Module 8 Neurosensory: Herniated Disk and Spinal Cord tumors Marnie Quick RN, MSN, CNRN.
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Transcript of Module 8 Neurosensory: Herniated Disk and Spinal Cord tumors Marnie Quick RN, MSN, CNRN.
A. Pathophysiology/etiologyNormal spine as related to herniated disk Herniated nucleus pulposus, slipped disk,
ruptured disk Function of disc is to allow for mobility of the
spine and act as shock absorber
Located between vertebral bodies
Composed of nucleus pulposus a gelatinous material surrounded
By annulus fibrosis- a fibrous coil
Risk factors developing herniated disk Standing erect- cumulative effect and daily stress Aging changes in disc and ligaments,
osteoarthritis Poor body mechanics Overweight Trauma
HNP- annulus becomes weakened/torn and the nucleus pulpsus herniates through it.
HNP compresses Spinal nerve (sensory or
motor component) as it leaves the spinal cord
Or the cord itself- the white tracks within the cord- rare
Sensory 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
B. Common manifestations/complications Lumbar HNP
Most 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
Other symptoms lumbar HNP: Postural changes Urinary/male sexual function changes Paresis or paralysis Foot drop Paresthesias Numbness Muscle spasms Absent cord reflexes
Common manifestations/complications Cervical HNP
C5-C6 disk- affects the 6th cervical nerve root Pain- neck, shoulder, anterior upper arm to thumb Absent/diminished reflexes to the arm Motor changes- paresis or paralysis Sensory- paresthesias or pain Muscle spasms
C. Therapeutic Interventions- diagnostic tests X-ray identify
deformities and narrowing of disk space
CT/MRI Mylogram p1336 Nerve conduction studies
(EMG) to detect electrical activity of skeletal muscles
Treatment- Conservative Bed 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- Conservative Heat/cold therapy to decrease muscle spasms Break the pain-spasm-pain cycle Ultrasound, massage, relaxation techniques Progressive mobilization with approved exercise
program –includes abdominal/thigh strengthening Teaching good body mechanics Weight loss TENS unit
Treatment- Surgery Laminectomy- removal of a portion of the lamina
to relieve pressure and to get to the herniated nucleus pulposus that is protruding out
Treatment- Surgery Spinal fusion removes most of the disk and
replaces it with bone usually from the patient iliac crest
Flexibility is lost at the site- requires longer hosp stay
Treatment- Surgery Foraminotomy is enlargement of the bony
overgrowth at the opening which is compressing the nerve
Microdiskectomy is 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 HNP Back school approach-
Causes of HNP Learn how to prevent Good body mechanics Exercises to strengthen leg and abdominal muscles
Change in life-style or occupation
D. Nursing Assessment Specific to HNP Health History
Assess for risk factors- the cumulative effect of standing erect and daily stress; aging changes in disc/ligaments; poor body mechanics; overweight; trauma
Employment, 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 coordination Sensation- sharp/dull of paperclip using
dermatome as reference Pain evaluation- pain scale Pre/Post-op assessment
Post-op assessment from HNP NVS sensory/motor- care not to injure op site Assess for CSF drainage or bleeding from op site Encourage turn (log roll, cough, deep breath) If 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
Assess for postural hypotension, especially if ind was on bed rest for several days/weeks prior to surgery
E. Pertinent nursing problems/interventions 1. Acute pain
Post 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
3. Constipation As a result of bed rest and decreased mobility and
fear of pain with straining of stool Constipation prevention methods– fluids, diet, etc
4. Home care When riding in a car, take frequent stops to move
and stretch Prevention– Back school approach May have to deal with pain as a chronic condition May need to make life/job changes
Spinal Cord Tumors A. 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 Spinal tumors are classified by anatomical area
and as primary or secondary
Spinal cord tumors by anatomical area Intramedullary- arise from neural tissues of the
spinal cord Extramedullary arise from tissues outside the
spinal cord may be benign or malignant Intradural-from the nerve roots or meninges in
subarachnoid space Extradural- from the epidural tissue or vertebra
Spinal cord tumors primary or secondary Primary- originating in the spinal cord or
meninges Secondary- metastases from other parts of the
body
Most 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
B. Common manifestation/complications Symptoms depend on the anatomical level of the
spinal column, the anatomical location, the type of tumor and the spinal nerves affected
Pain is the most common presenting symptom that is not relieved by bed rest
Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor
Manifestations thoracic cord tumor Paresis & spasticity of one leg then the other Pain back & chest, not relieved by bedrest;
sensory changes Babinski reflex Bowel (ileus); bladder dysfunction (UMN in
type)
C. Therapeutic interventions spinal tumors Diagnostic tests include:
X-ray of the spinal column Myelogram Lumbar puncture with CSF analysis
Medications 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
Surgery 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
D. Nursing assessment specific to cord tumors
Health history Pain, motor and sensory changes, bowel and
bladder changes, Babinski reflex. Physical exam
Similar to physical assessment for HNP
E. Pertinent nursing problems/interventions
1. Anxiety Metatastic tumor vs benign spinal cord tumor Education and support system
2. Risk for constipation From spinal cord compression, narcotics, bed rest Adjust fluid and diet
3. Impaired physical mobility From bed rest and motor involvement Basic nursing- ROM, etc
4. Acute pain From compression or invasion of tumor Assess and treat
5. Sexual dysfunction Male sacral reflex ark (S 2,3,4) interference Similar care as discussed with SCI
6. Urinary retention Reflex arc (S2,3,4) interference can cause neurogenic
bladder as discussed with SCI
7. Home care Rehabilitation Home evaluation Support groups
Nursing Care Plan: A Client with a Ruptured Intravertebral Disk LeMone p. 1340
http://wps.prenhall.com/wps/media/objects/737/755395/intervertebral_disk.pdf
Added Critical thinking questions LeMone p. 1340 Nursing Care Plan: A Client with Ruptured Intervertebral Disk 1. 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 disk?