Transcript Powerpoint

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 disk 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
Causes of degenerative disease: Video of diff causes:
http://www.spineandscoliosis.com/subject.php?pn=spinal-conditions
HNP- Herniated Nucleus Pulpsus
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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
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, sedentary life style
Smoking
Trauma
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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
Video:
http://www.spineandscoliosis.com/subject.php?pn=animatelumradsciatica
Common manifestations/complications
Lumbar HNP
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A common site is L4-5 disc- the 4th lumbar nerve root
Most common is posterior sensory nerve or root
compressed
Classic symptoms- low back sciatica pain. The pain
increases with increase in intrathorasic pressure- sneezing,
straining, coughing
Other symptoms- postural changes, urinary, male sexual
function, paresis/paralysis, foot drop, paresthesias,
numbness, muscle spasms, B&B incontinence, cord
reflexes decreased>absent
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- may cause pain and set up a
pain-spasm-pain cycle.
Collaborative Care: Diagnostic tests
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X-ray identify
deformities and
narrowing of disk space
CT/MRI
Mylogram- picture >
Diskogram
Nerve conduction studies
(EMG) to detect
electrical activity of
skeletal muscles
Collaborative Care:
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, anti-inflammatory,
muscle relaxants, antispasmodics and tranquilizers. Avoid
smoking
Heat/cold therapy to decrease muscle spasms
Break the pain-spasm-pain cycle with meds
(antispasmodics/pain meds)
Treatment- Conservative
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Intermittent skin traction (cervical/pelvic)
Ultrasound, massage, relaxation techniques
TENS unit (Transcutaneous electrical nerve stimulation)
Progressive mobilization with approved exercise program
–includes abdominal/thigh strengthening
Teaching good body mechanics
Weight loss
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
IDET or Percutanecus Disc Nucluoplasty
View video below:
http://www.spineandscoliosis.com/subject.php?pn=animat
e-nucleoplasty
Treatment- Surgery
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Spinal fusion removes most of the disk and replaces it
with bone usually from the patient iliac crest. View video:
http://www.spineandscoliosis.com/subject.php?pn=animate-spinalfusion
Videos of Lumbar inter-Body Fusion with cage:
http://www.spineandscoliosis.com/subject.php?pn=animate-alifmesh
http://www.spineandscoliosis.com/subject.php?pn=animate-ibf
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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. View video on Foraminotomy:
http://www.spineandscoliosis.com/subject.php?pn
=animate-cervpostfor
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
Charite disk: View Video on artificial disks:
http://www.spineandscoliosis.com/subject.php?pn=animatecervartificialdisc
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
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
Pertinent nursing problems/interventions
1. Acute pain
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Bedrest; medication (analgesics/antispasmotics; antiinflam); good body mechanics; back support (brace, etc)
Teach need to adhere to activity restrictions, grad inc,
Physician approved exercise program. Lumbar better to
stand than sit. Life style changes Avoid sit-ups
Post surgery the individual may have similar pain as preop due to lack of resiliency of the spinal nerves to
‘bounce’ back quickly
If use bone for fusion, 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
Chronic pain
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Surgery may not relieve pain
Nonpharmalogical methods to control pain
Pain clinic
Post-op care after spinal surgery
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Maintain proper body alignment
Pain control
Check dressing> blood/CSF; donor site
Monitor extremities: CMS (Circulation; Motor and
Sensory)
Assess paralytic ileus, bladder empting (bladder
scan/intermittent cath
Activity order
Teach use of brace/orthotic
Lumbar- avoid sitting prolonged periods
Firm mattress
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
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
Patho- normal spine as relates to 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 (origin in spinal cord) or secondary (metastatic
from other parts of the body)
Most spinal cord tumors found thoracic region
Compress, invade neural tissue, cause ischemia
Classification of spinal cord tumors by
anatomical area
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Extradural
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Outside the dura (outer layer of
the meninges)
from bones of spine, in
extradural space, or in
paraspinal tissue
90% of all spinal cord tumors
Usually malignant metastatic
lesions
Intradural: Inside the dura
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Intramedullary: within the
spinal cord itself (40% of
intradural tumors) Benign;
good prognosis
Extramedullary: within dura
mater outside of the spinal cord
Intermedullary spinal cord tumor
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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
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)
Collaborative Care for spinal cord tumor
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Diagnostic tests include:
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X-ray of the spinal column
Myelogram
Lumbar puncture with CSF analysis
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
Collaborative Care for spinal cord tumor
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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
HNP module for post-op care
Collaborative Care for spinal cord tumor
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Radiation Therapy spinal tumors
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Usually used for metastatic spinal cord
tumors to reduce size of the tumor to control
pain
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
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 ark (S2,3,4) interference can cause neurogenic
bladder as discussed with SCI
7. Home care
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Rhabilitation
Home evaluation
Support groups