Transcript Changes in Peripheral Nervous System

Spinal Cord Anatomy
 spinal cord anatomy
Spinal Cord Anatomy
Pathophysiology/Etiology
 Function of disc is to allow for mobility of the
spine and act as shock absorber
Pathophysiology/Etiology
 Located between
vertebral bodies
 Composed of nucleus
pulposus a gelatinous
material surrounded
by annulus fibrosis- a
fibrous coil
Pathophysiology/Etiology
 Spinal nerves come
out between vertebra
Herniated Disc
 Herniated nucleus pulposus, slipped disc, ruptured
disc
 HNP- annulus becomes weakened/torn and the
nucleus pulpsus herniates through it.
Risk Factors Standing erect- cumulative effect and daily stress
 Aging changes in disc and ligaments, osteoarthritis
 Poor body mechanics
 Overweight
 Trauma
Common
Manifestations/Complications
 HNP compresses
 Spinal nerve (sensory or
motor component) as it
leaves the spinal cord
 Or the cord itself- the white
tracts within the cord- rare
Common
Manifestations/Complications
 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
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
 herniated disc L4-L5
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 disc- 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
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, antiinflammatory, 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
 herniated disc repair
Treatment- Surgery
 Spinal fusion removes most of the disc and replaces it
with bone usually from the patient iliac crest
 Flexibility is lost at the site- requires longer hospital
stay
 spinal fusion
Treatment- Surgery
 Foraminotomy
 Enlargement of the bony overgrowth at the opening
which is compressing the nerve
 Microdiskectomy
 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
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 for HNP
 Sensory/motor assessment- care not to injure op
site
 Assess for CSF drainage or bleeding from op site
 Encourage turn (log roll, cough, deep breath)
 Assess for postural hypotension, especially if client
was on bed rest for several days/weeks prior to
surgery
Post-op Assessment for HNP
 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
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
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
Classification of 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
Classification of Spinal Cord Tumors
by Origin
 Primary- originating
in the spinal cord or
meninges that is not
relieved by bed rest
 Secondary-
metastases from
other parts of the
body
Spinal Cord Tumors
 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
Common Manifestations/Complications
 Symptoms depend on the anatomical level of the
spinal column, the anatomical location, the type of
tumor and the spinal nerves affected
 Pain that is not relieved by bed rest is the
most common presenting symptom
 Other symptoms are similar to those found with
HNP or spinal cord injury- sensory or motor
Common Manifestations/Complications
 Manifestations of 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)
Therapeutic Interventions
 Diagnostic tests include:
 X-ray of the spinal column
 Myelogram
 Lumbar puncture with CSF analysis
Therapeutic Interventions
 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
Therapeutic Interventions
 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
Nursing Assessment
 Health history
 Pain, motor and sensory changes, bowel
and bladder changes, Babinski reflex.
 Physical exam
 Similar to physical assessment for HNP
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
Nursing Problems/Interventions
 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
Nursing Problems/Interventions
 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 Disc
http://wps.prenhall.com/wps/media/objects/737/755395/intervertebral_disk.pdf
Added Critical thinking questions
Nursing Care Plan:
A Client with Ruptured Intervertebral Disc
 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 disc?
LeMone Blackboard: Media Links
http://wps.prenhall.com/chet_lemone_medicalsurg_3
/0,7859,757263-,00.html
http://www.spine-health.com/