by the Cobb
angle (Freidel et al., 2002).
Adolescents after spinal surgery do not return to their
normal activities for up to a year following surgery and
even then will have some activity restrictions, which set
them apart from their peers. Major spine surgery takes
the adolescent away from the peer group for a minimum
of 6 weeks during the surgical and postoperative period.
When the adolescent returns to school and social interac-
tion, his or her activities are restricted. The adaptation of
the group norms, such as playing sports, is now removed
from his social interactions. The peer group that helped
the adolescent develop his identity is removed. This may
have negative long-term effects on the adolescent’s social
life at a time when the adolescent is preoccupied with his
appearance. His self-worth can be perceived on compar-
isons of himself to the outside world.
Ahuja, Ahuja, Howes, and Davis (2004) performed
qualitative interviews of 10 adolescents and their fami-
lies attending a spinal clinic for postsurgical monitoring
of scoliosis. Social impairment was identified as a prob-
lem, and it was reflected in their interactions with their
peers. Their results showed that teens could benefit from
“buddying” with other teens who had similar procedures
or by participation in self-help groups. Parents and teens
desired an expected timetable of allowable activities to
manage their uncertainty.
In the case of my son, his main concern after re-
turning to school was when he could return to gym
class. Resuming physical education classes symbol-
ized a return to normalcy and fitting in. I worked
closely with his gym instructor to develop a plan for
him to play limited gym sports because he could not
play contact sports.
Negative body image is an ongoing concern for the
adolescent who has had surgical treatment for scoliosis.
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Often body image concerns are ignored when the patient
is male; however, evidence shows body image concerns to
be an ongoing problem area for boys. Payne and col-
leagues (1997) reported that boys with scoliosis reported
being less healthy and more likely to worry about their
body developing abnormally. They had greater concern
about the quality of peer relationships and consumed
more alcohol than their peers without scoliosis. Add-
itionally, they found that male adolescents with scoliosis
had a poorer body image, concern about body develop-
ment, and concern regarding peer relations. Research
monitoring adolescent girls following either bracing or
surgical intervention for scoliosis suggests that negative
body image can exist for significant periods of time.
Noonan, Dolan, Jacobson, and Weinstein (1997) reported
that in the immediate posttreatment period, girls experi-
enced more depression, discrimination, and poorer body
image in contrast with a matched control group. At an av-
erage follow-up of 7 years, there was no difference in the
experience of depression or discrimination. Significant
differences in body image scores persisted with those
treated with surgery having a more negative body image
in comparison with the braced or control group.
The visible scarring and the hidden instrumentation
are reminders that one will never have a perfect body and
can lead to doubts about self-worth and a lessening
of self-esteem (Reichel & Schanz, 2003). Inferior self-
esteem can be a major stressor in one’s emerging sexual-
ity (Noonan et al., 1997). The adolescent undergoes sig-
nificant emotional chaos as he attempts to relate to peers
and other adults and “fit in” to our societal image of the
male. Coping with these differences requires the teen to
either hide the differences or develop explanatory re-
sponses to the differences. My son likes to fabricate sto-
ries when someone asks him about his scars that are vis-
ible in the back of his neck and spine. His perception of
himself is captured in a poem he wrote for school. It is
about his feelings regarding having hardware in his body
holding his spine in place.
Hardware
You think you know me
You don’t even have a clue
There are things screwed inside of me
You wouldn’t understand
You don’t even have a clue
How different my mind works
You wouldn’t understand
What it’s like to be me
My mind works different
Then most people would understand
What it’s like to be me
Is something you can’t comprehend
Most people won’t understand
Why my body is different
It’s something you wouldn’t comprehend
But I’m not like most people
My body is different
Not like you would care
Most people judge others
Like they were cyborgs
Orthopaedic Nursing
Not like you would care
What I look like
Or what is inside my body
But you think you know me?
My son submitted his poem to the literary maga-
zine at school in an attempt to have his peers under-
stand his feelings after scoliosis surgery. The editor
of the magazine changed the poem to read “Things
are screwed up inside of me,” changing the connota-
tion of the poem. I presume that people really do not
understand how the adolescent boy with scoliosis
really feels.
He is followed on a yearly basis by the neurosur-
geon and the orthopaedic surgeon. He will need to
be followed for the rest of his life. Activities are re-
stricted: Diving, amusement rides, and contact
sports continue to be prohibited for his lifetime.
REFERENCES
Ahuja, A., Ahuja, S., Howes, J., Davies, P.R. (2004). Psy-
chological needs of adolescents with scoliosis: A Quali-
tative study 2004. British Editorial Society for Bone and
Joint Surgery. 86-B Supplement II, 112.
Alden, T., Ojemann, J., & Park, T. (2001). Surgical treatment
of Chiari I malformation: Indications and approaches.
Neurosurgical Focus, 11(1). Retrieved November 4, 2005
from http://www.medscape.com/viewarticle/405726
Alzate, J., Kothbauer, K., Jallo, G., & Epstein, F. (2001)
Treatment of Chiari type I malformation in patients with
and without syringomyelia: A Consecutive series of 66
cases. Neurosurgical Focus, 11(1). Retrieved November 4,
2005 from http://www.medscape.com/viewarticle/405717
Bunnell, W. (2005). Selective screening for scoliosis. Clinical
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Cohen, A. (2001). Chiari I malformation. Neurosurgical
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Toward a rational treatment of Chiari I malformation and
syringomyelia. Neurosurgical Focus. 8(3). Retrieved
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viewarticle/405588
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M., et al. (2004). Predictors of progression of scoliosis
after decompression of an Arnold Chiari I malformation.
