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Osteomyelitis, Osteoporosis, Low Back Pain, Intervertebral Disk Disease, Foot Disorders Zoya Minasyan, RN, MSN-Edu Focus on Osteomyelitis • Severe infection of the – Bone – Bone marrow – Surrounding soft tissue • Caused by variety of microorganisms • Most common microorganism is Staphylococcus aureus. Etiology and Pathophysiology ORGANISM POSSIBLE PROBLEM Staphylococcus aureus Pressure ulcer, penetrating wound, open fracture, orthopedic surgery, vascular insufficiency disorder Staphylococcus epidermidis Indwelling prosthetic device Streptococcus viridans Abscessed tooth, gingival disease Escherichia coli Urinary tract infection Mycobacterium tuberculosis Tuberculosis Neisseria gonorrhoeae Gonorrhea Pseudomonas sp. Puncture wounds, intravenous drugs Salmonella sp. Sickle cell disease Fungi, mycobacteria Immunocompromised host 3 Osteomyelitis • Infecting microorganisms can invade by – Indirect entry – Direct entry Osteomyelitis – Indirect entry • Associated with increased incidence of blunt trauma • Most common sites of indirect entry • • • • Distal femur Proximal tibia Humerus Radius • Adults with increased risk • • • • Vascular disorders Genitourinary and respiratory infections Spread infection from blood to bone Vascular-rich bone sites – Pelvis – Tibia – Vertebrae Direct entry • Direct entry Open wound May also occur in presence of foreign body – Implant, – Orthopedic prosthetic device . • After entry microorganisms grows causing increased pressure, because most bone is nonexpanding. • Increased pressure leads to ischemia and vascular compromise. • Eventually, infection passes through bone cortex and marrow cavity. • Results in cortical devascularization and necrosis Direct Entry • Once ischemia occurs, bone dies. • Sequestrum forms – Devitalized bone separates from living bone. • Part of periosteum that continues to have a blood supply forms new bone called involucrum. Development of Osteomyelitis Direct Entry • Sequestrum continues to be an infected island of bone, surrounded by pus. • Difficult for blood-borne antibiotics or white blood cells (WBCs) to reach sequestrum • Sequestrum can move out of bone and into soft tissue. • Once outside bone – Sequestrum may • Revascularize and then undergo removal by normal immune process • Be surgically removed through debridement of necrotic bone – If necrotic sequestrum is not resolved, develops a sinus tract, resulting in chronic, purulent cutaneous drainage. – Avascular scar tissue provides ideal site for continued microorganism growth. Clinical Manifestations Acute Osteomyelitis • Initial infection – Infection of <1 month in duration – Both systemic and local • Systemic – Fever, night sweats, chills, restlessness, nausea • Local – – – – Constant bone pain that worsens with activity Swelling, tenderness, warmth at infection site Restricted movement of affected part Later signs: drainage from sinus tracts Clinical Manifestations Chronic Osteomyelitis • Bone infection lasting longer than a month • Infection that has failed to respond to initial course of antibiotic therapy • Systemic signs may be diminished Clinical Manifestations Chronic Osteomyelitis Diagnostic Studies • Bone or soft tissue biopsy – Definitive way to determine causative microorganism • Patient’s blood and/or wound culture – Frequently positive for microorganism – Elevated WBC count – Erythrocyte sedimentation rate (ESR)page 1579 • Magnetic resonance imaging (MRI) • Computed tomography (CT) – Help identify extent of infection, including soft tissue involvement Collaborative Care • Intravenous (IV) antibiotic therapy • Cultures or bone biopsy should be done if possible. • Delaying antibiotic treatment may require surgical debridement and decompression. • Patients are often discharged to home care or skilled nursing facility with IV antibiotics delivered via – Central venous catheter – Peripherally inserted central catheter (PICC) Collaborative Care • Antibiotic therapy may be continued at home for 4 to 6 weeks or as long as 3 to 6 months. • Variety of antibiotics may be