Transcript Powerpoint

Module 8 Neurosensory:
Herniated Disk and Spinal Cord tumors
Marnie Quick RN, MSN, CNRN
A. Pathophysiology/etiology
Normal spine as related to herniated disk
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Herniated nucleus pulposus, slipped disk,
ruptured disk
Function of disc is to allow for mobility of the
spine and act as shock absorber
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Located between
vertebral bodies
Composed of nucleus
pulposus a gelatinous
material surrounded
By annulus fibrosis- a
fibrous coil
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Spinal nerves come
out between vertebra
from the reflex ark in
the spinal cord
Risk factors developing herniated disk
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Standing erect- cumulative effect and daily stress
Aging changes in disc and ligaments,
osteoarthritis
Poor body mechanics
Overweight
Trauma
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HNP- annulus becomes
weakened/torn and the
nucleus pulpsus herniates
through it.
HNP compresses
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Spinal nerve (sensory or
motor component) as it
leaves the spinal cord
Or the cord itself- the
white tracks within the
cord- rare
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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
B. Common manifestations/complications
Lumbar HNP
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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:
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Postural changes
Urinary/male sexual function changes
Paresis or paralysis
Foot drop
Paresthesias
Numbness
Muscle spasms
Absent cord reflexes
Common manifestations/complications
Cervical HNP
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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
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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
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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
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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
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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
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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
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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
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Back school approach
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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
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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
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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
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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 (speechhoarseness)- assess respiration, neck size,
swallowing and speech
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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
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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
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Surgery may not relieve pain
Nonpharmalogical methods to control pain
Pain clinic
3. Constipation
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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
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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
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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
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Intramedullary- arise from neural tissues of the
spinal cord
Extramedullary arise from tissues outside the
spinal cord may be benign or malignant
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Intradural-from the nerve roots or meninges in
subarachnoid space
Extradural- from the epidural tissue or vertebra
Spinal cord tumors primary or secondary
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Primary- originating in the spinal cord or
meninges
Secondary- metastases from other parts of the
body
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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
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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
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Manifestations thoracic cord tumor
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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
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Diagnostic tests include:
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X-ray of the spinal column
Myelogram
Lumbar puncture with CSF analysis
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Medications spinal tumors
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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
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Surgery for spinal cord tumors
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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
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Health history
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Pain, motor and sensory changes, bowel and
bladder changes, Babinski reflex.
Physical exam
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Similar to physical assessment for HNP
E. Pertinent nursing problems/interventions
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1. Anxiety
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Metatastic tumor vs benign spinal cord tumor
Education and support system
2. Risk for constipation
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From spinal cord compression, narcotics, bed rest
Adjust fluid and diet
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3. Impaired physical mobility
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4. Acute pain
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From bed rest and motor involvement
Basic nursing- ROM, etc
From compression or invasion of tumor
Assess and treat
5. Sexual dysfunction
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Male sacral reflex ark (S 2,3,4) interference
Similar care as discussed with SCI
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6. Urinary retention
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Reflex arc (S2,3,4) interference can cause neurogenic
bladder as discussed with SCI
7. Home care
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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
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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/