HERNIATED NUCLEUS PULPOSUS

I. Definition

Herniated Nucleus Pulposus (HNP) is defined as the protrusion of nucleus pulposus (central part of intervertebral disc) into spine causing compression of spinal nerve roots. It occurs when all or part of the spinal disk is forced through a weakened part of the disk which places pressure on nearby nerves. The compression of the nerve roots as well as the affectation of the adjacent nerves result in back pain and nerve root irritation.

The disease can also be called as to the following:- Lumbar radiculopathy

- Cervical radiculopathy

- Herniated intervertebral disk

- Prolapsed intervertebral disk

- Slipped disk

- Ruptured disk

- Herniated Disc

The disease is considered as radiculopathy since it affects spinal nerve roots.  A herniated disk is one cause of radiculopathy. It is specifically called as sciatica.

II. Pathophysiology

a. Anatomy and Physiology

The intervertebral disc is the largest avascular structure in the body. It arises from notochordal cells between the cartilaginous endplates, which regress from about 50% of the disc space at birth to about 5% in the adult, with chondrocytes replacing the notochordal cells. Intervertebral discs are located in the spinal column between successive vertebral bodies and are oval in cross section. The height of the discs increases from the peripheral edges to the center, appearing as a biconvex shape that becomes successively larger by about 11% per segment from cephalad to caudal (ie, from the cervical spine to the lumbosacral articulation). A longitudinal ligament attaches to the vertebral bodies and to the intervertebral discs anteriorly and posteriorly; the cartilaginous endplate of each disc attaches to the bony endplate of the vertebral body.

The disc's annular structure is composed of an outer annulus fibrosus, which is a constraining ring that is composed primarily of type 1 collagen. This fibrous ring has alternating layers oriented at 60° from the horizontal to allow isovolumic rotation. That is, just as a shark swimming and turning in the water does not buckle its skin, the intervertebral disc has the ability to rotate or bend without a significant change in volume and, thus, does not affect the hydrostatic pressure of the inner portion of the disc, the nucleus pulposus.

The nucleus pulposus consists predominantly of type II collagen, proteoglycan, and hyaluronan long chains, which have regions with highly hydrophilic, branching side chains. These negatively charged regions have a strong avidity for water molecules and hydrate the nucleus or center of the disc by an osmotic swelling pressure effect. The major proteoglycan constituent is aggrecan, which is connected by link protein to the long hyaluronan. A fibril

network, including a number of collagen types along with fibronectin, decorin, and lumican, contains the nucleus pulposus.

The hydraulic effect of the contained, hydrated nucleus within the annulus acts as a shock absorber to cushion the spinal column from forces that are applied to the musculoskeletal system. Each vertebra of the spinal column has an anterior centrum or body. The centra are stacked in a weightbearing column and are supported by the intervertebral discs. A corresponding posterior bony arch encloses and protects the neural elements, and each side of the posterior elements has a facet joint or articulation to allow motion.

The functional segmental unit is the combination of an anterior disc and the 2 posterior facet joints, and it provides protection for the neural elements within the acceptable constraints of clinical stability. The facet joints connect the vertebral bodies on each side of the lamina, forming the posterior arch. These joints are connected at each level by the ligamentum flavum, which is yellow because of the high elastin content and allows significant extensibility and flexibility of the spinal column.

Clinical stability has been defined as the ability of the spine under physiologic load to limit patterns of displacement so as to avoid damage or irritation to the spinal cord or nerve roots and to prevent incapacitating deformity or pain caused by structural changes. Any disruption of the components holding the spine together (ie, ligaments, intervertebral discs, facets) decreases the clinical stability of the spine. When the spine loses enough of these components to prevent it from adequately providing the mechanical function of protection, surgery may be necessary to reestablish stability.

b. Incidence

Approximately 80% of HNPs occur in the lumbar region. Approximately 20% of HNPs occur in the cervical region and 20-33% of these

have concurrent lumbar disc involvement.     The age-incidence curve for lumbar HNP peaks in the second through fourth

decades of life and the incidence is higher in males than females. The age-incidence curve for cervical HNP peaks in the fifth through sixth decades

of life and the incidence is higher in males than females.   Less than 1% of the HNPs occur in the thoracic region. The age-incidence curve

for thoracic HNP peaks in the fifth through sixth decades of life and the incidence is equal for both sexes.

