Herniated IntervertebralDisc

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CONCEPT MAP

Herniated Intervertebral Disk

Age

Diagnostic Tests:MRI, CT Scan and

X Ray

Occupational stress

Medical Management:Bed rest, immobilization

Surgical Management:Discectomy,

Laminectomy, Foramenotomy,

Clinical Manifestations:

Pharmacologic Therapy:Analgesics, muscle relaxant,

corticosteroid, sedatives

Back pain , also in knees, thighs or feet. Postural deformity Sensory loss

Muscle weakness, alteration in

reflexes

Acute Pain Disturbed Body Image Disturbed sensory perception

Impaired physical mobility

Current Trends/Updates

Evidenced-Based Practice

Bioethical/ Ethico-Legal

Nursing Theories

Health Teachings

Herniated Intervertebral Disk

In herniation of the intervertebral disk (ruptured disk), the nucleus of the disk protrudes into the annulus (the fibrous ring around the disk), with subsequent nerve compression. Protrusion or rupture of the nucleus pulposus usually is preceded by degenerative changes that occur with aging.

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Normal Herniated Intervertebral Disk

Pathophysiology of Herniated Intervertebral Disk

Predisposing Factor:

•Age-Degenerative changes that occur with aging.Usually at 4th decade of life.

Precipitating Factor:

•Occupational stress:- Causes chronic disc degeneration

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Spinal degeneration

Loss of Protein Polysaccharides

Decrease water content of nucleus pulposus

Development of radiating cracks in the annulus

Trauma

Injury to the cartilage

Protrusion of nucleus pulposus into the annulus

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Clinical Manifestations

Back pain, knifelike, aggravated by coughing, sneezing, bending, lifting, defecation, straight legraising.

Postural deformity/altered posture and gait

Sensory Loss

Altered reflexes and Muscle weakness

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Spinal x-rays: may show degenerative changes in spine/intervertebral space or rule out other suspected pathology, e.g.,tumors, osteomyelitis.

DIAGNOSTIC STUDIES

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Ct scan with/without enhancement: may reveal spinal canal narrowing, disc protrusion.

MRI: can reveal changes in bone, discs, and soft tissues and can validate disc herniation/surgical decisions.

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Nursing Considerations:

1. Explain procedure.2. Remove all metals from the client such as jewelry, braces, dentures3. Not indicated for patients with artificial pacemakers, skeletal tractions

and prosthesis.3. Assess for claustrophobia ; give psychosocial support.

Sedate patient if necessary.

Electrophysiological studies—electromyoneurography (emg) and nerve conduction studies (ncs): can localize lesionto level of particular spinal nerve root involved; nerve conduction and velocity study usually done in conjunction with study of muscle response to assist in diagnosis of peripheral nerve impairment and effect on skeletal muscle.

Myelogram: rarely performed, but when done, may be normal or show “narrowing” of disc space, specific location andsize of herniation.

Provocative tests (discography, nerve root blocks): determine site of origin of pain by replicating and then relievingsymptoms. can also be used to rule out sacroiliac joint involvement.

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Medical Management

The goals of treatment are (1) to rest and immobilize the cervical spine to give the soft tissues time to heal and (2) to reduce inflammation in the supporting tissues and the affected nerve roots in the cervical spine.

This could be achieved by:

•Bed rest

•Proper positioning on a firm mattress may bring dramatic relief from pain.

•Immobilization by traction or brace (e.g., neck collar)

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Non-surgical care alternatives to treat the pain, including:

1. Chiropractic

2. Bed rest and lumbo-sacral support belt.

3. Physical therapy

4. Massage therapy

5. Weight control

6. Spinal decompression

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Pharmacologic therapy

Analgesics•NSAIDs•Propoxyphene [Darvon]•Oxycodone [Tylox]

Muscle relaxants

Sedatives

Corticosteroids

•Cyclobenzaprine [Flexeril]•Methocarbamol•[Robaxin]•Metaxalone [Skelaxin])

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Surgical Management

Discectomy: removal of herniated or extruded fragments ofintervertebral disk

Laminectomy: removal of the bone between the spinalprocess and facet pedicle junction to expose the neural elements in the spinal canal ; allows the surgeon to inspect the spinal canal, identify and remove pathology, and relieve compression of the cord and roots

Hemilaminectomy: removal of part of the lamina and part of the posterior arch of the vertebra.

Partial laminectomy or laminotomy: creation of a hole in the lamina of a vertebra.

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• Discectomy with fusion: a bone graft (from iliac crest orbone bank) is used to fuse the vertebral spinous process; theobject of spinal fusion is to bridge over the defective disk tostabilize the spine and reduce the rate of recurrence

• Foraminotomy: removal of the intervertebral foramen to increasethe space for exit of a spinal nerve, resulting in reducedpain, compression, and edema

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Nursing Process

NURSING PRIORITIES1. reduce back stress, muscle spasm, and pain.2. promote optimal functioning.