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Freidel, K., Petermann, F., Reichel, D., Steiner, A.,
Warschburger, P., & Weiss, H. (2002). Quality of life in
women with idiopathic scoliosis. Spine, 27(4), E87–E91.
Gauvin, M-C., Vandal, S., Mercier, P., & Bradet, R. (2002).
Perception of the social support for adolescents who un-
dergo corrective back surgery for scoliosis. Comprehen-
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Herrman, J. (2005). The teen brain as a work in progress:
Implications for pediatric nurses. Pediatric Nurse, 31(2),
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Inoue, M., Nakata, Y., Minami, S., Kitahara, H., Otsuka, Y.,
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Katz, D. (2003). The etiology and natural history of idio-
pathic scoliosis. Journal of Prosthetics and Orthotics,
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LaMontagne, L., Hepworth, J., & Salisbury, M. (2001).
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LaMontagne, L., Hepworth, J., Cohen, F., & Salisbury, M.
(2003). Cognitive-behavioral intervention effects on ado-
lescents’ anxiety and pain following spinal fusion surgery.
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(2003). Effects of coping instruction in reducing young
adolescents’ pain after major spinal surgery. Orthopedic
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LaMontagne, L., Hepworth, J., Cohen, F., & Salisbury, M.
(2004). Adolescent scoliosis: Effects of corrective surgery,
cognitive-behavioral interventions, and age on activity
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Masafumi, M. (1999). Cause of idiopathic scoliosis. Spine,
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Browne, R. (2003). Sagittal plane deformity in the tho-
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Oxborrow, N. J. (2000) Assessing the child with scoliosis:
The role of surface topography. Archives of the Diseased
Child, 83, 453–455.
Chapter Offerings
August 17, 2007—4th Annual
Montana Orthopaedic Conference:
Improving the Care in Sports
Medicine and Injury, Holiday Inn
Parkside, Missoula, MT 59804.
Presented by Community Medical
Center. For more information: Linda
Hightower, (406) 728-4947 or email
linhi3921@msn.com.
154 Orthopaedic Nursing • May/June 2007 • Volume 26
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Payne, W., Ogilvie, J., Resnick, M., Kane, R., Transfeldt, E.,
& Blum, R. (1997). Does scoliosis have a psychological
impact and does gender make a difference? Spine, 22(12),
1380–1384.
Perez-Grueso, F., Fernandez-Baillo, N., Arauz de Robles,
S., & Fernandez, A. (2000). The low lumbar spine below
Cotrel-Dubousset instrumentation: Long term findings.
Spine, 25(18), 2333–2341.
Reichel, D., & Schanz, J. (2003) Developmental psychologi-
cal aspects of scoliosis treatment. Pediatric Rehabilitation,
6(3–4), 221–225.
Speer, M., George, T., Enterline, D., Franklin, A., Wolpert,
C., & Milhorat, T. (2000). A genetic hypothesis for Chiari
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Spiegel, D., Flynn, J., Stasikelis, P., Dormans, J.,
Drummond, D., Gabriel, K., et al. (2003). Scoliotic curve
patterns in patients with Chiari I malformation and/or
syringomyelia. Spine, 28(18), 2139–2146.
Slote, R. (2002). Psychological aspects of caring for the ado-
lescent undergoing spinal fusion for scoliosis. Orthopaedic
Nursing, 21(6),19–31.
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from http://www.srs.org/patients/review/
Smith., J. University of Utah School of Medicine. Scolio-
sis Clinic. Retrieved April 1, 2006 from http://medstat.
med.utah.edu/scoliosis/overview
Taft, E., & Francis, R. (2003). Evaluation and management
of scoliosis. Science Direct–Journal of Pediatric Health
Care, January-February, 42–44.
The Merck Manual online. (2006). Retrieved April 1, 2006
from www.merck.com.
U.S. Preventative Services Task Force. (2005). Screening for
idiopathic scoliosis in adolescents: Recommendation
Statement. American Family Physician. 71 (10). P.
1975–1976.
Wolff, S. (2002). Screening for adolescent idiopathic scolio-
sis. Guide to clinical preventive services: Report of the U.S.
Preventive Services Task Force. United States Department
of Health and Human Services. Office of Public Health and
Science (Apr. 2 ed.), pp. 517–29.
Yawn, B., & Yawn, R. (2000). The estimated cost of school
scoliosis screening. Spine, 25(18), pp. 2387–2391.
CALENDAR
October 25–26, 2007—Orthopaedic National Offerings
Nursing: New Concepts and
May 19–23, 2007—NAON 2007
Challenges, Minneapolis Convention
Annual Congress. A New Perspective:
Center, Minneapolis, MN. Presented
Energizing the Future, America’s
by the Twin Cities Chapter 29 of
Center, 701 Convention Plaza, St. Louis,
NAON and Hennepin County Medical
Missouri. For more information:
Center. For more information: Mary K.
www.orthonurse.org.
Wollan, (612) 873-2569 or
mary.k.wollan@co.hennepin.mn.us.
• Number 3