Prolapse Lumbar Disc

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PROLAPSE LUMBAR DISC

- also known as slipped disc, spinal disc herniation,

orprolapsus disci intervertebralis

- a tear in the outer, fibrous ring of an intervertebral

disc allows the soft, central portion to bulge out


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PATHOPHYSIOLOGY

Risk Factors:

1. Men

2. Increasing Age

3. Obesity

4. Degenerative Disorders

5. Trauma

6. Congenital Predisposition

Rupture ofAnnulus Pulposus(discs outer ring)


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PATHOPHYSIOLOGY

Protrusion of a portion of theNucleus pulposus

(soft, gelatinous inner part)

Pressure on spinal nerve roots

Signs and Symptoms


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SIGNS AND SYMPTOMS

Varies with the location and degree of herniation

and the course of its progression

Some are asymptomatic


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SIGNS AND SYMPTOMS

Back pain

- In lumbar herniation, often radiating down the

posterior thigh and leg, exacerbated by coughing,

sneezing, and straining

Motor and Sensory Impairment

- Muscle weakness, diminished deep tendon

reflexes in the lower extremitiespin and needle prick sensation


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SIGNS AND SYMPTOMS

Nerve Root Pain (Sciatica)

- In lumbar disc herniation, pressure on the sciatic

nerve produces severe, sometimes debilitating

pain

- Pain may also be felt on the lower extremities

since the Sciatic nerve extends to the gluteal area,

going down the posterior leg.


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SIGNS AND SYMPTOMS

Cauda equina syndrome

- Rare but a medical emergency where the nerves

at the very bottom of the spinal cord are pressed

on

- Causes low back pain and disturbances in bowel

and bladder function


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DIAGNOSTIC STUDIES

Straight-leg raising test or the LeSegue test result

is positive.

CT, MRI, or Myelography may reveal the locationof herniation.


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NURSING MANAGEMENT

Administer prescribed medications.

- May include muscle relaxants, narcotic or non-

narcotic analgesics

Provide on-going assessment.

- Assess the site, nature, course, and progress of

back pain

- Monitor motor and sensory status


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NURSING MANAGEMENT

Provide conservative management, if indicated.

- Encourage bed rest

- Position the patient with the head of bed

elevated at 30 degrees and knees slightly flexed- Apply heat

- Instruct in appropriate exercises to increase

muscle strength around the spinal cord (e.g. Pelvic

tilts, straight-leg raises)


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NURSING MANAGEMENT

- Keep the patient in proper body alignment when in

bed (provide firm mattress) and when turning

(use log-rolling technique)

- Teach proper body mechanics


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NURSING MANAGEMENT

Maximize functional abilities.

- Prevent complications of immobility

- Coordinate with a physiotherapist, chiropractor,

or osteopath for manipulation and other physicaltreatments

- Promote self-care


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NURSING MANAGEMENT

Provide preoperative and postoperative care if

Discectomy is ordered

Pre-operative Nursing Interventions:

a.1. Avoid taking aspirin or aspirin-containing products for 2 weeks prior to

surgery unless approved by physician

a.2. Discontinue nonsteroidal anti-

inflammatory medications 48 to 72 hoursbefore surgery


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NURSING MANAGEMENT




a.3. Bring a list of current medications beingtaken

a.4. Wear loose clothing that can easily be

removed (e.g., avoid clothing that pulls on

and off over the head)


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NURSING MANAGEMENT




a.5. Instruct the patient tobathe/shower/shampoo the evening before

or morning of surgery. Men should be

cleanly shaved.

a.6. Instruct the patient on oral intakerestrictions and medication schedule

as ordered


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NURSING MANAGEMENT




a.7. Inform patient that before going to theoperating room he will have to remove:

dentures, eye glasses, contact lenses,

appliances, prosthesis, make-up, nail polish,

hairpins, and undergarments


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NURSING MANAGEMENT



Post-operative Nursing Interventions:

b.1. Monitor vital signs frequently b.2. Activity/diet restrictions

b.3. Nursing personnel must assist with

initial ambulation

b.4. Medications available for pain andnausea upon request


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SURGICAL MANAGEMENT

The primary focus of surgery is to remove

pressure or reduce mechanical compression on

a neural element: either the spinal cord, or a

nerve root.


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SURGICAL MANAGEMENT

Foraminotomy

An incision is made in the back, the muscle peeled

away to reveal the bone underneath, and a small

hole cut into the vertebra itself. Through this hole,

using an arthroscope, the foramen can be

visualized, and the impinging bone or disk

material removed.


