INTERVERTEBRAL DISC

PROLAPSE(IVDP)

Is a hydrostatic, load bearing

structure between the

vertebral bodies from C2-3 to

L5-S1 .

Nucleus pulposus + annulus

fibrosus

Is relatively avascular.

L4-5, largest avascular

structure in the body.

U

.

.

Vital Functions of the IVD

Restricted intervertebral joint motion

Contribution to stability

Resistance to axial, rotational, and bending load

Preservation of anatomic relationship

Is a medical condition affecting the spine in

which a tear in the outer, fibrous ring (annulus

fibrosus) of an intervertebral disc allows the

soft, central portion (nucleus pulposus) to bulge

out beyond the damaged outer rings.

posterolateral disc herniation –

protrusion is usually posterolateral into vertebral canal, compress the roots of a spinal nerve.

protruded disc usually compresses next lower nerve as that nerve crosses level of disc in its path to its foramen. (eg.protrusion of fifth lumbar disc usually affects S1 instead.

central (posterior) herniation:

less frequently, a protruded disc above second lumbar vertebra may compress spinal cord itself or or may result in cauda equina syndrome.

lateral disc herniation:

may compress the nerve root above the level of the herniation

L4 nerve root is most often involved & patient typically have intense radicular pain.

TYPES OF HERNIATION

Degeneration

Loss of fluid in nucleus pulposus

Protrusion

Bulge in the disc but not a complete rupture

Prolapse

Nucleus forced into outermost layer of annulus fibrosus- not a complete rupture

Extrusion

A small hole in annulus fibrosus and fluid moves into epidural space

Sequestration

Disc fragments start to form outside of the disc area.

CLASSIFICATIONS OF HERNIATIONS

Schematic illustration

a) Normal

b) Bulging disk

c) Focal bulge or protrusion. The

nucleus material remains within the

outermost fibres of the annulus

fibrosus.

d) Prolapse or extrusion.

The nucleus material has penetrated

the annulus fibrosus but is contained in

front of the posterior

longitudinal ligament.

e) Sequester or free fragment.

Repetitive mechanical activities – Frequent bending, twisting,

lifting, and other similar activities without breaks and proper

stretching can leave the discs damaged.

Living a sedentary lifestyle – Individuals who rarely if ever engage

in physical activity are more prone to herniated discs because the

muscles that support the back and neck weaken, which increases

strain on the spine.

Traumatic injury to lumbar discs-

commonly occurs when lifting while bent at the waist, rather

than lifting with the legs while the back is straight.

CAUSES

Obesity – Spinal degeneration can be quickened as a result of the

burden of supporting excess body fat.

Practicing poor posture – Improper spinal alignment while sitting,

standing, or lying down strains the back and neck.

Tobacco abuse – The chemicals commonly found in cigarettes can

interfere with the disc’s ability to absorb nutrients, which results

in the weakening of the disc.

CAUSES

NORMAL DISC HERNIATED DISC

symptoms of a herniated disc can

vary depending on the location of the herniation and the types of soft tissue that become involved.

Herniated discs are not diagnosed immediately, as the patients come with undefined pains in the thighs, knees, or feet.

Location

The majority of spinal disc herniation cases occur in lumbar

region (95% in L4-L5 or L5-S1).

The second most common site is the cervical region (C5-C6, C6-

C7).

The thoracic region accounts for only 0.15% to 4.0% of cases.

Diagnosis is based on the history, symptoms, and physical

examination.

DIAGNOSIS

X-Ray : lumbo-sacral spine;Narrowed disc spaces.

Loss of lumber lordosis.

Compensatory scoliosis.

CT scan lumber spine; It can show the shape and size of the spinal canal, its contents, and the

structures around it, including soft tissues.

Bulging out disc.

MRI lumber spine; Intervertebral disc protrusion.

Compression of nerve root.

NARROWED SPACE

BETWEEN L5 AND S1

VERTEBRAE,

INDICATING PROBABLE

PROLAPSED

INTERVERTEBRAL DISC -

A CLASSIC PICTURE

Complications

Cauda equinasyndrome

Chronic pain

Permanant nerve injury

Paralysis

TREATMENT OPTIONS

Pain medications.

Bed rest

Oral steroids .

Nerve root block .

Surgery

Non-steroidal anti-inflammatory

drugs (NSAIDs).

Eg- Aspirin, Ibuprofen

Oral steroids

(e.g. prednisone or methylprednisolone).

Benzodiazepines( lowerdose)

Epidural cortisone injection.

Indicated treatment.

