Module 8 Neurosensory:

Herniated Disk and Spinal Cord tumors

Marnie Quick RN, MSN, CNRN

A. Pathophysiology/etiologyNormal spine as related to herniated disk Herniated nucleus pulposus, slipped disk,

ruptured disk Function of disc 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

Risk factors developing herniated disk Standing erect- cumulative effect and daily stress Aging changes in disc and ligaments,

osteoarthritis Poor body mechanics Overweight Trauma

HNP- annulus becomes weakened/torn and the nucleus pulpsus herniates through it.

HNP compresses Spinal nerve (sensory or

motor component) as it leaves the spinal cord

Or the cord itself- the white tracks within the cord- rare

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

B. 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

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 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 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, anti-inflammatory, 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

Treatment- Surgery 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 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 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

D. 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 from HNP 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 (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

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

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 A. 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 Spinal tumors are classified by anatomical area

and as primary or secondary

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

Spinal cord tumors primary or secondary Primary- originating in the spinal cord or

meninges Secondary- metastases from other parts of the

body

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 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

Manifestations 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)

C. Therapeutic interventions spinal tumors Diagnostic tests include:

X-ray of the spinal column Myelogram Lumbar puncture with CSF analysis

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

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

D. Nursing assessment specific to cord tumors

Health history Pain, motor and sensory changes, bowel and

bladder changes, Babinski reflex. Physical exam

Similar to physical assessment for HNP

E. Pertinent 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

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

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 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 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_medicalsurg_3/0,7859,757263-,00.html

http://www.spine-health.com/