Patient Case Presentation at Royal National Orthopaedic Hospital, Stanmore

1. Patient Case Presentation at Royal National Orthopaedic Hospital, Stanmore By Sarah Hart u0604985

2. Objectives of Presentation • Introduce the patient and their presenting condition. • Explain what a scoliosis is and it’s impact on lung function plus surgical implications. • Explain the problem list and treatment options set by the physiotherapist for the patient. • Explain the relevance of goals and outcome measures used for this pt.

3. Patient Case • 17yr old male, presenting with a 3 year history of scoliosis • Works as a labourer • 2 stage fusion with instrumentation. • Asthmatic uses bronchodilators every day • Plays recreational football

4. Scoliosis • Definition- A structurally normal spine that appears to have a lateral curve occasionally accompanied by rotation of the vertebral column • Congenital scoliosis is caused by defects in the spine present at birth. • Neuromuscular scoliosis is caused by problems with the nerves or muscles. They are unable to support the spine in its normal position. • Degenerative scoliosis is caused by deterioration of the bony material (discs) that separate the vertebrae.

5. Scoliosis (Continued) • Cobb angle:- A measure of the curvature of the spine, determined from measurements made on X-ray photographs. • A small degree of curving in the spine does not usually cause any medical problems. But larger curves can lead to certain disorders, such as posture imbalance, muscle fatigue, and back pain. Severe scoliosis can interfere with breathing and lead to spondylosis

6. Pre-op 1st stage • Lung function test- or Pulmonary Function Tests (PFTs), measure lung function, specifically the measurement of the amount (volume) and/or speed (flow) of air that can be inhaled and exhaled. (Pryor and Prasad 01) • It provides an objective measure to how well a patient lungs are performing before surgery to how they are performing after surgery. • Calculations are drawn from their PEF, FEV1,FVC, arm span x 2 and weight • The requirement is that the patient reaches 80% of their pre-op lung function to help prevent surgical actelectasis.

7. Lung function tests • Peak expiratory flow (PEF). This measures how quickly you can exhale. It is usually measured at the same time as your forced vital capacity (FVC). • Forced expiratory volume (FEV). This measures the amount of air you can exhale with force in one breath. The amount of air you exhale may be measured at 1 second (FEV1

8. Lung function tests • Forced expiratory flow 25% to 75%. This measures the air flow halfway through an exhale (FVC). • Forced vital capacity (FVC). This measures the amount of air you can exhale with force after you inhale as deeply as possible (Hough 01).

9. 1st stage of surgery. • Anterior release stage • The incision site is a posterolateral thoracotomy • From this incision invertebral disc and end plates can be removed, this allows for the spine to be manipulated by the surgeon to begin straighten the spine out, while disc space is occupied by a glue with bone fragments to allow for fusion of the vertebra

10. Post-op 1st stage –Precautions • Follow post-op instructions- precautions, which physiotherapist adheres/reinforces. • Chest drain is in situ due to the incision site. • No mobilising. • Problems- pain, reduced lung volume, unable to mobilise between stages. • Chest physiotherapy- ACBT with either cough/huff

11. 2nd stage of surgery posterior fusion • There is a midline incision down the vertebra. The paraspinal muscles are then moved from the spinous processes of the vertebrae • Instrumentation is then placed alongside the affected vertebra

12. Post-op 2nd stage –Precautions • Dependant on surgeon restrictions are either:- • Not to mobilise until the brace, (hard back- soft front) has been cast in a supine position. • Or pt can mobilise once chest drain is out with a soft corset.

13. Short-term goals • Increase lung volume, • Increase surface area for gas exchange • Prevent actelectasis in bases • Maintain lung function •  Clear secretion if not, Possibility of chest infection • Maintain/ Increase surface area for gas exchange • Maintain muscle strength. •  Maintain muscle power for when pt is mobilising. • Encourage blood movement in lower limbs, helping prevent DVT’s

14. Mid-term goals • Once corset/Brace is on the aims are the same:- • Transfers from bed > SOEOB > chair • Sit > stand • Stand > mobilise • Stair assessment.

15. Long-term goals • To adhere to guidelines the surgeon has given the patient. • Avoid bending 90° at hips • Avoid excesses twisting. • Wear brace within guidelines set by the surgeon. • Avoid contact sports for 12 months

16. References • Scoliosis picture- http://www.flickr.com/photos/drpix/2143804115/ • Scoliosis vs. normal- spinehttp://www.chiroinmotion.com/images/scoliosis2.gif • Lung picture- http://www.cancerline.com/gUserFiles/lungs_detail.jpg • Inspirometer- http://www.eecs.wsu.edu/~schneidj/accident/Images/inspirometer.jpg • Surgical pictures- http://www.medscape.com/viewarticle/441199_4 • Hough, A, 2001, Physiotherapy in Respiratory Care: An evidence-based approach to respiratory and cardiac management: A Problem-solving Approach (Physiotherapy in respiratory care), London • Pryor. J, Prasad, H, 2001, Physiotherapy for Respiratory and Cardiac Problems: Adults and Paediatrics (Paperback) London