Nursing Care for Scoliosis Patients
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Mary Ann Jordan, R.N., C.P.A.N.  |
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Sarah is a 12-year-old junior high school student who was screened by the school nurse for scoliosis. She was found to have a prominent shoulder blade and one shoulder higher than the other. Her hips are uneven, and when she bends forward, a rib prominence is noticed. The nurse sent a note home requesting a scoliosis evaluation. Sarah was happy that she was finally getting her back examined because she does not like the way she looks in a bathing suit or enjoy shopping for fancy dresses for her school dances because the fit is uneven. Scoliosis is a lateral (sideward) curvature of the spine. The spine bends to one side or to both sides at different levels. The exact cause of idiopathic scoliosis is unknown. It often runs in families and is genetic in nature. Kyphosis is an abnormally increased rounding in the thoracic spine, as viewed from the side. Sarah's parents have a friend who works for Shriners Hospitals for Children in Philadelphia, so they sought help from the Shriners Pediatric Spine Center of Excellence. When Sarah's mom called, she completed an application over the phone and arranged an appointment for a consultation. At the assessment and consultation visit, the care coordinator, who is a nurse, took a brief medical history of Sarah before she went for x-rays (AP and lateral thoracolumbar spine on a 14 x 36" film). Bending films were also taken to test the spine's flexibility. FAMILY DISCUSSIONS After consulting with the physicians, it was determined that Sarah has idiopathic scoliosis with a curve of 60 degrees. Scoliosis treatment methods include bracing or surgery. However, bracing is usually started when a spinal curve reaches 25 to 30 degrees, and bracing cannot "hold" curves greater than 40 degrees. |
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Since bracing was not a feasible option, the physicians suggested that Sarah needed surgery. The surgical procedures were discussed, and the care coordinator answered the family's questions.
SURGICAL OPTIONS
Several types of spinal fusion are being performed at Shriners Hospitals for Children, including posterior and/or anterior spinal fusion. The posterior spinal fusion (PSF) is performed on the back of the spine, with an incision down the center of the patient's back. The anterior spinal fusion (ASF) is performed on the front half of the spine, which is reached through an incision on the side of the chest. The ASF can also be performed by using a thoracoscope. A scope is used for visualization, with spinal fusion performed through small holes in the chest similar to knee arthroscopy. It is determined that Sarah will benefit from a PSF.
CASE EXAMPLE (a different patient)
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Fig. 1a: This is a 13-year-old with a progressive right thoracic scoliosis measuring 55°
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Fig 1c: Postoperatively, the curve is reduced to 15°. Correction was obtained by utilizing screws and hooks with sublaminar wires to assist with curve translation.
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EDUCATING THE FAMILY
The nurse supplied the family with written materials, including a preoperative spinal fusion information packet; an activity list, which is a schedule of when Sarah may or may not resume activities she was involved in prior to her surgery; research consents, if applicable; and name and phone number of a family whose child had a similar curve and same procedure.
No more information is given at the first visit because the family is usually overwhelmed. It is suggested that they go home, further discuss the issues, consider a surgery date, and follow up with the nurse the next week. In Sarah's case, once the family followed up and set a date, Sarah began preparing for surgery.
PRESURGICAL TESTS
Preparation for surgery began with several tests. Consults were sent to the family for pulmonary function test (PFT), ECG, and basic labs (CBC, electrolytes, creatine kinase, sed rate, PT, PTT, platelets, and urinalysis).
PFTs evaluate respiratory status, and if the results are abnormal, the patient will need surgical clearance from a pulmonologist. Rarely, children with scoliosis show moderate constrictive disease on their PFTs secondary to asthma. If the results on the ECG are abnormal, an echocardiogram should be performed and cardiology clearance obtained.
Occasionally, the neurological exam by the physician is abnormal and an MRI is done to ensure that the spine is free of tumors, intraspinal lesions, or syrinx (a cyst in the spinal cord). A syrinx sometimes needs to be surgically drained or decompressed before spinal fusion surgery. A consult with a neurosurgeon for surgical clearance must also be obtained if MRI findings are abnormal. SSEP is a noninvasive measurement of conduction in the central nervous system. Small electrodes are inserted onto the patient's scalp and extremities and connected to a monitor.
SSEP monitoring is done during the surgical procedure to pick up any neurological problems that occur when spinal instrumentation is inserted and when the spinal curve is being straightened. A pre-op baseline SSEP is used as a comparison during surgery.
BLOOD UNITS NEEDED
Each patient undergoing this type of spinal surgery needs approximately two to four units of blood available, an amount specifically determined by the surgeon. If able, the patient can donate two units of autologous blood. Close family members can directly donate other units. If the family is not able to provide the required amount of blood, the nurse can obtain blood from a blood bank.
The Shriners operating room uses a cell-saver machine, and most patients receive at least one unit of cell-saver. Sarah needed to start taking iron supplements one week before donating blood, and then for 7-10 days following surgery. Because the surgical team prefers not to use frozen blood, Sarah donated her blood within five weeks before surgery so the blood would not expire.
INFORMING THE CHILD'S SCHOOL
Another presurgical duty of the spine nurse was to contact Sarah's school gym teacher to inform him that she wouldn't be able to participate in a full physical education program for six months after surgery. After that period, Sarah will be able to participate in limited gym activities.