prescribed. – Penicillin; Neomycin, vancomycin ; Cephalexin (Keflex); Cefazolin (Ancef) – May be prescribed oral therapy for 6 to 8 weeks instead of IV antibiotics. • Patient’s response monitored through bone scans and ESR tests. Collaborative Care • Surgical treatment for chronic osteomyelitis – Removal of poorly vascularized tissue and dead bone – Extended use of antibiotics – Antibiotic-impregnated polymethyl meth-acrylate bead chains may also be implanted. • After debridement, wound may be closed and a suction irrigation system inserted. • Intermittent or constant irrigation of affected bone with antibiotics • Protection of limb or surgical site with casts or braces. Collaborative Care • Hyperbaric oxygen therapy with 100% oxygen as adjunct therapy – Stimulate circulation and healing • Orthopedic prosthetic devices • Muscle flaps, skin grafting provide wound coverage over dead space (cavity) in bone. • Bone grafts may help restore blood flow. • Amputation may be indicated if – Extensive bone destruction – Necessary to preserve person’s life and/or improve quality of life Nursing Assessment – Past health history • Bone trauma, open fracture, open or puncture wounds, other infections – Medications – Surgery or other treatments – Subjective data • • • • IV drug use Anorexia, weight loss, chills Weakness, paralysis, muscle spasms Local tenderness over affected area, increase in pain in affected area – Objective data • General: restlessness, high spiking temperature, night sweats • Integumentary: diaphoresis, erythema, warmth, edema at infected bone • Musculoskeletal: restricted movement, wound drainage, spontaneous fractures Nursing Diagnoses • Acute pain • Ineffective self-health management • Impaired physical mobility Planning • Overall goals – Have pain and fever control. – Do not experience any complications associated with osteomyelitis. – Maintain a positive outlook on outcome of disease. Nursing Implementation • Health promotion – Control infections already in body – Susceptible adults • Immunocompromised • Wear orthopedic prosthetic devices Nursing Implementation • Acute intervention – Some immobilization of affected limb will ↓ pain – Limb should be handled carefully to avoid excessive manipulation and ↑ pain – Assess and manage patient’s pain level. – Apply dressings – Frequent bed rest in early stages • Good body alignment and frequent position changes prevent complications associated with immobility and promote comfort. • Footdrop can develop quickly in lower extremity if foot is not supported in a neutral position by a splint, or if there is excessive pressure from a splint. Nursing Implementation – Instruct patient to avoid activities that ↑ circulation and swelling and serve as stimuli to spread infection • Exercise, heat application – Teach patient potential adverse and toxic reactions with prolonged and high-dose antibiotic therapy. – Importance of continuing antibiotics after symptoms have subsided should be stressed. – Periodic nursing visits provide support and decrease anxiety. – Frequent dressing changes for open wounds – May require supplies and instruction in technique Osteoporosis • Metabolic bone disease characterized by – – – – Porous bone Low bone mass Structural deterioration of bone tissue Increased bone fragility • More common in women than men for several reasons – – – – Lower calcium intake than men Less bone mass because of smaller frame Bone resorption begins earlier and accelerates after menopause. Pregnancy and breast feeding deplete woman’s skeletal reserve of calcium. – Longevity increases likelihood of osteoporosis (women live longer than men). Osteoporosis • Etiology and Pathophysiology • Risk factors – – – – – – – – – – – Female gender Increasing age Low body weight White or Asian ethnicity Family history Early menopause Excess alcohol intake Cigarette smoking Sedentary lifestyle Insufficient calcium intake Long-term use of corticosteroids, thyroid replacement, antiseizure drugs • Low testosterone levels in menMany drugs can interfere with bone metabolism. – – – – – Corticosteroids Antiseizure