ADULT SPINE DISORDERS

1. ADULT SPINE DISORDERS

2. Objectives • Discuss the anatomy of the spine in relation to fractures or degenerative disease. • Identify common nursing goals in care of the adult spine patient. • Describe typical nursing concerns for a post-op spine patient.

3. Anatomy • Bony = Vertebrae • Soft tissue = Discs, ligament • Cord & Nerve Roots

4. Definitions Cervical (7) Thoracic (12) Lumbar (5) Sacral (5)-fused

5. Definitions con’t • Normal Curve-”S shaped” looking from lateral view • Scoliosis – abnormal lateral curve with rotation of vertebrae as well • Kyphosis- anterior curvature of thoracic spine • Radicular- referred pain from pressure on spinal nerve root

6. Spine Fracture • Etiology: • Trauma vs non traumatic • Elderly – Tumors, metabolic, renal, thyroid • Stable vs unstable • Neurologic status

7. 3 Column Theory • Any 2 = unstable Posterior third Middle Third Anterior Third Anterior

8. Fractured C-Spine Examples • Odontoid • Hangman’s • Tear drop • Jefferson’s

9. Odontoid • Type I • Type II • Most difficult to heal-shown • Type III

10. Hangman’s • Hyperextension and distraction • Injury occurs in anterior portion of C2 vertebrae • Piths spinal cord

11. Tear Drop • Hyperflexion • Anterior Ligament pulls off corner of anterior vertebrae • UNSTABLE

12. Jefferson’s Fracture • Burst fracture of C1, disrupting the ring of the atlas • Spinal canal is widened • 50% - NO neuro deficits • Occasionally requires fusion of occiput to C1

13. Complications • Atlanto-occipital dislocation • Neurologic damage • Permanent or temporary below level of bony injury • Death

14. Diagnostic Studies Needed • X-ray 2 planes • AP & x table lateral • May need swimmer’s view for ? Otontoid fx • Flexion Extension • C-spine Ligamentous injury • Spasm 10-14 days

15. Diagnostic Studies Needed con’t • CT scan • MRI if nerve injury suspected

16. Therapeutic Modalities • Log roll • Specialty beds • Braces • Surgery

17. Surgical Spinal Fixation • Halo • Posterior Spinal fusion • Rods, Hooks, Screws • Anterior Spinal fusion • Plates, Cage

18. Nursing Interventions • Neurologic Status Documentation • Sensation level • Motor function • Spasm • Nursing / Body Mechanics • Communication of findings key!!

19. Neurologic Status Documentation Sensation Levels • Sensation levels • Shoulder = C-5 • Nipple T-4 • Umbilicus T-10 • Great toe L-4

20. Neurologic Status Documentation Motor Function • Motor Function • EHL toe extension L4-5 • Tighten Anus S 3-5 • Thumb pointing up, index finger straight ahead C-6-8

21. Nursing Considerations • Cast Syndrome • Potentially life threatening syndrome caused by hyperextension of lumbar spine that results in compression of the superior mesenteric artery-bowel ischemia • Brace use / skin care / pin care • Activity / Bowels / Nutrition

22. Nursing Considerations • Home Care Instructions • Neurovascular symptoms to report • Brace use • Surgical care

23. Question #1 Joshua, 19, was involved in a motor vehicle crash, unbelted. He reportedly has an L-2 burst fracture. As his nurse, you would: A. Have him use the trapeze to lift himself in bed. B. Log roll him side to side as a unit. C. Have him sit first then dangle his legs to prevent dizziness. D. Boost him with help lifting under his armpits.

24. Answer #1 Joshua, 19, was involved in a motor vehicle crash, unbelted. He reportedly has an L-2 burst fracture. You will : b. Log roll him side to side as a unit. Rationale: Log rolling a spine patient is essential to prevent further neurological impairment

25. Question #2 Joshua is taken emergently to the OR for decompression and posterior spinal fusion. His post-op orders call for a TLSO. Which of the following instructions about TLSO care is correct? a. Red and purple marks on skin under brace are normal. b. It is acceptable to wear it loose. c. Take it off when ever you are standing upright. d. Report any vomiting or abdominal pain immediately.

26. Answer #2 Joshua is taken emergently to the OR for decompression and Posterior spinal fusion. His post-op orders call for a TLSO. Which of the following statements are true? D. Report any vomiting or abdominal pain immediately. Rationale: Vomiting or abdominal pain might indicate compression against the abdominal cavity, causing vomiting and abdominal pain.

