Changes in Peripheral Nervous System
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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/