drugs (e.g., valproate [Depakote], phenytoin [Dilantin]) Aluminum-containing antacids Certain cancer treatments Excessive thyroid hormones Normal vs. Osteoporotic Bone Osteoporosis • In osteoporosis, bone resorption exceeds bone deposition. • Occurs most commonly in spine, hips, and wrist • Diseases associated with osteoporosis • • • • • • • Intestinal malabsorption Kidney disease Rheumatoid arthritis Hyperthyroidism Chronic alcoholism Cirrhosis of the liver Diabetes mellitus Osteoporosis • “silent disease” because there are no symptoms; the usual first signs are back pain and spontaneous fractures • Manifestations include – Sudden strain, Fractures, Back pain, Loss of height, Spinal deformities • Good and poor sources of Ca Poor sources of calcium – Eggs, Beef, Cream cheese, Poultry, Pork, Apples and bananas Good sources of calcium – Milk , Yogurt, Turnip greens, Spinach, Cottage cheese, Ice cream, Sardines Collaborative Care: Osteoporosis • Exercise should be encouraged to build up and maintain bone mass • Types of exercise – – – – Weight bearing Walking Stair climbing Dancing • Supplemental vitamin D may be recommended. • Patients should be instructed to quit smoking or cut down on alcohol intake to ↓ losing bone mass Collaborative Care • Drug therapy – – – – Calcium Vitamin D Calcitonin Bisphosphonates inhibit osteoclast-mediated bone resorption (e.g., etidronate [Didronel], alendronate [Fosamax]). – Selective estrogen receptor modulators • Raloxifene (Evista) – Teriparatide (Forteo) • Portion of parathyroid hormone • First drug to stimulate new bone formation Low Back Pain • Low back pain common because lumbar region – Bears most of the weight of body – Is the most flexible region of the spinal column – Contains nerve roots that are vulnerable to injury or disease • Several risk factors – – – – – Lack of muscle tone Excess body weight Poor posture Cigarette smoking Stress • Associated with low back pain – Prolonged periods of seating – Repetitive heavy lifting – Vibration Low Back Pain • Low back pain most often due to musculoskeletal problems 1. 2. 3. 4. 5. Acute lumbosacral strain Instability of lumbosacral bony mechanism Osteoarthritis of lumbosacral vertebrae Degenerative disk disease Herniation of intervertebral disk Acute Low Back Pain • Lasts 4 weeks or less • Associated with some type of activity that causes undue stress on tissues of lower back • Symptoms often do not appear at time of injury but develop later because of gradual ↑ in paravertebral muscle spasms. • One test is straight-leg raise. – Positive for disk herniation when radicular pain occurs • MRI and CT not done unless trauma or systemic disease is suspected Acute Low Back Pain Collaborative Care • Treated on an outpatient basis if acute muscle spasms and pain are not severe and debilitating – – – – – Analgesics Muscle relaxants Massage and back manipulation Alternating use of heat and cold compresses Opioid analgesics for severe pain • Brief period of rest at home may be necessary. • Most persons do better with continuation of their regular activities. • All patients should avoid activities that aggravate pain: – – – – Lifting Bending Twisting Prolonged sitting • Most cases improve in 2 weeks. Acute Low Back Pain Nursing Assessment • Subjective data – – – – – – – – – – – – – – – – – – Acute or chronic lumbosacral strain/ trauma Osteoarthritis Degenerative disk disease Obesity Use of opioid and nonopioid analgesics, muscle relaxants, nonsteroidal antiinflammatory drugs, corticosteroids Use of over-the-counter remedies Previous back surgery, epidural or corticosteroid injections Smoking Lack of exercise Poor posture Muscle spasms Activity intolerance Constipation Interrupted sleep Pain in back, buttocks, or legs associated with walking, turning, straining, coughing, leg raising Numbness or tingling of legs, feet, toes Occupation requiring heavy lifting, vibrations, or extended driving Change in role within family structure due to inability to work and provide income Acute Low Back Pain Nursing Assessment • Objective data – – – – – – – – – – Guarded movement