HERNIATED NUCLEUS PULPOSUS

BY: INDIRA GAYLE G RIOROSO BSN 4-2 BATCH 2013 Cavite State University

Disc Hernation - Physiology

Herniated

nucleus pulposus, HNP- annulus becomes weakened/torn and the nucleus pulposus herniates through it. Tears in the annulus

Disc Hernation - Physiology

Compression

of the nerve root in the foramen leads to pain slipped disc, ruptured disc

Sagittal Section through the Spinal Cord

Intervertebral disc 2. Vertebral body 3. Dura mater 4. Extradural or epidural space

5. Spinal cord
6. Subarachnoid space

 Sensory

root or nerve of the spinal nerve is usually affected resulting in sensory symptomsPAIN, 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

Common Manifestations

Common Manifestations
Most

common site for HNP is L4-5 disc- the 5th lumbar nerve root Most common is the posterior sensory nerve root compressed Classic symptoms- low back sciatica pain

Other symptoms
Postural

changes Urinary/male sexual function changes Paresis or paralysis Foot drop Numbness Muscle spasms Absent cord reflexes

SYMPTOMS OF HERNIATED LUMBAR DISK

Muscle spasm Muscle weakness or atrophy in later stages Pain radiating to the buttocks, legs, and feet Pain made worse with coughing, straining, or laughing Severe low back pain Tingling or numbness in legs or feet

SYMPTOMS OF HERNIATED CERVICAL DISK

Arm muscle weakness Deep pain near or over the shoulder blades on the affected side Neck pain, especially in the back and sides Increased pain when bending the neck or turning head to the side Pain radiating to the shoulder, upper arm, forearm, and rarely the hand, fingers or chest Pain made worse with coughing, straining, or laughing Spasm of the neck muscles

Diagnostic Exams
X-ray

identify deformities and narrowing of disk space CT/MRI Spine MRI or spine CT will show spinal canal compression by the herniated disk.

Electromyography is a test that measures muscle response to nervous stimulation. Each muscle fiber that contracts will produce an action potential.

The nerve conduction velocity test is performed to evaluate nerve function. It tests the speed impulses travel through a nerve.

 Myelogram

may be done to determine the size and location of disk herniation. The contrast dye makes the spinal canal clearly visible in this X-ray image. A herniated disc can be seen compressing the spinal nerves.

Physical Examination
Fever

possible infection Vertebral tenderness - not specific and not reproducible between examiners Limited spinal mobility not specific (may help in planning P.T. If sciatica is present do straight leg raise Positive test reproduces the symptoms of sciatica pain that radiates below the knee (not just back or hamstring)

straight leg raise test

The straight leg raise test is positive if pain in the sciatic distribution is reproduced between 30 and 70 passive flexion of the straight leg. Dorsiflexion of the foot exacerbates the pain

Treatment Conservative Tx.

Moderate

bed rest Spinal manipulation Physical therapy Medication

NSAIDs Muscle

relaxants Rarely narcotics

 Bed rest with firm mattress; log roll; side lying position with knees bent and pillow between legs to support legs Avoid flexion of the spinebrace/corset, cervical collar to provide support Medications- nonnarcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodics and tranquilizers

 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

Management
SURGERY

Diskectomy - removes a protruding disk. This procedure requires general anesthesia (asleep and no pain) and 2 - 3 day hospital stay. Microdiskectomy - a procedure removing fragments of nucleated disk through a very small opening. 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.

 Foraminotomy

- Enlargement of the bony overgrowth at the opening which is compressing the nerve - Use of electron microscope through a small incision to remove a portion of the HNP that is displaced

Microdiskectomy

If cervical HNP, usually use the anterior approach in the neck

MEDICATIONS
Nsaid Steroid

injection Muscle relaxant Narcotics

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

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

2. Chronic Pain
Surgery

may not relieve pain methods

Nonpharmalogical

to control pain clinic

Pain

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