Pathologic lesions (i.e. spondylosis and spinal stenosis) have been noted in 50% of the cases with lumbar HNP.

c. Causes or Risk Factors

The exact cause of herniated nucleus pulposus is unknown, however, it can be attributed to the following risk factors:

1. Accident or injury. Direct trauma to the vertebra affecting the intervertebral contents.

2. Obesity. Demands extra effort in the weight-bearing functions of the vertebra.3. Activities that strain the back. Disrupts the equal distribution of pressure within

the intervertebral contents.

4. Sex (males). They engage in activities that strains the back.5. Cigarette smoking. Impairs the perfusion of oxygen in the bones affecting bone

strength.6. Aging. Loss of calcium ions affecting bone strength.7. Genetics. mutation in genes coding for proteins involved in the regulation of the

extracellular matrix or the annulus pulposus, such as MMP2 and THBS2, has been demonstrated to contribute to lumbar disc herniation.

d. Pathophysiologic Mechanism

Herniated nucleus pulposus can be traced back from different risk factors. Commonly,

HNP is caused by trauma on the intervetebral discs such as accident or injury, being

overweight and engaging in various activities that demand a lot of effort from the spine.

Accident or injury causes direct trauma on the spine which can also affect or injure the

intervertebral discs. Being overweight, on the other hand, puts on a lot of weight on the spine,

demanding constant exertion of pressure from the spine to carry on the extra weight.

Activities that strain the vertebra is also a very crucial predisposing factors in the

development of HNP since such activities disrupts the equal distribution of pressure on the

intervertebral discs because these activities increase the pressure on the discs. In connection

to the latter, males have higher chances of developing the disease since they engage in such

type of activities more frequently than females. These three factors result in the compression

of the anterior side of the disc. Because of the compression, the contents of the intervertebral

disc, most especially the nucleus pulposus, will be pressed against the already thinned (due to

stretching) annulus pulposus on the posterior part.

It is also highly considered that HNP is caused by general wear and tear such as the

different degenerative changes that occur in aging. These degenerative changes primarily

include loss of calcium from the bones which eventually lead to loss of bone strength. Also,

the effects of smoking is related in this regard since smoking, especially lone-term smoking,

reduces bone strength because of the disruption of oxygen perfusion into the bones given that

the cigarette-smoking can lead to vasoconstriction. The loss of the strength of the bones

compromises the function of the vertebra to protect the different intrevertebral contents, one

of which, the nucleus pulposus. Because of the latter, there will be the asymptomatic

fissuring and fragmentation within the disk which will lead to the compression of one side of

the intervertebral disc and exertion of pressure to the other side. Degeneration of the annulus

pulposus can also be considered which will then disrupts the isovolmic rotation of the

vertebra.

It is also considered that mutation in genes coding for proteins involved in the

regulation of the extracellular matrix or the annulus pulposus, such as MMP2 and THBS2,

has been demonstrated to contribute to lumbar disc herniation. Weak annulus pulposus means

a compromise in the functions of the said structure which then results to a disruption in the

isovolmic rotation of the vertebra.

These factors will eventually lead to the herniation of the disk into the spinal canal or

the neural foramen. Since the outer annulus pulposus suffers from the pressure exerted by the

nucleus polpusus, the latter will then gradually prolapsed through the annulus pulposus

leading to its innervation which will then be manifested by mild to severe back pain that

radiates to the pelvis and the legs. The innervations of the annulus pulposus allow disk

fragment to herniate through it which will then lead to a diminished tension on the annulus

that is manifested by weakness on the affected part. The decrease in the tension of the

annulus leads to its rupture allowing the nucleus pulposus to potrude resulting now to spinal

nerve compression that leads to the different manifestations of HNP. Such manifestations

include back pain that radiates across the buttock and down the leg, weakness of leg and foot

on the affected side, numbness and tingling of toes, Lasegue’s sign, depressed or absent

Achilles reflex, muscle spasm in the lumbar area, shoulder pain that radiates down the arm to

hand, paresthesia and sensory disturbances.

III. Medical Management

a. Laboratory and Diagnostic Procedures

1. Physical Examination and History of Pain

A physical examination and history of pain can indicate the presence of a herniated disk. Often, the pain is most severe at the lower back and it radiates across the buttock and spreads down the leg (along the sciatic side).

Leg pain that occurs when you sit down on an exam table and lift your leg straight up usually suggests a herniated lumbar disk.