Depressed or absent Achilles tendon reflex Patellar tendon reflex Positive straight-leg raise test Positive crossover straight-leg test Decreased range of motion of spine Tense, tight vertebral muscles on palpation Localization of site of lesion CT scan MRI Acute Low Back Pain Nursing Diagnoses • • • • Acute pain Impaired physical mobility Ineffective coping Ineffective self-health management Planning • Goals – Have satisfactory pain relief. – Avoid constipation secondary to medication and immobility. – Learn back-sparing practices. – Return to previous level of activity within prescribed restrictions. Nursing Implementation Health Promotion • As a role model, nurse should use proper body mechanics at all times. – Primary consideration when teaching patients transfer and turning techniques • Assess patient’s use of body mechanics, and offer advice when activities could produce back strain. Nursing Implementation Acute Intervention • Do’s – Prevent lower back from straining forward by placing a foot on a step or stool during prolonged standing – Maintain appropriate body weight – Sleep in a side-lying position with knees and hips bent – Sleep on back with a lift under knees and legs or back with 10-inch-high pillow under knees to flex hips and knees – Exercise 15 minutes in the morning and evening regularly – Use local heat and cold application – Use a pillow for sitting Nursing Implementation Acute Intervention • Don’ts – Lean forward without bending knees – Lift anything above level of elbows – Stand in one position for prolonged time – Sleep on abdomen or on back or side with legs out straight – Exercise without consulting health care provider if having severe pain Nursing Implementation Acute Intervention • Primary nursing responsibilities – Educate patient about health problem. – Educate patient on appropriate exercises. – Use analgesics, NSAIDs, muscle relaxants, and thermotherapy while avoiding bed rest. Chronic Low Back Pain • Lasts longer than 3 months or is a repeated incapacitating episode • Causes – Degenerative disk disease – Lack of physical exercise – Prior injury – Obesity – Structural and postural abnormalities – Systemic disease Chronic Low Back Pain • Osteoarthritis (OA) of lumbar spine is found in patients over 50. • Chronic back pain in younger patients with OA usually involves thoracic or lumbar spine. • Discomfort is ↑ following periods of inactivity. – Particularly on awakening or after long periods of sitting Chronic Low Back Pain • Spinal stenosis – Narrowing of vertebral or nerve root canals – May be congenital – More often acquired through degenerative or traumatic changes to spine – In lumbar area • Compression of nerve roots can result with disk herniation. Pain often starts in low back and radiates to buttock and leg. • Worsens with walking, particularly standing without walking Chronic Low Back Pain • Treatment for chronic back pain – Reduction in pain associated with daily activities – Rest and local heat application when cold, damp weather aggravates back pain – Mild analgesics to decrease pain and stiffness – Weight reduction – Sufficient rest periods – Local heat and cold application – Exercise and activity throughout day – Keep muscle and joints mobilized – Antidepressants • Surgical interventions – Indicated in patients • With severe chronic low back pain • Who do not respond to conservative care • Who have neurologic deficits Intervertebral Disk Disease • Degenerative disk disease (DDD) – Structural degeneration of lumbar disk – is a normal process of aging; Common in persons by age 60 – Results in intervertebral disks losing elasticity, flexibility, and shock-absorbing capabilities – Thinning of disks occurs as nucleus pulposus (gelatinous center of disk) starts to dry out and shrink – Compression of nerve roots and cord may occur. – Damage to spine by DDD contributes to osteoarthritis of spine. Causes of Degenerative Disk Damage INTERVERTEBRAL LUMBAR DISK DAMAGE ETIOLOGY AND PATHOPHYSIOLOGY • Acute herniated intervertebral disk Can be result of • Natural degeneration with age • Repeated