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Module 8 Neurosensory : Herniated Disc and Spinal Cord tumors. Spinal Cord Anatomy. spinal cord anatomy. Spinal Cord Anatomy. Pathophysiology /Etiology. Function of disc is to allow for mobility of the spine and act as shock absorber. Pathophysiology /Etiology. - PowerPoint PPT Presentation
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Spinal Cord Anatomyspinal cord anatomy
Spinal Cord Anatomy
Pathophysiology/Etiology
Function of disc is to allow for mobility of the spine and act as shock absorber
Pathophysiology/Etiology
Located between vertebral bodies
Composed of nucleus pulposus a gelatinous material surrounded by annulus fibrosis- a fibrous coil
Pathophysiology/Etiology
Spinal nerves come out between vertebra
Herniated DiscHerniated nucleus pulposus, slipped disc,
ruptured discHNP- annulus becomes weakened/torn and the
nucleus pulpsus herniates through it.Risk Factors-Standing erect- cumulative effect and daily stressAging changes in disc and ligaments,
osteoarthritisPoor body mechanicsOverweightTrauma
Common Manifestations/Complications
HNP compressesSpinal nerve (sensory or
motor component) as it leaves the spinal cord
Or the cord itself- the white tracts within the cord- rare
Common Manifestations/ComplicationsSensory 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
Common Manifestations/Complications Lumbar HNPMost 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
herniated disc L4-L5
Other Symptoms Lumbar HNP:Postural changesUrinary/male sexual function changesParesis or paralysisFoot dropParesthesiasNumbnessMuscle spasmsAbsent cord reflexes
Common Manifestations/Complications Cervical HNPC5-C6 disc- affects the 6th cervical nerve
root
Pain- neck, shoulder, anterior upper arm to thumb
Absent/diminished reflexes to the armMotor changes- paresis or paralysisSensory- paresthesias or painMuscle spasms
Therapeutic Interventions- Diagnostic Tests
X-ray identify deformities and narrowing of disk space
CT/MRIMylogram p1336Nerve conduction
studies (EMG) to detect electrical activity of skeletal muscles
Treatment- ConservativeBed 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
Treatment- ConservativeHeat/cold therapy to decrease muscle
spasmsBreak the pain-spasm-pain cycleUltrasound, massage, relaxation techniquesProgressive mobilization with approved
exercise program –includes abdominal/thigh strengthening
Teaching good body mechanicsWeight lossTENS unit
Treatment- SurgeryLaminectomy- removal of a portion of the
lamina to relieve pressure and to get to the herniated nucleus pulposus that is protruding out
herniated disc repair
Treatment- SurgerySpinal fusion removes most of the disc and
replaces it with bone usually from the patient iliac crest
Flexibility is lost at the site- requires longer hospital stay
spinal fusion
Treatment- SurgeryForaminotomy
Enlargement of the bony overgrowth at the opening which is compressing the nerve
Microdiskectomy 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
Prevention of HNPBack school approach-
Causes of HNPLearn how to prevent Good body mechanicsExercises to strengthen leg and abdominal
muscles
Change in life-style or occupation
Nursing Assessment Specific to HNP Health HistoryAssess for risk factors- The cumulative effect of standing erect
and daily stress Aging changes in disc/ligaments Poor body mechanics OverweightTraumaEmployment History of pain and other neuro changes
Nursing Assessment Specific to HNP Physical Exam Use similar methods to assess as utilized
SCI
Muscle strength and coordinationSensation- sharp/dull of paperclip using
dermatome as referencePain evaluation- pain scalePre/Post-op assessment
Post-Op Assessment for HNP
Sensory/motor assessment- care not to injure op site
Assess for CSF drainage or bleeding from op site
Encourage turn (log roll, cough, deep breath)
Assess for postural hypotension, especially if client was on bed rest for several days/weeks prior to surgery
Post-op Assessment for HNPIf Anterior Cervical-
Assess injury to the carotid, esophagus, trachea, laryngeal nerve (speech- hoarseness)
Assess respiration, neck size, swallowing and speech
If Post-Op Lumbar- Assess bowels sounds, voiding. Minimize stress of post-op site- flat with pillow
between knees, log roll, etc
Nursing Problems/Interventions 1. Acute PainPost 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
2. Chronic PainSurgery may not relieve pain
Nonpharmalogical methods to control pain
Pain clinic
3. ConstipationAs a result of bed rest and decreased
mobility and fear of pain with straining of stool
Constipation prevention methods– fluids, diet, etc
4. Home CareWhen riding in a car, take frequent stops
to move and stretchPrevention– Back school approachMay have to deal with pain as a chronic
conditionMay need to make life/job changes
Spinal Cord Tumors 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
Classification of Spinal Cord Tumors by Anatomical AreaIntramedullary- arise from neural
tissues of the spinal cord
Extramedullary- arise from tissues outside the spinal cord may be benign or malignantIntradural-from the nerve roots or meninges in
subarachnoid spaceExtradural- from the epidural tissue or
vertebra
Classification of Spinal Cord Tumors by OriginPrimary-
originating in the spinal cord or meninges that is not relieved by bed rest
Secondary- metastases from other parts of the body
Spinal Cord TumorsMost 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
Common Manifestations/ComplicationsSymptoms depend on the anatomical level of
the spinal column, the anatomical location, the type of tumor and the spinal nerves affected
Pain that is not relieved by bed rest is the most common presenting symptom
Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor
Common Manifestations/ComplicationsManifestations of thoracic cord tumor
Paresis & spasticity of one leg then the otherPain back & chest, not relieved by bedrest Sensory changes Babinski reflexBowel (ileus); bladder dysfunction (UMN in
type)
Therapeutic Interventions
Diagnostic tests include:X-ray of the spinal columnMyelogramLumbar puncture with CSF analysis
Therapeutic InterventionsMedications 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
Therapeutic InterventionsSurgery 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
Nursing AssessmentHealth history
Pain, motor and sensory changes, bowel and bladder changes, Babinski reflex.
Physical examSimilar to physical assessment for HNP
Nursing Problems/Interventions1. Anxiety
Metatastic tumor vs benign spinal cord tumorEducation and support system
2. Risk for constipationFrom spinal cord compression, narcotics, bed
restAdjust fluid and diet
Nursing Problems/Interventions3. Impaired physical mobility
From bed rest and motor involvementBasic nursing- ROM, etc
4. Acute painFrom compression or invasion of tumorAssess and treat
5. Sexual dysfunctionMale sacral reflex ark (S 2,3,4) interferenceSimilar care as discussed with SCI
Nursing Problems/Interventions6. Urinary retention
Reflex arc (S2,3,4) interference can cause neurogenic bladder as discussed with SCI
7. Home careRehabilitationHome evaluationSupport groups
Nursing Care Plan: A Client with a Ruptured Intravertebral Disc
http://wps.prenhall.com/wps/media/objects/737/755395/intervertebral_disk.pdf
Added Critical thinking questions Nursing Care Plan: A Client with Ruptured Intervertebral Disc1. 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?
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 disc?
LeMone Blackboard: Media Links
http://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.html
http://www.spine-health.com/