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SURGICAL MANAGEMENT

Discectomy

This is the surgical removal of herniated disc

material that presses on a nerve root or the spinal

cord.

The procedure involves removing the central

portion of an intervertebral disc, the nucleus

pulposus, which causes pain by stressing the

spinal cord or radiating nerves.


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THE CASE

Patients Initials: AAAA

Age: 49 years old

Nationality: Indian

Consultant Surgeon: Dr. Khalid Saeed

Date of Admission: 8/6/2011

Diagnosis: Prolapsed Lumbar Disc L4-5 Right


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THE CASE

A 49 years old, Indian male was admitted in the

MDH Surgical Ward with a 3-month history of hip

pain radiating to the feet, occurring alternately

without numbness, paresthesia or motor power

disturbance. He sought conservative treatment in

the past but was unrelieved.

Non smoker, claims no allergies to food and

medications, and with no previously related

medical history.


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THE CASE

Vital signs upon admission:

Temp: 36.8C per orem

Pulse: 86 beats/min

RR: 22 breaths/min

SPO2: 100 %

Bp: 110/70 mmHg

General Appearance:

- Appears thin and not in distress, ambulatory


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THE CASE

Physical Examination:

Head: No significant findings

Chest: Clear breath sounds

Heart: no murmur noted (S1 + S2 + 0)

Abdomen: soft, non tender

Extremeties: No significant findings

Nervous system: GCS = 15, verbally responsive,

conscious and coherent


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THE CASE

Routine and Diagnostic Investigations:

Hgb 14.2

Serum Electrolytes within normal limits

BUN within normal limits

Hepatitis Profile no significant findings

BT within normal limits

RBS within normal limits

Serum Creatinine within normal limits


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THE CASE

Routine and Diagnostic Investigations:

Urinalysis within normal limits

PT and INR within normal limits

Chest X-ray no significant findings

ECG no significant findings

MRI Disc dehydration and

minor posterior disc bulge

and annular tear at L5/S1

but no significant foramen

or canal narrowing


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THE CASE

Course in the Surgical Ward:

June 8, 2011

Patient was kept on bed rest. Normal diet wasgiven. Vital signs were taken. All Pre-operative

investigations were done. He was started on

antibiotics and pain relievers and was posted for

Discectomy on 9/6/2011.


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THE CASE


June 9, 2011

Patient was shifted to Operating Theater at0900H. At 1300H, patient was received from the

recovery room, status post Fenestration and

Discectomy L4-5 with Foraminotomy. He had IVF

of DNS 500 cc to run for 6 hours, with Porto-Vacdrain, and Foleys catheter connected to urobag.


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THE CASE


June 9, 2011

He was placed on hard mattress, on complete bedrest. Vital signs, intake and output were

monitored. On antibiotics of Cefizox 1 gm 1 vial IV

BID, and Tavanic 500 mg 1 vial IV OD, with pain

reliever Tramal 50 mg 1 amp IM BID, and Olfen 75mg 1 amp IM BID. At 2100H, he was placed on

liquid diet as tolerated.


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THE CASE


June 10, 2011 (1st POD)

Dressing was mildly soakedPVAC drained to 30 cc, blood stained

FC 900 cc clear

Vital Signs are stable, not in distress


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THE CASE


June 11, 2011 (2nd POD)

Started ambulation exercisesSurgical dressing was changed, Wound appears

clean

FC was removed

PVAC drained to 7 cc, serous


Started with normal diet and oral medicines


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THE CASE


June 12, 2011 (3rd POD)

Ambulation was well-tolerated(+) non productive cough noted

Surgical dressing was changed, Wound appears

dry and clean

PVAC drained to 10 cc, serous



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THE CASE


June 13,2011 (4th POD)

Vital Signs are stable, not in distressPVAC was removed

June 14, 2011 (5th POD)


Defecated


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THE CASE


June 15, 2011 (6th POD)

No pain as verbalizedAmbulated

Wound is clean and dry

For discharge


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THE CASE

Discharge Orders:

Celebrex 1 tab BID for 15 days

Sirdalud 2 mg 1 tab BID for 15 daysDorofen cap 1 tab TID for 30 days

Osteocare 1 tab BID for 30 days

Tavanic 500mg 1 tab OD for 5 days

Sickleave for 6 weeks

Follow up after 1 week


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Prolapse Lumbar Disc