3. support patient/so in rehabilitation process.4. provide information concerning condition/prognosis and treatment needs.

Nursing Assessment

ACTIVITY/REST

may report: history of occupation requiring heavy lifting, sitting, driving for long periods

may exhibit: atrophy of muscles on the affected sidegait disturbances

EGO INTEGRITY

may report: fear of paralysisfinancial, employment concerns

may exhibit: anxiety, depression, withdrawal from family/so

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NEUROSENSORY

may report: tingling, numbness, weakness of affected extremity/extremities

may exhibit: decreased deep tendon reflexes; muscle weakness, hypotoniatenderness/spasm of paravertebral musclesdecreased pain perception (sensory)

PAIN/DISCOMFORT

may report: pain knifelike, aggravated by coughing, sneezing, bending, lifting, defecation, straight legraising; unremitting pain or intermittent episodes of more severe pain; radiationto leg/feet, buttocks area (lumbar), or shoulder or head/face, neck (cervical)heard “snapping” sound at time of initial pain/trauma or felt “back giving way”limited mobility/forward bending

may exhibit: stance: leans away from affected areaaltered gait, walking with a limp, elevated hip on affected sidepain on palpation

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Nursing Diagnoses

cute related to physical injury agents: nerve compression, muscle spasm

mpaired physical mobility related to pain and discomfort, muscle spasms restrictive therapies, e.g., bedrest, traction neuromuscular impairment

nxiety related to situational crisis

isturbed body image related to postural deformity

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Planning

The goals for the patient may include relief of pain, improved mobility, increased knowledge and self care ability, and prevention of complications.

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Nursing Interventions/ Management

POSITIONING THE PATIENT

To position the patient, a pillow is placed under the head and the knee rest is elevated slightly to relax the back muscles.

The patient is encouraged to move from side to sideto relieve pressure and is reassured that no injury will result from moving.

The patient turns as a unit (logrolls), without twisting the back.

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LOGROLLING

The patient’s arms will be crossed and the spine aligned.

To avoid twisting the spine, the head, shoulders, knees, and hips are turned atthe same time so that the patient rolls over like a log.

When in a side-lying position, the patient’s back, buttocks, and legs are supported with pillows.

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Bed rest for 1 to 2 days on a firm mattress (to limit spinal flexion) is encouraged to reduce the weight load and gravitational forces, thereby freeing the disk from stress

The patient is allowed to assume a comfortable position; usually, a semi-Fowler’s position with moderate hip and knee flexion relaxes theback muscles.

When the patient is in a side-lying position, a pillow is placed between the legs.

To get out of bed, the patient lies on one side while pushing up to a sitting position.

NSAIDs and systemic corticosteroids may be administered to counter the inflammation that usually occurs in the supporting tissues and the affected nerve roots.

Moist heat and massage help to relax spastic muscles and have a sedative effect.

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Evaluation

Expected patient outcomes may include:

1. Reports decreasing frequency and severity of pain

2. Demonstrates improved mobility:

a. Demonstrates progressive participation in self-care activities

b. Identifies prescribed activity limitations and restrictions

c. Demonstrates proper body mechanic

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Current Trends/Updates/Researches

Genes Linked To Spinal Disc Degeneration Identified ScienceDaily (Mar. 17, 2009) — Lumbar disc degeneration is an uncomfortable condition that affects millions of people, but two University of Alberta researchers have identified some of the genes that are causing problems.and Tapio Videman, in the Faculty of Rehabilitation Michele Crites-Battie Medicine, have discovered eight genes that are directly related to disc degeneration."We found more genes associated with disc degeneration than was discovered in 30 prior studies," said Videman. "This is very exciting.“The pair started by studying 25 specific genes they thought could be linked to the disease.They picked these "candidate" genes based on the views of two leading experts and Videman have collaborated with through thein the field who Crites-Battie years. They narrowed their search down using state-of-the-art DNA analyzers, then applying statistical methods and analyzing MRIs of twins' spines.

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"Identifying genes involved can provide important insights into the biological mechanisms behind disc degeneration and a better understanding of . "This can eventuallywhat is going wrong in the system," said Crites-Battie lead to effective interventions for the problem.“

The pair will now look at the interaction between these eight genes and their environment. This will help them identify what gene forms indicate susceptibility."This will tell us who should avoid physical loading, and in which people obesity could be a risk factor for spine problems," said Videman.But this could be a long process as disc degeneration is what's called polygenic, meaning it involves more than one gene.

"There are likely to be quite a number of genes involved and a system of complex gene-gene and gene-environment interactions," said Crites-Battie. "Obtaining a full appreciation of the genetic architecture of disc degeneration is likely to be a very lengthy, involved process."