stress or trauma to spine – Nucleus may first bulge and then herniate, placing pressure on nerves. • Most common ruptures at lumbosacral disks INTERVERTEBRAL LUMBAR DISK DAMAGE CLINICAL MANIFESTATIONS • Most common feature of lumbar disk damage is low back pain. • Indications of disk herniation – Pain that radiates down buttock and below knee – Along distribution of sciatic nerve • Straight-leg raising-test may be positive. • Reflexes may be depressed or absent, depending on the spinal nerve root involved • Back or leg pain may be reproduced by raising leg and flexing foot at 90 degrees. • Paresthesia or muscle weakness in legs, feet, or toes may be reported • Multiple nerve root compression may be manifested as bowel and bladder incontinence or impotence. Cervical Disk Disease • Pain radiating into arms and hands, following the pattern of the nerve involved • As in lumbar disk damage, reflexes may or may not be present, and there is often weakness of hand grip. INTERVERTEBRAL LUMBAR DISK DAMAGE DIAGNOSTIC STUDIES • X-rays are done to note structural damage. • MRI, or CT scan localizes damaged site. • Epidural venogram or diskogram may be necessary. • EMG of extremities determines severity of nerve irritation. INTERVERTEBRAL LUMBAR DISK DAMAGE COLLABORATIVE CARE • Managed first with at least 4 weeks of conservative therapy – Limitation of extremes of spinal movement • Brace, corset, or belt – – – – – Local heat or ice Ultrasound and massage Traction Transcutaneous electrical nerve stimulation (TENS) Drug therapy • NSAIDs, short-term opioids, muscle relaxants – Epidural corticosteroid injections • Once symptoms subside, back-strengthening exercises begin. – Twice a day – Encouraged for a lifetime INTERVERTEBRAL LUMBAR DISK DAMAGE SURGICAL THERAPY • Indicated when – Diagnostic tests indicate problem is not responding to conservative treatment – Patient is in consistent pain – Persistent neurologic deficit • Intra-discal electro-thermoplasty (IDET) – Minimally invasive outpatient procedure – May help in treating back and sciatica pain – Involves insertion of needle into affected disk with guidance of an x-ray – Wire is then threaded down through needle and into disk. – Wire is heated, which de-nervates small nerve fibers that have grown into cracks and invaded degenerating disk. INTERVERTEBRAL LUMBAR DISK DAMAGE SURGICAL THERAPY • Radiofrequency discal nucleoplasty – Needle is inserted into disk similar to IDET. – Special radiofrequency probe is used. – 20% of nucleus is removed. • Decompresses disk • Decreases pressure on both disk and surrounding nerve roots • Inter-spinous process decompression system (X Stop) – Made of titanium and fits into mount placed on vertebrae in lower back INTERVERTEBRAL LUMBAR DISK DAMAGE SURGICAL THERAPY • Laminectomy • Surgical excision of part of posterior arch of vertebra to gain access to part of or entire protruding disk to remove it. Minimal hospital stay. • Diskectomy Microsurgical diskectomy • Uses microscope to allow better visual of disk and disk space to aid in the removal of damaged portion • Helps maintain bony stability of spine Percutaneous laser diskectomy • Outpatient surgical procedure • Uses tube passed through retroperitoneal soft tissues to lateral border of disk with local anesthesia and aid of fluoroscopy • Laser is then used on damaged portion. • Minimal blood loss INTERVERTEBRAL LUMBAR DISK DAMAGE SURGICAL THERAPY • Charité disk – Artificial disk made up of high-density core sandwiched between two cobalt-chromium end plates – Surgically placed in spine through small incision below umbilicus after damaged disk is removed – Allows for movement at level of implant – Goals of artificial disk replacement surgery are to restore movement and eliminate pain. Charité Disk The Charité artificial disk, used in degenerative disk disease to replace a damaged intervertebral disk. The Charité artificial disk consists of two cobalt-chromium alloy endplates sandwiched around a movable high-density plastic core. The design of the disk helps align the spine and preserve its natural ability to