Rosemarie Gamboa Melissa S. Gines KYPHOSIS A.

Definition

-Also known as rounback or Kelsos hunchback. - is a condition of over-curvature of the thoracic vertebrae(upper back). It can be either the result of degenerative diseases (such as arthritis), developmental problems (the most common example being Scheuermann's disease), osteoporosis with compression fractures of the vertebrae, or trauma.

Types

Postural kyphosis (M40.0), the most common type, normally attributed to slouching, can occur in both the old[1] and the young. In the young, it can be called 'slouching' and is reversible by correcting muscular imbalances. In the old, it may be called 'hyperkyphosis' or 'dowagers hump'. About one third of the most severe hyperkyphosis cases have vertebral fractures.[2] Otherwise, the aging body tends towards a loss of musculoskeletal integrity,[3] and kyphosis can develop due to aging alone.[2][4]

Scheuermann's kyphosis (M42.0) is significantly worse cosmetically and can cause varying degrees of pain, and can also affect different areas of the spine (the most common being the mid-thoracic area). Scheuermann's disease is considered a form of juvenile osteochondrosis of the spine, and is more commonly called Scheuermann's disease. It is found mostly in teenagers and presents a significantly worse deformity than postural kyphosis. A patient suffering from Scheuermanns kyphosis cannot consciously correct posture.[5] The apex of the curve, located in thethoracic vertebrae, is quite rigid. The patient may feel pain at this apex, which can be aggravated by physical activity and by long periods of standing or sitting. This can have a significantly detrimental effect on their lives, as their level of activity is curbed by their condition; they may feel isolated or uneasy amongst peers if they are children, depending on the level of deformity. Whereas in postural kyphosis, the vertebrae and disks appear normal, in Scheuermanns kyphosis, they are irregular, often herniated, and wedge-shaped over at least three adjacent levels.Fatigue is a very common symptom, most likely because of the intense muscle work that has to be put into standing and/or sitting properly. The condition appears to run in families. Most patients who undergo surgery to correct their kyphosis have Scheuermann's disease. Congenital kyphosis (Q76.4) can result in infants whose spinal column has not developed correctly in the womb. Vertebrae may be malformed or fused together and can cause further progressive kyphosis as the child develops.[6] Surgical treatment may be necessary at a very early stage and can help maintain a normal curve in coordination with consistent followups to monitor changes. However, the decision to carry out the procedure can be very difficult due to the potential risks to the child. A congenital kyphosis can also suddenly appear in teenage years, more commonly in children with cerebral palsy and other neurological disorders. Gibbus deformity is a form of structural kyphosis, often a sequela to tuberculosis.

Characteristics

Head is too far forward Neck has an increased curve Shoulders are falling forward and down Chest and Rib Cage collapsing Upper Back is rounding (Kyphosis) Lower Back has an increased curve (Lordosis)

Pelvis tilting forward (anterior tilt) Knees locked

Etiology Many potential causes of kyphosis have been described. Scheuermann disease and postural round back are often identified in adolescents. Congenital abnormalities, such as failure of formation or failure of segmentation of the spinal elements, can cause a pathologic kyphosis. Autoimmune arthropathy, such as ankylosing spondylitis, can cause rigid kyphosis to develop as the spinal elements coalesce. Kyphosis can also develop as a result of trauma, a spinal tumor, or an infection. Iatrogenic causes of kyphosis include the effects of laminectomy and irradiation, which lead to incompetence of the anterior or posterior column. Finally, metabolic disorders and dwarfing conditions can lead to kyphosis.This article focuses on kyphosis due to Scheuermann disease and postural, postinfectious, posttraumatic, or iatrogenic etiologies. Anatomy and Physiology

In vertebrates, thoracic vertebrae compose the middle segment of the vertebral column, between the cervical vertebrae and the lumbar vertebrae.] In humans, they are intermediate in size between those of the cervical and lumbar regions; they increase in size as one proceeds down the spine, the upper vertebrae being much smaller than those in the lower part of the region. They are distinguished by the presence of facets on the sides of the bodies for articulation with the heads of the ribs, and facets on the transverse processes of all, except the eleventh and twelfth, for articulation with the tubercles of the ribs.Humans have 12, but numbers vary greatly; for example, most marsupials have 13, but koalas have only 11. 12 to 15 is common among mammals, with 18 to 20 in horses, tapirs, rhinoceroses, and elephants, and extremes in mammals are marked by certain sloths with 25 andcetaceans with 9. By convention, the human thoracic vertebrae are numbered, with the first one (T1) located closest to the skull and higher numbered vertebrae (T2-T12) proceeding away from the skull and down the spine.These are the general characteristics of the second through eighth thoracic vertebrae. The first and ninth through twelfth vertebrae contain certain peculiarities, and are detailed below.The bodies in the middle of the thoracic region are heart-shaped, and as broad in the antero-posterior as in the