2. Neurologic Examination

A neurological examination will evaluate muscle reflexes, sensation, and muscle strength. Often, examination of the spine will reveal a decrease in the spinal curvature in the affected area.

3. Foraminal Compressin test of Spurling

A foraminal compression test of Spurling is done to diagnose cervical radiculopathy. Cervical radiculopathy is considered when increased pain or numbness is felt if the head is bent forward or towards the sides as the healthcare provider applies pressure on the top of the head.

4. Radiography

Radiography refers to the use of X-rays to view a non uniformly composed material such as the human body. By utilizing the physical properties of the ray an image can be developed displaying clearly, areas of different density and composition.

POSSIBLE RESULTS:

a. Plain Radiographs

In cases of disk bulging, plain radiographs reveal indirect findings of disk degeneration in the form of loss of height of the intervertebral disk, vacuum phenomenon in the form of gas in the disk, and endplate osteophytes. Moderate bulges appear as nonfocal protrusion of disk material beyond the borders of the vertebra; this is typically broad based, circumferential, and symmetric.

In most cases of herniated nucleus pulposus (HNP), plain radiographs of the lumbosacral spine or cervical spine are not needed. Plain radiographs do not reveal disk herniation; they are usually used to exclude other conditions (eg, fracture, cancer, infection). When the clinical condition strongly suggests HNP, plain radiographs can be avoided.

b. Myelograph

Myelographic findings in patients with HNP include extradural deformity or displacement of the contrast-filled thecal sac. In addition, myelograms may show elevation, deviation, or amputation of the root sleeve and edema of the affected nerve.

When used in routine practice, magnetic resonance (MR) myelography has been shown to be of limited value. In one study, it assisted in establishing a diagnosis in only a small percentage of cases (6%). The technique was of limited additional value in patients with multilevel pathology, and it was of even less value in patients with scoliosis, for whom it was used to help establish the most likely level to account for the pathology.

c. Spine x-ray

X-ray is a test that uses radiation to produce images of the bones and organs of the body. Spine X-rays provide detailed images of the bones of the spine, and can be taken separately for the three main parts of the spine--cervical (neck), thoracic (mid back) and lumbar (lower back).

Spine X-Ray is done to rule out other causes of back or neck pain. However, it is not possible to diagnose a herniated disk by spinal x-ray alone.

POSSIBLE RESULT: Sagittal view of the cervical spine demonstrating an anterior cervical disc herniation at C2- C3 level, plus osteophyte formation with calcification of the anterior longitudinal ligament. The epiglottis (e) indicates narrowing of the airway (between arrows).

5. Electromyelography (EMG)

Electromyelography involves testing the electrical activity of muscles. Often, EMG testing is performed with another test that measures the conducting function of nerves. This is called a nerve conduction study.

EMG is done to determine the exact nerve root that is involved.

POSSIBLE RESULT: A decrease in the electrical activity of the muscles is highly possible when a patient is suspected of HNP. The presence of spinal nerves in the affected portion of the spine implies the affectation of the functions of the said nerves, one of which, motor functions. These spinal nerves innervate the different muscles of the body, hence, the compression of which leads to decreased release of impulses to the different muscles.

6. Nerve conduction velocity test

Nerve conduction velocity test is a test of the speed of electrical signals through a nerve. The distance between electrodes and the time it takes for electrical impulses to travel between electrodes are used to determine the speed of the nerve signals.

POSSIBLE RESULT: Any peripheral neuropathy can cause abnormal results, as can damage to the spinal cord and disk herniation (herniated nucleus pulposus) with nerve root compression.

7. Computed Tomography

Computed Tomography is a medical imaging method employing tomography created by computer processing. Digital geometry processing is used to generate a three-dimensional image of the inside of an object from a large series of two-dimensional X-ray images taken around a single axis of rotation.

POSSIBLE RESULT: CT has proved to be as good as or even better than myelography alone in the diagnosis of herniated disk. CT scanning with myelography is superior to either one alone.

a. In subligamentous herniation, images show a focal, smooth, outward displacement of the disk margin in the spinal canal, in the neural foramen, or lateral to the neural foramen. CT scans may further demonstrate calcification or, less commonly, gas in the herniation.

b. In disk herniation, CT scans show a soft-tissue mass with effacement of the epidural fat and displacement of the thecal sac. If the fragment is no longer restrained by the PLL but is still in contact with the disk margin, an irregular, lobulated excrescence on the disk margin is seen. A separated disk fragment is often detected in the epidural fat adjacent to the dural sac or sheath of a nerve root. The disk margin may appear normal. The attenuation of the nuclear fragments of a fragmented disk is usually 80-120 HU.