move. INTERVERTEBRAL LUMBAR DISK DAMAGE SURGICAL THERAPY • Spinal fusion – Spine is stabilized with a bone graft from patient’s fibula or iliac crest or from a donated cadaver bone – Metal fixation with rods, plates, or screws • Provides stability and decreases vertebral motion Nursing Management Spinal Surgery: Postoperative • Maintain proper alignment of spine • Patient may be able – To dangle legs at side of the bed – To stand • To ambulate first day after surgery • Logroll patient when turning • Pillows under thighs of each leg when supine and between legs when side-lying • Most patients will require opioids for 24 to 48 hours. • Preferred method is patient-controlled analgesia (PCA). Nursing Management Spinal Surgery: Postoperative • If spinal canal was entered during surgery, potential for cerebrospinal fluid (CSF) leakage • Severe headache or leakage of CSF on dressing should be reported. – CSF appears as clear or slightly yellow drainage on dressing. • • • • • CSF has high concentrations of glucose. A dipstick test for glucose will be positive. Document amount, color, and characteristics of drainage. Frequently monitor peripheral neurologic signs. Movement of arms and legs and assessment of sensation should be unchanged vs. preoperative status. – Repeat assessments every 2 to 4 hours during first 48 hours post surgery. – Extremity circulation should be assessed by temperature, capillary refill, and pulses. Nursing Management Spinal Surgery: Postoperative – Manifestations • Nausea • Abdominal distention • Constipation – Stool softeners may aid in relief and prevention. Nursing Management Spinal Surgery: Postoperative • Adequate bladder emptying may be altered. • Patients should use commode or ambulate to bathroom when allowed. • Intermittent catheterization or indwelling catheter may be necessary. • Surgeon will decide activity needed. • Patient usually ambulates early in postoperative period. • Nurse’s responsibility to know specific orders related to activity • Instruct patient to avoid sitting for prolonged periods of time. Encourage – Walking – Lying down – Shifting weight from one foot to the other when standing Surgery on Cervical Spine • Be alert for symptoms of spinal cord edema such as respiratory distress and worsening neurologic status of the upper extremities. • After surgery, patient’s neck is immobilized in soft or hard cervical collar. • Patient should learn to mentally think through activities that may cause injury: – Bending – Lifting – Stooping • Twisting of spine is contraindicated Bone Tumors • Osteochondroma – Benign bone tumor-overgrowth of cartilage and bone near the end of the bone at the growth plate (metaphyseal portion) • Osteosarcoma – Aggressive and rapidly metastasizes to distant sites (usually on metaphyseal portion) • Metastatic bone cancer – Result from a primary tumor-brest, prostate, lungs, kidney, and throid – Cancer cell travels via the lymph and blood supply Osteosarcoma Osteosarcoma of the tibia. Tumor has infiltrated the cortex and formed soft-tissue masses on both sides of the bone. Osteosarcoma Chondrosarcoma in a 92-year-old woman. Paget's disease • is a disorder of the normal bone remodeling process. Normal bone has a balance of forces that act to lay down new bone and take up old bone;"bone remodeling" is essential for maintaining the normal calcium levels in our blood. In bone affected by Paget's disease, the bone remodeling is disturbed and not synchronized. As a result, the bone that is formed is abnormal, enlarged, not as dense, brittle, and prone to breakage. • Medications, orthopedic surgery for fractures, hip and knee replacements, discourage weight lifting, twisting. Balanced nutrition, vit D, Ca, and protein, and patient education. Hallux valgus A, Severe hallux valgus with bursa formation. B, Postoperative correction. • • Painfull deformity of great toe, bony enlargement of first metatarsal Wearing shoes with wide forefoot, surgical treatment removal of bony enlargement. Foot Disorders Claw-toe deformity. A type of hammer toe caused by chronic irritation from poorly fitting shoes.