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					                           RNSG2432 ONLLINE NOTES
     Module 8: Neurosensory Disorders: Herniated Disk and Spinal Cord Tumors
                         Marnie Quick, RN, MSN, CNRN
                                Revised 1/28/09
                                Herniated Disk

Etiology/Pathophysiology for Herniated Disk (HNP)
    1. Normal spine physiology as it relates to herniated disk
            a. Also called herniated nucleus pulposus (HNP), slipped disk, ruptured
               disk.
            b. Disk is located between the vertebral bodies and is composed of
               nucleus pulposus (gelatinous material) that is surrounded by the
               annulus fibrosis (fibrous coil).
            c. The disk’s function is to allow for mobility of the spine and act as a
               shock absorber.
            d. Spinal nerves come out between vertebras from the reflex ark of the
               spinal cord. (Lewis 1449 Fig 56-11;1453 Fig 56-15)
            e. HNP is
    2. Etiology of HNP (Lewis 1681 Fig 64-6)
            a. Degeneration of the disc causing part of the disc to herniate
            b. Stress or trauma to the spine
    3. Risk factors for developing herniated nucleus pulposus (HNP):
            a. Standing erect-cumulative effect and daily stress
            b. Aging changes in disc and ligaments, osteoarthritis
            c. Poor body mechanics
            d. Overweight; sedentary lifestyle
            e. Smoking
            f. Trauma- injury to the spine
    4. Herniated disk (HNP) occurs when the annulus becomes weakened or torn
       and the nucleus pulposus herniates through it. The part that is herniating
       out compresses the spinal nerve either the sensory or motor component as
       it leaves the cord.
    5. The sensory root or nerve of the spinal nerve is usually affected resulting in
       sensory symptoms. The motor root to nerve may be affected which results in
       motor symptoms (paresis or paralysis) to wherever the nerve is innervating
       or dermatome. (Lewis1593) Signs and symptoms depend of what nerve
       root, spinal nerve (dermatome) or although uncommon, where the spinal
       cord is compressed.
    6. Radiculopathy is the term used to describe pathology of the nerve root, one
       cause being HNP.

Common Manifestations/Complications for Herniated Disk (HNP)
  1. Lumbar
        a. A common site for an HNP is the lower lumbar area- L4-L5 disc
           herniation affecting the 4th lumbar nerve root. Usually the more
           posterior sensory nerve or nerve root is compressed, as opposed to
           the anterior motor.
        b. The classic symptom of low back sciatica pain occurs. This pain
           radiates across the buttocks and down the posterior part of the leg to
           the ankle. Pain increases with increases in intrathoracic pressure-
           straining, sneezing, coughing, etc. Straight leg raises also increase the
           pain.




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         c. Other symptoms- postural changes, urinary and male sexual function
             changes, paresis (weakness) or paralysis, foot drop, paresthesias,
             numbness, muscle spasms and decrease or absent cord reflexes,
             bowel and bladder incontinence.
         d. Muscle spasms may cause pain and set up a pain-spasm-pain cycle,
             where the individual has pain which causes muscle spasms, which in
             turn increases the pain and continues to cycle.
   2. Cervical
         a. C6-7 disk which affects the 6th cervical nerve root typically resulting in
             pain to the neck, shoulder, anterior upper arm to the thumb.
         b. Affects reflexes to the arm, motor changes (paresis or paralysis) if
             motor root affected, paresthesias or pain if sensory, and cord
             syndrome (refer to spinal cord injury) if cord compressed. Muscle
             spasms may occur, as well as the pain-spasm-pain cycle.

Collaborative Care for Herniated Disk (HNP) (Lewis 1682 Table 64-9)
  1. Diagnostic tests
          a. X-ray- identify deformities and narrowing of disk space
          b. CT/MRI
          c. Mylogram (inject dye into subarachnoid space at L4-5 level),
              diskogram (inject dye into the disk)
          d. Nerve conduction studies (EMG) to detect electrical activity of skeletal
              muscles.
  2. Treatment- Conservative
        a. Firm mattress; log roll, and with lumbar disc, use a side-lying position
            with knees and hips flexed with a pillow between legs to support legs.
        b. Avoid flexion/extension of the spine- use brace/corset, cervical collar to
            provide support. Apply prior to getting out of bed for stability.
        c. Medications: nonnarcotic analgesics, anti-inflammatory, muscle
            relaxants, antispasmodics and tranquilizers. Avoid smoking
        d. Heat/cold therapy to decrease muscle spasms
        e. Intermittent skin traction (cervical/pelvic traction)
        f. Ultrasound, massage, relaxation techniques
        g. TENS unit (transcutaneous electrical nerve stimulation)
        h. Progressive mobilization with approved exercise program (typically
            includes abdominal and thigh strengthening exercises as that those
            muscles are used when lifting) Sit-ups put too much strain on the back.
        i. *Teach good body mechanics.
        j. Weight loss.
        k. Conservative treatment lasts 4 weeks, unless severe neuro deficits
            develop
  3. Treatment- Surgery
        a. Laminectomy- Removal of a portion of the lamina to relieve pressure
            and to get to and remove the part of the herniated nucleus pulposus
            (disc) protruding out against the spinal nerve.
        b. IDET- intradiscal electrothermoplasty outpatient insertion of needle into
            disk- wire inserted and heated- melts part of annulus to stimulate
            regeneration. Also similar technique using radiofrequency- coblation
            nucleoplasty.
        c. Foraminotomy- enlargement of the bony overgrowth at the opening
            which is compressing the nerve.
        d. Microdiskectomy- use of electron microscope through a small incision to
            remove a portion of HNP that is displaced. If cervical disc usually use