Deformity of the dural sac and nerve sheath, along with the bony changes, help in the diagnosis:

Axial CT myelogram of a large, central calcified disk extrusion present at the T5-6 level. It causes severe spinal cord compression.

Axial CT myelogram shows a posterior central disk extrusion present at the T11-12 level.It compresses the cord.

Sagittal reformatted CT myelogram shows a large, calcified, posterior central disk extrusion causing severe cord compression at the T5-6 level. Axial CT myelogram shows posterior, central disk protrusion present at T11-12 level. Mild cord compression is noted.

8. Magnetic Resonance Imaging (MRI)

Magnetic Resonance Imaging is a method of imaging the interior of structures noninvasively. MRI is important because it is noninvasive, safe, and yields information that cannot be obtained with any other techniques. Its most common use by far is in diagnostic medicine but MRI has other applications, particularly in the oil and food industries.

Spine MRI or spine CT will show spinal canal compression by the herniated disk.

POSSIBLE RESULT: A positive MRI result shows the extruded disc material as a dark mass, and this is the true value of an MRI – revealing the exact location and severity of nerve compression produced by a herniated intervertebral disc.

MRI exquisitely delineates herniated nucleus pulposus (HNP) and its relationship with adjacent soft tissues. On MRI, HNPs appear as focal, asymmetric protrusions of disk material beyond the confines of the anulus. HNPs themselves are usually hypointense. However, because disk herniations are often associated with a radial anular tear, high signal intensity in the posterior anulus is often seen on sagittal T2-weighted images. On sagittal MRIs, the relationship of HNPs and degenerated facets to exiting nerve roots within the neural foramina is well delineated. In addition, free fragments of the disk are easily detected on MRI.

Axial T1-weighted image shows protrusion of a left paracentral disk with compression of left S1 root.

Axial T2-weighted image shows protraction of a left paracentral disk with compression of left S1 root.

Recurrent postoperative disk extrusion at L4-5 after L4-5 diskectomy. Axial and sagittal T1-weighted images obtained before and after contrast enhancement reveal a rim of enhancing, recurrent left central disk extrusion with downward migration.

Right L5 radiculopathy. Sagittal T1-and T2-weighted images show a large, right central disk extrusion at L4-5 that markedly compresses the thecal sac. The extruded disk migrates cranially, compressing the right L5 nerve root.

Right S1 radiculopathy. Axial T1- and T2-weighted images at L5-S1 show a large, right paracentral disk extrusion causing marked compression of the thecal sac. Images show compression, but the right S1 root is not visible. The extruded disk also has mild cranial extension that compresses the right L5 root.

Sagittal T2-weighted imaging of lumbosacral spine shows an annular tear at L4-5 and disk protrusion at the L5-S1 levels.

Sagittal T1- and T2-weighted images and axial T1- and T2-weighted images show degenerative changes at the L1-2 and L2-3 levels, facet hypertrophy at the L4-5 level, and disk herniation leading to extrusion and compressing the left L5 root.

Sagittal T1- and T2-weighted gradient-echo images obtained at C5-6 show a moderate to severe central disk extrusion that causes cord compression with abnormal signal intensity in the cord. Gradient-echo images improve the contrast to distinguish between the hyperintense disk and the hypointense osteophytosis.

In cases of disk bulging, early findings on MRI include loss of the normal posterior disk concavity. Moderate bulges appear as nonfocal protrusions of disk material beyond the borders of the vertebrae; bulges are typically broad based, circumferential, and symmetric.

A radial tear of the anulus fibrosus is considered a sign of early disk degeneration. It is accompanied by other signs of disk degeneration, such as a bulging anulus, loss of disk height, herniation of the nucleus pulposus, and changes in the adjacent endplates. Although a radial tear of the anulus fibrosus can be detected as an area of increased signal intensity on T2-weighted and gadolinium-enhanced MRIs, the association between the annular tear on MRIs and the symptomatic disks is unclear.

b. Pharmacologic Management

A. Analgesics (Drugs for pain)

1. Nonsteroidal Anti-Inflammatory medications (NSAIDs)

These drugs are used for long-term pain control and given to people with a sudden herniated disk caused by some sort of injury (such as a car accident or lifting a very heavy object) that is immediately followed by severe pain in the back and leg.