Physical therapy include modalities to

temporarily relieve pain (i.e. traction, electrical

stimulation massage).

Patient education on proper body mechanics.

Weight control.

Tobacco cessation.

Lumbosacral back support.

TREATMENT

surgerySurgery is generally considered only as a last resort,

or if a patient has a significant neurological deficit.

The presence of cauda equina syndrome is

considered a medical emergency requiring

immediate attention and possibly surgical

decompression.

The indications for surgery

1

• persistent pain and signs of sciatic tension after 2–3 weeks of conservative treatment.

2

• a cauda equina compression syndrome – this is an emergency;

3

• neurological deterioration while under conservative treatment;

INTRADISCAL ELECTROTHERMIC THERAPY (IDET)

It is a fairly advanced procedure in

which electrothermal catheter is

inserted to the intervertebral disc heats

the posterior annulus of the disk,

causing contraction of collagen fibers

IDET is a minimally invasive outpatient

surgical procedure developed over the

last few years to treat patients with

chronic low back pain that is caused by

tears or small herniations of their

lumbar discs.

NUCLEOPLASTY

Nucleoplasty is the most advanced form of percutaneous discectomy developed to date.

Tissue removal from the nucleus acts to “decompress” the disc and relieve the pressure exerted by the disc on the nearby nerve root

DISCECTOMY/MICRODISCECTOMY -

This procedure is

used to remove part

of an intervertebral

disc that is

compressing the

spinal cord or a nerve

root.

CHEMONUCLEOLYSIS-

Chemonucleolysis is the term

used to denote chemical

destruction of nucleus pulposus

[Chemo+nucleo+lysis].

This involves intradiscal

injection of

chymopapain which causes

hydrolysis of he cementing

protein of the nucleus pulposus.

This causes decrease in water

binding capacity leading to

reduction in size and drying the

disc.

LAMINECTOMY-

Removes the lamina

part to relieve spinal

stenosis or nerve

compression

LUMBAR FUSION

Fusion surgery helps two or

more bones grow together

into one solid bone. Fusion

cages are new devices,

essentially hollow screws

filled with bone graft, that

help the bones of the spine

heal together firmly.

lumbar fusion is only

indicated for recurrent

lumbar disc herniations, not

primary herniations

DISC ARTHROPLASTY

Artificial Disc Replacement (ADR), or Total Disc Replacement (TDR), is a type of arthroplasty.

It is a surgical procedure in which degenerated intervertebral discs in the spinal column are replaced with artificial devices in the lumbar (lower) or cervical (upper) spine.

Used for cases of cervical disc herniation

Assessment

determining the onset,

location, and radiation of pain,

paresthesias, limited movement,

diminished function of the neck, shoulders, and

upper extremities

NURSING MANAGEMENT

explanations about the surgery and reassurance that surgery

will not weaken the back.

Preoperative assessment also includes an evaluation of

movement of the extremities as well as bladder and bowel

function

To facilitate the postoperative turning procedure, the patient

is taught to turn as a unit (called logrolling)

Encouraged to take deep breaths, cough

PROVIDING PREOPERATIVE CARE

Vital signs are checked frequently and the wound is

inspected for hemorrhage

IV morphine -24-48

Sensation and motor strength of the lower extremities

are evaluated at specified intervals, along with the

color and temperature of the legs and sensation

of the toes.

Assess for CSF leakage

ASSESSING THE PATIENT AFTER SURGERY

Assess for paralytic ileus

Assess for urinary retention

Acute pain related to the surgical procedureNursing Interventions

The patient may be kept flat in bed for 12 to 24 hours in cervical

surgery

Pillow is placed under the head and the knee rest is elevated slightly

to relax the back muscles( cervical surgery)

Extreme knee flexion must be avoided

Administering the prescribed postoperative analgesic agent,

positioning for comfort, and reassuring the patient that the pain can

be relieved.

NURSING DIAGNOSIS

Impaired physical mobility related to the postoperative

surgical regimen

Nursing interventions

provide cervical collar cervical collar

provide L-S binders

The neck should be kept in a neutral(midline) position

Patients are assisted during position changes(log rolling )

Deficient knowledge about the postoperative course and home care management

INTERVENTIONS

A cervical collar is usually worn for about 6 weeks.

Instructed about strategies for pain management and about signs and symptoms of complications

The nurse assesses the patient’s understanding of these management strategies

advised to avoid heavy work for 2 to 3 months after surgery.

Exercises are prescribed to strengthen the abdominal and erector spinal muscles

Avoid sitting/standing for prolonged periods

Avoid twisting movements

Regular follow up