transverse direction. At the ends of the thoracic region they resemble respectively those of the cervical and lumbar vertebrae. They are slightly thicker behind than in front, flat above and below, convex from side to side in front, deeply concave behind, and slightly constricted laterally and in front. They present, on either side, two costal demifacets, one above, near the root of the pedicle, the other below, in front of the inferior vertebral notch; these are covered with cartilage in the fresh state, and, when the vertebrae are articulated with one another, form, with the intervening intervertebral fibrocartilages, oval surfaces for the reception of the heads of the ribs.The pedicles are directed backward and slightly upward, and the inferior vertebral notches are of large size, and deeper than in any other region of the vertebral column.The laminae are broad, thick, and imbricated that is to say, they overlap those of subjacent vertebrae like tiles on a roof.The vertebral foramen is small, and of a circular form.The spinous process is long, triangular on coronal section, directed obliquely downward, and ends in a tuberculated extremity. These processes overlap from the fifth to the eighth, but are less oblique in direction above and below.The superior articular processes are thin plates of bone projecting upward from the junctions of the pedicles and laminae; their articular facets are practically flat, and are directed backward and a little lateralward and upward.The inferior articular processes are fused to a considerable extent with the laminae, and project but slightly beyond their lower borders; their facets are directed forward and a little medialward and downward.The transverse processes arise from the arch behind the superior articular processes and pedicles; they are thick, strong, and of considerable length, directed obliquely backward and lateralward, and each ends in a clubbed extremity, on the front of which is a small, concave surface, for articulation with the tubercle of a rib.

INDIVIDUAL TORACIC VERTEBRAE

First thoracic vertebra The first thoracic vertebra has, on either side of the body, an entire articular facet for the head of the first rib, and a demi-facet for the upper half of the head of the second rib. The body is like that of a cervical vertebra, being broad, concave, and lipped on either side. The superior articular surfaces are directed upward and backward; the spinous process is thick, long, and almost horizontal. The transverse processes are long, and the upper vertebral notches are deeper than those of the other thoracic vertebrae. The thoracic spinal nerve 1 (T1) passes out underneath it. Second thoracic vertebra The thoracic spinal nerve 2 (T2) passes out underneath it. Third thoracic vertebra The thoracic spinal nerve 3 (T3) passes out underneath it. Fourth thoracic vertebra The fourth thoracic vertebra, together with the fifth, is at the same level as the sternal angle. The thoracic spinal nerve 4 (T4) passes out underneath it.

Surface orientation of T3 and T7, at middle of spine of scapula and at inferior angle of the scapula, respectively. Fifth thoracic vertebra The fifth thoracic vertebra, together with the fourth, is at the same level as the sternal angle. The human trachea divides into two mainbronchi at the level of the 5th thoracic vertebra, but may also end higher or lower, depending on breathing.The thoracic spinal nerve 5 (T5) passes out underneath it. Sixth thoracic vertebra The thoracic spinal nerve 6 (T6) passes out underneath it. Seventh thoracic vertebra The thoracic spinal nerve 7 (T7) passes out underneath it. Eighth thoracic vertebra The eighth thoracic vertebra is, together with the ninth thoracic vertebra, at the same level as the xiphoid process.The thoracic spinal nerve 8 (T8) passes out underneath it. Ninth thoracic vertebra The ninth thoracic vertebra may have no demi-facets below. In some subjects however, it has two demi-facets on either side; when this occurs the tenth doesn't have facets but demi-facets at the upper part.The thoracic spinal nerve 9 (T9) passes out underneath it.The xiphisternum (or xyphoid process of the sternum) is at the same level in the axial plane. Tenth thoracic vertebra The tenth thoracic vertebra has (except in the cases just mentioned) an entire articular facet (not demi-facet) on either side, which is placed partly on the lateral surface of the pedicle. It doesn't have any kind of facet below, because the following ribs only have one facet on their heads. The thoracic spinal nerve 10 (T10) passes out underneath it.