The spine nurse also contacted the school nurse to initiate homebound instruction for 6 to 8 weeks post-op. When Sarah returns to school, she should have access to the elevator and be allowed to leave class 5 to 10 minutes early to avoid crowded hallways. Because Sarah will only be able to lift a limited amount of weight, she will need two sets of books--one for school and the other for home.
ONGOING SUPPORT
Completing the necessary testing and blood donation can be overwhelming and confusing to the patient and family. Sarah and her parents kept in close contact with the care coordinator for spine patients at the Philadelphia Shriners Hospital.
To help Sarah and her family deal with anxiety about the upcoming surgery and recovery period, the spine nurse strongly suggested they attend one of the meetings of Curvebusters, a support group which meets at Shriners once a month. Social Services would become involved with the case as needed.
PRE-OP TEACHING
Pre-op teaching by the spine nurse starts from the initial consult through the day of surgery. It begins with explaining the degree of the curve, the surgical procedure, the length of incision, and duration of hospital stay.
Estimated blood loss, prevention of paralysis, and the risks and benefits of surgery are also emphasized. Post-op dressing changes, bracing needs, pain management, activity levels, and homebound instruction are included, and the nurse promises to return calls the same day or before noon the next day.
After all the tests are completed, Sarah is ready for surgery!
SEDATION AND TRANSPORT TO OPERATING ROOM
Early on the morning of surgery, Sarah receives a sedative and a sip of water. She and her family are escorted to the OR/PACU (Post Anesthesia Care Unit), where they are greeted by the nurse and anesthesiologist. She will have a peripheral IV started in the pre-op holding area and two more IVs and an A-line inserted after she is asleep.
A wake-up test, along with SSEP monitoring during surgery, will determine that no neurological damage has occurred. Toward the end of the surgery, after the hardware has been placed, the anesthesiologist will decrease the amount of anesthesia and ask the patient to move her feet. After successful completion of the wake-up test, the anesthesia will be resumed and the surgery will be completed. Patients have no recollection of this test, nor do they experience pain.
Sarah's surgery will take 5 hours. A 12- to 16-inch incision is made down her back and the spine exposed by peeling back the muscle. Next, small (2-cm) pieces of rib are resected to reduce the rib deformity. The hooks, screws and rods are placed and the spine is straightened. For Sarah, the surgeon chose to use her ribs for bone graft. Some patients will have small pieces of their pelvis used as bone graft. Your doctor will decide what is best for you. The rib pieces are placed against the spine, under the rod, to facilitate the fusion. The OR/PACU staff is in contact with Sarah's parents during surgery with updates on progress.
After surgery, Sarah is taken to the PACU, where she will be monitored for 2 to 3 hours. Routine PACU monitoring includes vital signs, intake and output, neurovascular checks, dressing and skin checks, and labs, including ABGs, hemoglobin, and hematocrit
. Patients receive oxygen via face tent at 40% concentration to keep oxygen saturation above 94%. Most patients have a hemovac in their back incision, a chest tube or rib protector, and a Foley catheter along with two peripheral IVs and an A-line.
A chest x-ray is done to check for lung expansion and atelectasis (partial collapse of sections of the lung), and the position of the hardware in the back can also be seen. Pain is controlled by patient-controlled anesthesia (PCA) using morphine. Immediately after surgery, most children rate their pain as "5" on a severity scale of 1-5. By the first post-op day, the usual rating is 2 to 3. IV antibiotics are given until the patient's drains are removed. A posterior spinal fusion is a big operation. The nurses and doctors work very hard to make the patient as comfortable as possible. Six weeks after surgery, most kids say that they do not remember much of their first few days after surgery.
Sarah is moved to the Extended Post-Anesthesia Care Unit (EPACU) for two days. The two hemovac drains and one chest tube are removed once drainage decreases to a minimal amount. She is taken off the PCA pump and put on oral medication. Her diet is advanced to clear liquids, and she is allowed to sit in a chair. By Day 4 Sarah will be transferred out of EPACU to continue her recovery. Before she is discharged from the hospital, Sarah will begin to build up her strength and endurance by walking and performing some nonstrenuous activities of daily living.
Sarah and her family are taught how to care for her wounds, and she is given a prescription for pain medication. Sarah will return to the outpatient center for a wound check, and her dressing will be taken off and any remaining steri-strips on her back will be removed. Her pain level will also be assessed at this time.
Sarah will return to the outpatient center two and six months post-surgery for x-rays and follow-up. After the six-month check-up, Sarah will come to the outpatient center every six months three times and then yearly until she is discharged from the Shriners Hospital system at age 21. The care coordinator is always available by phone to answer any questions or handle any issues that may arise.
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Fig 1b: This lateral radiograph shows a straight lateral thoracic spine, referred to as hypokyphosis.
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Fig 1d: Post-op lateral profile showing a restoration of the lateral profile to a more normal range.
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HOW IS SARAH NOW?
Six to eight weeks post-surgery, Sarah is doing very well. She has returned to school and is slowly increasing her activity level. She has discontinued taking pain medication and frequently attends Curvebusters, the support group for children with scoliosis. She enjoys counseling other young people who are about to have surgery. She is happy with the way her clothes fit--and she has spent a lot of money at the mall since she looks so great!