27. Spondylolysis / Spondylolisthesis • Define: • Spondylo = vertebrae • Lysis = broken • Listhesis = slipped forward

28. Spondylolysis / Spondylolisthesis • M = F Teens or Elderly • Genetics, stress, degenerative • Gymnasts, football lineman, weight lifters • Elderly OA of facets > loose joints, repetitive stress on vertebrae

29. Spondylolysis / Spondylolisthesis • Chronic or acute LBP • Often radicular in nature • Exam • Spasms + SLR • Tight hamstrings

30. Spondylolysis / Spondylolisthesis • Treatment- Conservative • Rest 3 days maximum!! /Back Brace • Analgesics / Antispasmodics / ice or heat • Physical therapy / Back School (Education) • Avoid painful activities

31. Spondylolysis / Spondylolisthesis • PSF with or without instrumentation • ASF for severe slips or failed PSF

32. Question #3 The surgeon has chosen to fix a spine with pedicle screws and posterior spinal fusion. During a post-op nursing assessment, which one of the following would be urgently reported to the surgeon? a. Absent or sluggish bowel sounds. b. Pain and spasm in lower mid back. c. Inability to feel side of left thigh or move left leg. d. Burning on urination.

33. Answer #3 The surgeon has chosen to fix a spine with pedicle screws and posterior spinal fusion. During pre-op nursing assessment you note this (these) urgently reportable changes related to fracture site. C. Inability to feel side of left thigh or move left leg Rationale: This would be indicative of neurological impairment and are essential to be reported immediately. The other problems are expected and/or not emergent.

34. Herniated Nucleus Pulposa • M > F 20-45yrs • Etiology • Degeneration • Abnormal body mechanics • Deconditioned - Poor muscle tone • Trauma

35. Herniated Nucleus Pulposa • History- Some Event • Back and leg pain • Numbness and/or dysesthesias • Muscle weakness-nerve distribution • ^ with sitting / sneezing, coughing • Worse with valsalva

36. Herniated Nucleus Pulposa • Exam “Classic Sign” • Painful SLR • Won’t lean forward • Change in sensation, strength or reflexes • Bowel or Bladder changes

37. Herniated Nucleus Pulposa • Radiographs / MRI /EMG

38. Herniated Nucleus Pulposa • Treatment- Conservative (80%) • Rest 3 days max • Analgesics / Antispasmodics / ice or heat • Physical therapy / Education • Avoid painful activities • Epidural Steroids • Surgical • Laminectomy no fusion

39. Question #4 Fred c/o pain, which is horrible if he sneezes. He can’t even sit in his car. He was dx with a herniated disc, hates hospitals & wants to know what else can be done besides surgery. Which of the following is the best response? a. Rest, analgesics, antispasmodics, and back care education help 80% of the people. b. He should continue all activity even if it is painful for 3 days. c. There is no other treatment. He needs a fusion. d. Steroid injection it works 100% of the time.

40. Answer #4 Fred c/o pain, which is horrible if he sneezes. He can’t even sit in his car. He was dx with a herniated disc, hates hospitals & wants to know what else can be done besides surgery. You explain: A. Rest, analgesics, antispasmodics, and back school help 80% of the people. Rationale: For this type of problem, conservative treatment is the most beneficial.

41. Degenerative Disc Disease • M >F Not Always Elderly •  water content in disc • Annular ligament fiber failure • Hx: back pain w/ activities for a while • May have radicular symptoms

42. Spinal Cord Problems • SCI • Spinal Stenosis

43. Spinal Cord Injury • Traumatic M>F • Complete vs Incomplete • Meaning some sparing of neurological function, either sensory or motor • Level is everything!

44. Levels • Spinal Cord – C1-L1 • Conus Medularis Dist spinal cord • Bowel Bladder • Cauda Equina Lesions = Roots below Conus L-2

45. Spinal Stenosis • Etiology: congenital vs acquired (degenerative) • Lumbar region most common • Also called neurogenic claudication

46. Spinal Stenosis • Back pain, leg pain when upright • Walking usually makes symptoms worse-“neurogenic claudication” • Relieved by bending, sitting • Nocturnal leg cramps

47. Spinal Stenosis • Exam normal • Can be abnormal if severe hypertrophy of bone in foramen, causing nerve root compression • Check pulses r/o PVD- may need ABIs • Check for hip OA • X-ray: normal for age but may demonstrate hypertrophy of bone in foramen • MRI to eval. nerves

48. Spinal Stenosis Treatment • Activity modification • Altered expectations • Therapy to improve endurance, strength • Epidural steroids • Surgery: Decompression • +/- fusion

49. Degenerative Scoliosis • Lateral curvature of the spine • 40-50 ° may require surgery • Etiol: Degenerative disc

50. Kyphosis (45°) • Posterior “hump” thoracic region • Etiology • Congenital • Scheuermann’s disease • Neuromuscular • Ankylosing spondylitis • Metabolic (Osteoporosis) • Tumor