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Module 8 Neurosensory: Herniated Disk and Spinal Cord tumors

Module 8 Neurosensory: Herniated Disk and Spinal Cord tumors. Marnie Quick RN, MSN, CNRN. A. Pathophysiology/etiology Normal spine as related to herniated disk. Herniated nucleus pulposus, slipped disk, ruptured disk

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Module 8 Neurosensory: Herniated Disk and Spinal Cord tumors

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  1. Module 8 Neurosensory: Herniated Disk and Spinal Cord tumors Marnie Quick RN, MSN, CNRN

  2. A. Pathophysiology/etiologyNormal spine as related to herniated disk • Herniated nucleus pulposus, slipped disk, ruptured disk • Function of disc is to allow for mobility of the spine and act as shock absorber

  3. Located between vertebral bodies • Composed of nucleus pulposus a gelatinous material surrounded • By annulus fibrosis- a fibrous coil

  4. Spinal nerves come out between vertebra from the reflex ark in the spinal cord

  5. Risk factors developing herniated disk • Standing erect- cumulative effect and daily stress • Aging changes in disc and ligaments, osteoarthritis • Poor body mechanics • Overweight • Trauma

  6. HNP- annulus becomes weakened/torn and the nucleus pulpsus herniates through it. • HNP compresses • Spinal nerve (sensory or motor component) as it leaves the spinal cord • Or the cord itself- the white tracks within the cord- rare

  7. Sensory root or nerve of the spinal nerve is usually affected resulting in sensory symptoms- pain, parenthesis, or loss of sensation • Motor root or nerve may be affected which results in motor symptoms- paresis or paralysis • Manifestations depend on what nerve root, spinal nerve is being compressed– which dermatomes • Radiculopathy- pathology of the nerve root

  8. B. Common manifestations/complications Lumbar HNP • Most common site for HNP is L4-5 disc- the 5th lumbar nerve root • Most common is the posterior sensory nerve or root compressed • Classic symptoms- low back sciatica pain. The pain increases with increase in intrathorasic pressure

  9. Other symptoms lumbar HNP: • Postural changes • Urinary/male sexual function changes • Paresis or paralysis • Foot drop • Paresthesias • Numbness • Muscle spasms • Absent cord reflexes

  10. Common manifestations/complications Cervical HNP • C5-C6 disk- affects the 6th cervical nerve root • Pain- neck, shoulder, anterior upper arm to thumb • Absent/diminished reflexes to the arm • Motor changes- paresis or paralysis • Sensory- paresthesias or pain • Muscle spasms

  11. C. Therapeutic Interventions- diagnostic tests • X-ray identify deformities and narrowing of disk space • CT/MRI • Mylogram p1336 • Nerve conduction studies (EMG) to detect electrical activity of skeletal muscles

  12. Treatment- Conservative • Bed rest with firm mattress; log roll; side lying position with knees bent and pillow between legs to support legs • Avoid flexion of the spine- brace/corset, cervical collar to provide support • Medications- nonnarcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodics and tranquilizers

  13. Treatment- Conservative • Heat/cold therapy to decrease muscle spasms • Break the pain-spasm-pain cycle • Ultrasound, massage, relaxation techniques • Progressive mobilization with approved exercise program –includes abdominal/thigh strengthening • Teaching good body mechanics • Weight loss • TENS unit

  14. Treatment- Surgery • Laminectomy- removal of a portion of the lamina to relieve pressure and to get to the herniated nucleus pulposus that is protruding out

  15. Treatment- Surgery • Spinal fusion removes most of the disk and replaces it with bone usually from the patient iliac crest • Flexibility is lost at the site- requires longer hosp stay

  16. Treatment- Surgery • Foraminotomy is enlargement of the bony overgrowth at the opening which is compressing the nerve • Microdiskectomy is use of electron microscope through a small incision to remove a portion of the HNP that is displaced. If cervical HNP, usually use the anterior approach in the neck

  17. Prevention of HNP • Back school approach- • Causes of HNP • Learn how to prevent • Good body mechanics • Exercises to strengthen leg and abdominal muscles • Change in life-style or occupation

  18. D. Nursing Assessment Specific to HNP Health History • Assess for risk factors- the cumulative effect of standing erect and daily stress; aging changes in disc/ligaments; poor body mechanics; overweight; trauma • Employment, history of pain, and other neuro changes

  19. Nursing Assessment specific to HNP Physical exam • Use similar methods to assess as utilized SCI • Muscle strength and coordination • Sensation- sharp/dull of paperclip using dermatome as reference • Pain evaluation- pain scale • Pre/Post-op assessment

  20. Post-op assessment from HNP • NVS sensory/motor- care not to injure op site • Assess for CSF drainage or bleeding from op site • Encourage turn (log roll, cough, deep breath) • If anterior cervical- assess injury to the carotid, esophagus, trachea, laryngeal nerve (speech- hoarseness)- assess respiration, neck size, swallowing and speech