232  RNSG 2432
            anterior approach. Also diskectomy and percutaneous laser diskectomy
            can be used.
        e. Charite disk (artificial disk-Lewis 1683 Fig 64-7) used when disk
            damage is associated with degenerative disk disease (DDD)
        f. Spinal fusion- removes most of disk and replaces it with bone (usually
            from the individual’s iliac crest or cadaver bone). Also used are
            rods/plates/screws to stabilize vertebra. May also use InFuse Bone
            Graft/LT-CAGE (device has genetically engineered protein that
            stimulates the body to grow new bone at the spinal fusion site.
            Flexibility of the vertebra is lost at the site and the individual usually
            requires a longer hospital stay. Fusion surgery may use the anterior or
            posterior route to the disk.
  4. Prevention
          a. ‘Back school’ approach, including body mechanics; learn how to
              prevent/causes
          b. Change in life-style/occupation.

Nursing Assessment Specific to Herniated Disk (HNP)
   1. Health history
          a. Assess for risk factors- the cumulative effect of standing erect and
              daily stress; aging changes in disc/ligaments; poor body mechanics;
              overweight; trauma, etc.
          b. Employment/occupation, history of pain and other neuro changes
   2. Physical exam- Utilize similar methods used to assess spinal nerves/cord in
      spinal cord injury.
          a. Use similar methods to assess as utilized with SCI (Module7)
          b. Muscle strength and coordination
          c. Sensation- Sharp/dull of cotton-tip applicator using dermatomes as
              reference.
          d. Pain evaluation- pain scale
          e. Post-op assessment
                    1) NVS- sensory/motor use care not to injure op site.
                    2) Assess for CSF drainage or bleeding from op site.
                    3) Encourage turn (log roll), cough, deep breath
                    4) If anterior cervical- assess injury to the carotid, esophagus,
                        trachea, laryngeal nerve (speech- will sound hoarse)-assess
                        respiration, neck size, swallowing, speech.
                    5) If post-op lumbar- assess bowel sounds, voiding. Minimize
                        stress of post-op site- flat with pillow between knees, log roll,
                        etc
                    6) Assess for postural hypotension- especially if individual was
                        on bed rest for several days/weeks prior to surgery

Pertinent Nursing Problems and Interventions for HNP (Nursing Process)
  1. Acute pain
         a. Bedrest; medication- may need both antispasmoic as well as analgesic
            and other medications-anti-inflammatory, steroids, etc; good body
            mechanics, back support and other techniques as stated under
            collaborative care
         b. Teach need to adhere to activity restrictions, gradual increase in
            activity, Physician approved exercise plan (exercises that increase
            strength in thighs and abdominal muscles- avoid sit-ups or strenuous




                                                                        RNSG 2432  233
             exercises), need to increase flexibility, if lumbar- it is better to stand
             than sit, and possible need for life style changes.
          c. Post surgery the individual may have similar pain as pre-op. This is due
             to the lack of residency of the spinal nerves to ‘bounce’ back. If the
             pain is worse check the site- bleeding or swelling may be causing the
             increased pain. Also check for cerebral spinal fluid leak.
          d. The donor site (iliac crest or fibula) may cause more pain than back
             (disk) operative site.