Mechanism of action: This drug works by blocking the production of prostaglandins, body chemicals that cause inflammation and contribute to the brain’s perception of pain.

2. Narcotic pain killers. May be given if the pain does not respond to anti-inflammatory drugs. And this are drugs taken to relieve discomfort, distinct from anesthetics (drugs that deaden feeling) and sedatives (drugs that aid relaxation or sleep).

Mechanism of action: The precise mechanism of action is unknown although the narcotics appear to interact with specific receptor sites to interfere with pain impulses.

3. Hydrocodone (Vicodin). It works by suppressing the brain’s perception of pain.4. Naproxen (Naprosyn). It blocks the production of certain chemicals called

prostaglandins that may trigger pain and inflammation.

5. Tramadol (Ultram). It produces a pain-killing effect by interfering with the action of chemicals called neurotransmitters that are vital for nerve transmission.

6. Celecoxib (Celebrex). It works as an oxygenase inhibitor.

B. Muscle relaxants

Mechanism of action: These drugs are used to relieve pain by relaxing muscles that are abnormally contracted (in spasm). They serve as a neuromuscular blockers and spasmolytics.

1. Carisoprodol (Soma). It relaxes muscles by blocking the transmission of impulses along certain nerves in the brain stem and the spinal cord.

2. Metaxalone (Skelaxin). The mode of action of this drug has not been clearly identified, but may be related to its sedative properties. Metaxalone does not directly relax tense skeletal muscles in man.

3. Cyclobenzaprine hydrochloride (Flexeril). It works by affecting nerves that control muscles, but it does not interfere with muscle function.

C. Steroids

May be given either by pill or directly into the blood through an IV.

Mechanism of action: This drug travel in the blood that are attached to protein carriers. When steroid hormones arrive at their target cells, they dissociate to their protein carriers and pass through the plasma membrane of the cell. Some steroid hormones bind to specific receptor proteins in the cytoplasm and then move as a hormone receptor complex into the nucleus. Other steroids travel directly into the nucleus encountering their receptor proteins.

Steroid injections(into the back in the area of the herniated disk). These can help control pain for several months. It can also reduce swelling around the disk and relieve many symptoms.

c. Surgical Management

Surgery may be an option for the few patients whose symptoms persist despite other treatments.

1. Diskectomy

Diskectomy is a surgical procedure that removes a protruding disk. This procedure requires general anesthesia (asleep and no pain) and 2-3 day hospital stay. The patient will be encouraged to walk the first day after surgery to reduce the risk of blood clots. Complete recovery takes several weeks. If more than one disk needs to be taken out or if there are other problems in the back besides a herniated disk, more

extensive surgery may be needed. This may require a much longer recovery period. Diskectomy is done when a herniated disk makes a patient suffer from:

Severe leg pain or numbness that badly affects activities of daily living Weakness in muscles of the lower leg or buttocks An inability to control bowel movements or urination

2. Chemonucleolysis

Chemonucleolysis involves the injection of an enzyme (called chymopapain) into the herniated disk to dissolve the protruding gelatinous substance. This procedure may be an alternative to diskectomy in certain situations.

This procedure may be done when the following conditions are met:

History, physical examination, and diagnostic imaging (CT scan, MRI) indicate that the disc is bulging, but the material inside the disc (nucleus) has not ruptured into the spinal canal.

Pain and nerve damage have not improved after at least 4 weeks of nonsurgical treatment.

Symptoms are severe and disabling.

3. Microdiskectomy

Microdiskectomy is a procedure removing fragments of nucleated disk through a very small opening.

Surgery may be considered if tests show that the symptoms are due to a herniated disc and the doctor thinks surgery may help relieve the symptoms. The following factors are often considered when deciding to have surgery.

A history of persistent leg pain, weakness, and limitation of daily activities that has not gotten better with at least 4 weeks of nonsurgical treatment.

Results of a physical examination that show you have weakness, loss of motion, or abnormal sensation (feeling) that is likely to get better after surgery.

Diagnostic testing, such as magnetic resonance imaging (MRI), computed tomography (CT), or myelogram, that indicates your herniated disc would respond to surgery.

4. Laminectomy

This type of surgery is the most often performed. It is the removal of the part of the vertebral lamina. The surgery is done to relieve pressure on the nerves.