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This discovery comes about a year after the pair's award winning 10-year international twin-spine study proved that disc degeneration is affected largely by genetics.

"For years it has been thought that wear and tear was the main cause," said .Crites-BattieThe U of A researchers have made huge strides in the field and are determined to put an end to lower-back pain.

"This study could lead to interventions and actions individuals could take to minimize disc degeneration to which [patients] might be particularly prone," . "We are very excited about continuing down this trail andsaid Crites-Battie believe there is still much more to be learned."

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Evidence-Based Practice

Narrowing of Lumbar Spinal Canal Predicts Chronic Low Back Pain More Accurately than Intervertebral Disc Degeneration: A Magnetic Resonance Imaging Study in Young Finnish Male Conscripts

The objective of this magnetic resonance imaging study was to evaluate the role of degenerative changes, developmental spinal stenosis, and compression of spinal nerve roots in chronic low back (CLBP) and radicular pain in Finnish conscripts. The degree of degeneration, protrusion, and herniation of the intervertebral discs and stenosis of the nerve root canals was evaluated, and the midsagittal diameter and cross-sectional area of the lumbar vertebrae canal were measured in 108 conscripts with CLBP and 90 asymptomatic controls.The midsagittal diameters at L1-L4 levels were significantly smaller in the patients with CLBP than in the controls. Moreover, degeneration of the L4/5 disc and protrusion or herniation of the L5/S1 disc and stenosis of the nerve root canals at level L5/S1 were more frequent among the CLBP patients. Multifactorial analysis of the magnetic resonance imaging findings provided a total explanatory rate of only 33%. Narrowing of the vertebral canal in the anteroposterior direction was more likely to produce CLBP and radiating pain than intervertebral disc degeneration or narrowing of the intervertebral nerve root canals. CM

Bioethical Principles/Ethico-Legal

Principle of Beneficence

Principle of Respect for Autonomy

Principle of Human Dignity

Principle of Informed Consent

Principle of Double Effect

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Nursing Theories

Sister Callista Roy Adaptation Model

Jean Watson Human Caring

Other theory

Wear and Tear Theory of Aging

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Health Teachings

Pain Management• Limit bed rest; keep knees flexed to decrease strain on back• Nonpharmacologic approaches: distraction, relaxation, imagery,thermal interventions (eg, ice or heat), stress reduction• Pharmacologic approaches: nonsteroidal anti-inflammatory drugs,analgesics, muscle relaxants

Exercise• Stretch to enhance flexibility, do strengthening exercises• Perform prescribed back exercises to increase function, emphasizing gradual increases in time and repetitions

Body Mechanics• Practice good posture• Avoid twisting body• Push objects rather than pull them• Keep load close to body when lifting• Bend knees and tighten abdominal muscles when lifting

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•Avoid overreaching• Use wide base of support• Use back brace to protect back

Work Modifications• Adjust work area to avoid stress on back• Adjust height of chair or work table• Use lumbar support in chair• Avoid prolonged standing and repetitive tasks• Avoid bending, twisting, and lifting heavy objects• Avoid work involving continuous vibrations

Stress Reduction• Discuss with patient the interdependence of stress and anxiety onmuscle tension and pain• Explore effective coping mechanisms• Teach stress reduction techniques• Refer patient to back clinic

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Health Promotion

Standing• Avoid prolonged standing and walking.• When standing for any length of time, rest one foot on a smallstool or box to relieve lumbar lordosis.• Avoid forward flexion work positions.• Avoid high heels.

Sitting• Avoid sitting for prolonged periods.• Sit in a straight-back chair with back well supported and arm rests to support some of the body weight; use a footstool to position knees higher than hips if necessary.• Eradicate the hollow of the back by sitting with the buttocks “tucked under.”• Maintain back support; use a soft support at the small of the back.• Avoid knee and hip extension. When driving a car, have the seat pushed forward as far as possible for comfort.• Guard against extension strains—reaching, pushing, sitting with legs straight out.• Alternate periods of sitting with walking.

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•Place a firm bed board under the mattress.• Avoid sleeping in a prone position.• When lying on the side, place a pillow under the head and onebetween the legs, with the legs flexed at the hips and knees.• When supine, use a pillow under the knees to decrease lordosis.

Lifting• When lifting, keep the back straight and hold the load as close to the body as possible.• Lift with the large leg muscles, not the back muscles.• Use trunk muscles to stabilize the spine.• Squat while keeping the back straight when it is necessary to pick something off the floor.• Avoid twisting the trunk of the body, lifting above waist level, and reaching up for any length of time.

Exercising• Daily exercise is important in the prevention of back problems.• Walking and gradually increasing the distance and pace of walking is recommended.• Perform prescribed back exercises twice daily, increasing exercise gradually.• Avoid jumping and jarring activities.

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