   2. Chronic pain
         a. Surgery may not relieve pain
         b. Nonpharmalogical methods to control pain
         c. Pain clinic
   3. Post-op care spinal surgery
         a. Maintain proper body alignment—LOG ROLL!! Use sufficient staff
         b. Pain control
         c. Check dressing for blood or CSF leak (CSF is clear colorless containing
             glucose; halo sign on linen; may have blood mixed in); ck donor site
         d. Monitor extremities neurovascular/CMS- Circulation (temp/capillary
             refill/pulses), Motor and Sensory checks
         e. Assess for paralytic ileus, bladder empting (intermittent cath)
         f. Check activity order
         g. Teach use of brace/orthotic
         h. If lumbar and with activity order- avoid sitting prolonged periods-
             encourage walking, lying down
         i. Firm mattress
   4. Constipation
         a. Due to bedrest/decreased mobility & fear of pain with straining of stool.
         b. Constipation prevention methods- fluids, diet, etc
   5. Home care
         a. When riding in a car, take frequent stops to move and stretch
         b. Prevention, ‘Back school’ approach- body mechanics, no twisting
         c. May have to deal with it as a chronic condition. Make life/occupational
             changes
                                 Spinal Cord Tumors

Etiology/Pathophysiology of Spinal Cord Tumors
   1. Normal spine physiology as it relates to spinal cord tumors.
          a. The CNS is made up of neural tissue (neurons) and support tissue
             (glial).These tissues can undergo changes and result in spinal cord
             tumors. Blood vessels and bone (vertebra) also can be part of the
             tumors.
   2. Spinal cord tumors are classified by primary or secondary; by anatomical area
      (extradural/intradural); and by neural tissue (discussion of these neural
      tissues will be discussed with brain tumors) (Lewis 1609 Fig 61-14 & 1610
      Table 61-15)
          a. Primary- originating in the spinal cord/meninges
          b. Secondary- metastatic from other parts of the body
          c. Extradural- Outside the dura (outer layer of the meninges) from bone
             of spine, in extradural space, or in paraspinal tissue. 90% of all spinal
             cord tumors. Tend to be malignant metastatic lesions
          d. Intradural: Inside the dura
                    1) Intramedullary- arise from neural tissues of the spinal cord



234  RNSG 2432
                  2) Extramedullary- within dura mater outside of the spinal cord
  3. Intradural-extramedullary tumors generally have a good prognosis; not others
  4. Most spinal cord tumors are found in the thoracic region.
  5. Spinal cord tumors can compress (as in the benign), invade the neural tissue,
     or cause ischemia to the area because of vascular obstruction.

Common Manifestations/Complications of Spinal Cord Tumors
  1. Symptoms depend on the anatomical level of the spinal column, the
     anatomical location, the type of tumor and the spinal nerves affected.
  2. Pain is the most common presenting symptom- not relieved by bed rest.
  3. Other symptoms are similar to those found with HNP or spinal cord injury-
     sensory and motor.
  4. Manifestations (symptoms) of thoracic cord tumors
        a. Paresis & spasticity of one leg then the other
        b. Pain back & chest, not relieved by Bedrest; sensory changes
        c. Babinski reflex
        d. Bowel (ileus); bladder dysfunction (UMN in type)

Collaborative Care for Spinal Cord Tumors
  1. Diagnostic Tests
         e. X-ray; CT/MRI
         f. Myelogram
         g. Lumbar puncture with CSF analysis
  2. Medications
         a. Control pain- narcotic analgesics, may be given epidural catheter, PCA;
            NSAID’s
         b. Reduce cord edema and tumor size- steroids dexamethasome
            (Decadron) high dose for a few days, then taper off (Medrol dose pack)
  3. Surgery
         a. Laminectomy to remove or to decrease the size (decompression
            laminectomy) of the spinal cord tumor.
         b. Spinal fusion or the insertion of rods if several vertebras involved and
            the column is unstable.
         c. Refer to above (HNP) for post-op care
  4. Radiation Therapy
         a. Usually used for metastatic spinal cord tumors to reduce size of the
            tumor to control pain.

Nursing Assessment Specific to Spinal Cord Tumors
   1. Health history
         a. Pain, motor and sensory changes, bowel and bladder changes,
             Babinski reflex. Similar to HNP
   2. Physical exam
         a. Similar to physical assessment for HNP- sensory/motor

Pertinent Nsg Problems/Interventions for Cord Tumors (Nursing Process)
  1. Anxiety
         a. Metatastic tumor vs. benign spinal cord tumor
         b. Education and support system
  2. Risk for constipation
         a. From spinal cord compression, narcotics, bed rest
         b. Adjust fluid and diet
  3. Impaired physical mobility



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          a. From bed rest and motor involvement
          b. Basic nursing- ROM, etc
  4.   Acute pain
          a. From compression or invasion of tumor
          b. Assess and treat
  5.   Sexual dysfunction
          a. Male sacral reflex ark (S 2,3,4) interference
          b. Similar care as discussed with SCI
  6.   Urinary retention
          a. Reflex ark (S 2,3,4) interference can cause neurogenic bladder
              as discussed with SCI
  7.   Home care
          a. Rehabilitation
          b. Home evaluation
          c. Support groups




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