  21. If post-op lumbar- assess bowels sounds, voiding. Minimize stress of post-op site- flat with pillow between knees, log roll, etc • Assess for postural hypotension, especially if ind was on bed rest for several days/weeks prior to surgery

  22. E. Pertinent nursing problems/interventions 1. Acute pain • Post surgery the individual may have similar pain as pre-op due to lack of resiliency of the spinal nerves to ‘bounce’ back quickly • Donor site (illiac crest) may cause more pain than laminectomy • Individual may be in a pain-spasm-pain cycle, therefore may need both antispasmodic as well as analgesic

  23. 2. Chronic pain • Surgery may not relieve pain • Nonpharmalogical methods to control pain • Pain clinic

  24. 3. Constipation • As a result of bed rest and decreased mobility and fear of pain with straining of stool • Constipation prevention methods– fluids, diet, etc

  25. 4. Home care • When riding in a car, take frequent stops to move and stretch • Prevention– Back school approach • May have to deal with pain as a chronic condition • May need to make life/job changes

  26. Spinal Cord Tumors A. Patho- normal cord & cord tumors • CNS is made up of neural tissue (neurons) and support tissue (glial) • These tissues undergo changes and result in spinal cord tumors • Blood vessels and bone (vertebra) also can be part of the tumor • Spinal tumors are classified by anatomical area and as primary or secondary

  27. Spinal cord tumors by anatomical area • Intramedullary- arise from neural tissues of the spinal cord • Extramedullary arise from tissues outside the spinal cord may be benign or malignant • Intradural-from the nerve roots or meninges in subarachnoid space • Extradural- from the epidural tissue or vertebra

  28. Spinal cord tumors primary or secondary • Primary- originating in the spinal cord or meninges • Secondary- metastases from other parts of the body

  29. Most spinal cord tumors are found in the thoracic region • Spinal cord tumors can compress (benign), invade the neural tissue, or cause ischemia to the area because of vascular obstruction

  30. B. Common manifestation/complications • Symptoms depend on the anatomical level of the spinal column, the anatomical location, the type of tumor and the spinal nerves affected • Pain is the most common presenting symptom that is not relieved by bed rest • Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor

  31. Manifestations thoracic cord tumor • Paresis & spasticity of one leg then the other • Pain back & chest, not relieved by bedrest; sensory changes • Babinski reflex • Bowel (ileus); bladder dysfunction (UMN in type)

  32. C. Therapeutic interventions spinal tumors • Diagnostic tests include: • X-ray of the spinal column • Myelogram • Lumbar puncture with CSF analysis

  33. Medications spinal tumors • Control pain- narcotic analgesics, may be given epidural catheter, PCA, NSAID’s • Reduce cord edema and tumor size- steroids dexamethasome (Decadron) high dose for a few days, then taper off with a Medrol dose pack

  34. Surgery for spinal cord tumors • Laminectomy to remove or to decrease the size (decompression laminectomy) of the spinal cord tumor • Spinal fusion or the insertion of rods if several vertebra involved and the column is unstable • Radiation to reduce size and control pain

  35. D. Nursing assessment specific to cord tumors • Health history • Pain, motor and sensory changes, bowel and bladder changes, Babinski reflex. • Physical exam • Similar to physical assessment for HNP

  36. E. Pertinent nursing problems/interventions • 1. Anxiety • Metatastic tumor vs benign spinal cord tumor • Education and support system • 2. Risk for constipation • From spinal cord compression, narcotics, bed rest • Adjust fluid and diet

  37. 3. Impaired physical mobility • From bed rest and motor involvement • Basic nursing- ROM, etc • 4. Acute pain • From compression or invasion of tumor • Assess and treat • 5. Sexual dysfunction • Male sacral reflex ark (S 2,3,4) interference • Similar care as discussed with SCI

  38. 6. Urinary retention • Reflex arc (S2,3,4) interference can cause neurogenic bladder as discussed with SCI • 7. Home care • Rehabilitation • Home evaluation • Support groups

  39. Nursing Care Plan: A Client with a Ruptured Intravertebral Disk LeMone p. 1340 http://wps.prenhall.com/wps/media/objects/737/755395/intervertebral_disk.pdf

  40. Added Critical thinking questions LeMone p. 1340 Nursing Care Plan: A Client with Ruptured Intervertebral Disk • 1. If Marees’ C6-C7 disk is herniated, where does the dermatome for C7 spinal nerve supply? • 2. Is Marees’ anterior or posterior nerve root being compressed by the herniation? • 3. Why is Maree Ivans prescribed both analgesics and muscle relaxants around the clock when awake? • 4. How does a cervical collar help? What else may help relieve the pain? • 5. If the conservative methods did not work, what else might the physician have done? • 6. Why are conservative methods tried for a period of time rather than immediate surgery?

  41. 7. Where is the posterior/anterior nerve root?8. Where is the lamina? 9. Would the Dr use the anterior or posterior surgical route to get to her disk?

  42. LeMone Blackboard: Media Links http://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.html http://www.spine-health.com/

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