When the spinal cord or other nerves get irritated, they can cause weakness, numbness and pain in the arm or leg.

5. Spinal fusion

This is a procedure that involves the insertion of a wedge-shaped piece of bone chips between the vertebrae to stabilize them. The bone is usually taken from from a client donor site such as the iliac crest.

Spinal fusion may be recommended for persistent pain that does not get better with other treatments. It may be done in the following cases:

Along with other surgical procedures for spinal stenosis, such as foraminotomy or laminectomy

After diskectomy in the neck Injury or fractures to the bones in the spine Weak or unstable spine caused by infections or tumors Spondylolisthesis, a condition in which one vertebrae slips forward on top

of another Abnormal curvatures, such as those from scoliosis or kyphosis

6. Foraminotomy

Foraminotomy is the enlargement of the opening between the disk and facet joint to remove bony overgrowth compressing the nerve. The location and size of the incision is according to the physicians preference and location and size of the ruptured disk. The posterior approach is taken for lumbar surgery.

c. Supportive Management

1. Diet and exerciseDiet and exercise must be encouraged to the patient since they are crucial and

improving back pain. This is because extra weight being carried by an individual makes back pain worse.

Exercise, also, may help improve posture. Appropriate exercise can help take pressure off inflamed nerve structures, while improving overall posture and flexibility.

2. Physical therapy

Physical Therapy is important for it works on strengthening the muscles of the abdomen and lower back to help support the spine. Flexibility of the spine and legs is taught in order to gradually aid in the resumption of the normal functions of the spine and the back. This can be achieved by the physical therapists’ performance of diathermy (project heat deep into the tissues of the back) or manual therapy especially if the mobility of the spine is impaired.

3. Back braces

Back braces help support the spine by aiding the spine to bear the weight of the head. However, overuse of these devices can weaken the abdominal and back muscles leading to a worsening of the problem. This, nevertheless, can be addressed by using weight belts which are helpful in preventing injuries.

4. Traction

Traction is used to decrease pressure on the affected disk and may also address muscle spasms. However, it does not directly reduce the HNP.

5. Use of devices

a. A lumbar support can be helpful for a herniated disk at this level as a temporary measure to reduce pain and improve posture.

b. Bed rest on firm mattress with bed boards.

6. Prevention of complication of immobility

Health care providers must assure that efficient circulation and must be vigilant, especially prevent, the development of bed sores especially if hospital admission was indicated.

7. Health Education

Educate all patients about body mechanics, and discuss the risk factors for faulty body mechanics, so that applications can be incorporated into individual work settings, including appropriate seating (eg, lumbar support).

IV. Nursing Management

1. Administer analgesics and other medications as ordered in order to prevent the sensation of pain and maintain the comfort of the client.

2. Use a firm mattress and bed board under the client in order to assure the alignment of the disks and to avoid exacerbations.

3. Make certain that traction and/or braces are correctly applied and maintained and that weights hang freely in order for the traction and the braces to be efficient.

4. Use the fracture bedpan to avoid lifting of hips.5. Use frequent and extensive back care to relax muscles and promote circulation6. Support body alignments at all times in order not to exacerbate the condition.7. Use log-rolling methods to turn the client (instruct the client to fold arms across the

chest, bend the knee on the side opposite the direction of the turn, and then roll over) in order for the client to avoid extra effort in lifting his or her body.

8. Teach the importance of weight loss, wearing low-heeled shoes, and appropriate body mechanics in order to avoid extra pressure on the affected disks.

9. Increase fluid intake and encourage diet rich in nutrient-dense foods such as fruits, vegetables, whole grains, and legumes to improve and maintain nutritional status as well as prevent constipation; if necessary use stool softener to prevent straining.

10. Provide special care for the client undergoing repair or removal of a disc.a. Explain that pain may persist postoperatively for some time because of edemab. Place the bedside table, phone, and call bell within reach to prevent twistingc. Observe the dressing for hemorrhage and leakage of spinal fluid; notify the

physician immediately if either occursd. Observe for inadequate ventilation, especially in clients who have undergone a

cervical laminectomye. Assess the patient for changes in neurologic functioning

11. Allow the client to be dependent, but foster independence to maintain or uphold the over-all well-being of the client.

12. Encourage the patient to perform exercises as prescribed to strengthen abdominal muscles for back support

13. Encourage the client to express feelings about altered functioning and self-image as well as their fears about the present condition and future disability to allay anxiety.