Module 8 Neurosensory:

Herniated Disk and Spinal Cord tumors

Marnie Quick RN, MSN, CNRN

A. Pathophysiology/etiology
Normal 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
 Spinal nerves come
out between vertebra
from the reflex ark in
the spinal cord
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
2. Chronic pain
 Surgery may not relieve pain
 Nonpharmalogical methods to control pain
 Pain clinic
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?
LeMone Blackboard: Media Links

http://wps.prenhall.com/chet_lemone_medi
calsurg_3/0,7859,757263-,00.html

http://www.spine-health.com/