Eleventh thoracic vertebra In the eleventh thoracic vertebrae the body approaches in its form and size to that of the lumbar vertebrae. The articular facets for the heads of the ribs are of large size, and placed chiefly on the pedicles, which are thicker and stronger in this and the next vertebrae than in any other part of the thoracic region. The spinous process is short, and nearly horizontal in direction. The transverse processes are very short, tuberculated at their extremities, and do have articular facets. The thoracic spinal nerve 11 (T11) passes out underneath it. Twelfth thoracic vertebra The twelfth thoracic vertebra has the same general characteristics as the eleventh, but may be distinguished from it by its inferior articular surfaces being convex and directed lateralward, like those of the lumbar vertebrae; by the general form of the body, laminae, and spinous process, in which it resembles the lumbar vertebrae; and by each transverse process being subdivided into three elevations, the superior, inferior, and lateral tubercles: the superior and inferior correspond to the mammillary and accessory processes of the lumbar vertebrae. Traces of similar elevations are found on the transverse processes of the tenth and eleventh thoracic vertebrae. The thoracic spinal nerve 12 (T12) passes out underneath it.

Management to Kyposis

Orthosis (brace) Modern brace for the treatment of a thoracic kyphosis. The brace is constructed using a CAD-CAM device. At this stage, this is the only CAD / CAM brace designed to treat a thoracic kyphosis. It is called kyphologic. Body braces showed benefit in a randomised controlled trial. The Milwaukee brace is one particular body brace that is often used to treat kyphosis in the US. Modern CAD / CAM braces are used in Europe to treat different types of kyphosis. These are much easier to wear and have better in-brace corrections than reported for the Milwaukee brace. Since there are different curve patterns (thoracic, thoracolumbar and lumbar) different types of braces are in use. The advantages / disadvantages of different braces are discussed in a recent review article. Modern brace for the treatment of a lumbar / thoracolumbar kyphosis. The brace is constructed using a CAD / CAM device. At this stage this brace is the only CAD / CAM brace designed to treat a lumbar kyphosis and is called physio-logic brace. Restoration of the lumbar lordosis is the major aim.[7] Specialised Physical therapy In Germany, a standard treatment for both Scheuermann's disease and lumbar kyphosis is the Schroth method, a system of physical therapy for scoliosis and related spinal deformities.[9] on supine lying place pillow under scapular region and posteriorly strech the cervical spine. Surgery Surgical treatment can be used in severe cases. In patients with progressive kyphotic deformity due to vertebral collapse, a procedure called akyphoplasty may arrest the deformity and relieve the pain. Kyphoplasty is a minimally invasive procedure,[10] requiring only a small opening in the skin. The main goal is to return the damaged vertebra as close as possible to its original height.[11

Nursing management 1. Teach/encourage exercises as ordered. 2. Provide care for patients with braces. 3. Provide cast/traction care. 4. Provide care for patient with Harrington insertion. 5. Promote comfort with proper fit of brace/cast . 6. Advice the patient to rest in bed on firm matress or with bed board beneath matress for support. 7. Keep pillow between flex knees while inside lying position minimizes strain on back muscles. 8. Avoid prolong periods of sitting. 9. Assess skin integrity and fit of brace and cast. 10. Teach proper skin care to patient and family. 11. Adjust diet for decrease activity. 12. Assess respiratory, circulatory and neurologic systems. 13. Provide opportunity for the child to express fears and ask questions about deformities and or brace were. 14. Administer analgesic , antibiotics and anti-anxiety drugs as ordered. 15. Provide adequate information, if correcting surgery is needed. 16. Provide emotional support, the patient slightly exhibit mood changes and periods of depression. Complication a. Disabling back pain b. Neurological symptoms including leg weakness or paralysis c. Decrease lung capacity. d. Round back deformity e. Pneumonia f. Atelectasis g. Deep vein thrombosis h. Fat embolism i. Hardware fracture

j. Spinal cord injury k. Sexual disfunction l. Pseudo athrosis

Pathophysiology

The patient may trauma , developmental problems or degenerative diseased.

Result in vascular disturbance in the vertebral epiphysis

Subsequent stress of weight bearing

Compromised Vertebrae

Result in thoracic hump or curvature