Neurosensory HNP,Spinal Tumors

7/30/2019 Neurosensory HNP,Spinal Tumors

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Module 8 Neurosensory:Herniated Disk and Spinal Cord tumors

Marnie Quick RN, MSN, CNRN


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A. Pathophysiology/etiology Normal spine as related to herniated disk

Herniated nucleus pulposus, slipped disk,ruptured disk

Function of disc is to allow for mobility of thespine and act as shock absorber


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Located betweenvertebral bodies

Composed of nucleus pulposus a gelatinousmaterial surrounded

By annulus fibrosis- afibrous coil


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Spinal nerves comeout between vertebra

from the reflex ark inthe spinal cord


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Risk factors developing herniated disk Standing erect- cumulative effect and daily stressAging changes in disc and ligaments,osteoarthritisPoor body mechanicsOverweight

Trauma


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HNP- annulus becomesweakened/torn and the

nucleus pulpsus herniatesthrough it.HNP compresses

Spinal nerve (sensory or motor component) as itleaves the spinal cordOr the cord itself- thewhite tracks within thecord- rare


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Sensory root or nerve of the spinal nerve isusually affected resulting in sensory symptoms-

pain, parenthesis, or loss of sensationMotor root or nerve may be affected whichresults in motor symptoms- paresis or paralysis

Manifestations depend on what nerve root, spinalnerve is being compressed which dermatomesRadiculopathy- pathology of the nerve root


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B. Common manifestations/complicationsLumbar HNP

Most common site for HNP is L4-5 disc- the 5 th lumbar nerve root

Most common is the posterior sensory nerve or root compressedClassic symptoms- low back sciatica pain. The

pain increases with increase in intrathorasic pressure


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Other symptoms lumbar HNP:Postural changesUrinary/male sexual function changesParesis or paralysisFoot dropParesthesias

NumbnessMuscle spasmsAbsent cord reflexes


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Common manifestations/complicationsCervical HNP

C5-C6 disk- affects the 6 th cervical nerve rootPain- neck, shoulder, anterior upper arm to thumbAbsent/diminished reflexes to the armMotor changesparesis or paralysisSensory- paresthesias or pain

Muscle spasms


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C. Therapeutic Interventions- diagnostictests

X-ray identifydeformities and

narrowing of disk spaceCT/MRIMylogram p1336

Nerve conduction studies

(EMG) to detectelectrical activity of skeletal muscles


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Treatment- ConservativeBed rest with firm mattress; log roll; side lying

position with knees bent and pillow between legs

to support legsAvoid flexion of the spine- brace/corset, cervicalcollar to provide support

Medications- nonnarcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodicsand tranquilizers


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Treatment- ConservativeHeat/cold therapy to decrease muscle spasmsBreak the pain-spasm-pain cycleUltrasound, massage, relaxation techniquesProgressive mobilization with approved exercise

program includes abdominal/thigh strengthening

Teaching good body mechanicsWeight lossTENS unit


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Treatment- SurgeryLaminectomy- removal of a portion of the laminato relieve pressure and to get to the herniated

nucleus pulposus that is protruding out


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Treatment- SurgerySpinal fusion removes most of the disk andreplaces it with bone usually from the

patient iliac crestFlexibility is lost at the site- requires longer hosp stay


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Treatment- SurgeryForaminotomy is enlargement of the bonyovergrowth at the opening which is compressing

the nerveMicrodiskectomy is use of electron microscopethrough a small incision to remove a portion of the HNP that is displaced. If cervical HNP,usually use the anterior approach in the neck


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Prevention of HNPBack school approach-

Causes of HNP

Learn how to preventGood body mechanicsExercises to strengthen leg and abdominal muscles

Change in life-style or occupation


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D. Nursing Assessment Specific to HNPHealth History

Assess for risk factors- the cumulative effect of standing erect and daily stress; aging changes in

disc/ligaments; poor body mechanics;overweight; traumaEmployment, history of pain, and other neurochanges


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Nursing Assessment specific to HNPPhysical exam

Use similar methods to assess as utilized SCIMuscle strength and coordinationSensation- sharp/dull of paperclip usingdermatome as referencePain evaluation- pain scale

Pre/Post-op assessment


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Post-op assessment from HNP NVS sensory/motor- care not to injure op siteAssess for CSF drainage or bleeding from op siteEncourage 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


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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, etcAssess for postural hypotension, especially if indwas on bed rest for several days/weeks prior tosurgery


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E. Pertinent nursing problems/interventions1. Acute pain

Post surgery the individual may have similar painas pre-op due to lack of resiliency of the spinal

nerves to bounce back quickly Donor site (illiac crest) may cause more pain thanlaminectomy

Individual may be in a pain-spasm-pain cycle,therefore may need both antispasmodic as well asanalgesic


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2. Chronic painSurgery may not relieve pain

Nonpharmalogical methods to control painPain clinic


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3. ConstipationAs a result of bed rest and decreased mobility andfear of pain with straining of stool

Constipation prevention methods fluids, diet, etc


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4. Home careWhen riding in a car, take frequent stops to moveand stretch

Prevention Back school approachMay have to deal with pain as a chronic conditionMay need to make life/job changes


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Spinal Cord Tumors

A. Patho- normal cord & cord tumorsCNS is made up of neural tissue (neurons) andsupport tissue (glial)

These tissues undergo changes and result inspinal cord tumorsBlood vessels and bone (vertebra) also can be

part of the tumor Spinal tumors are classified by anatomical areaand as primary or secondary


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Spinal cord tumors by anatomical areaIntramedullary- arise from neural tissues of thespinal cord

Extramedullary arise from tissues outside thespinal cord may be benign or malignant

Intradural-from the nerve roots or meninges insubarachnoid spaceExtradural- from the epidural tissue or vertebra


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Spinal cord tumors primary or secondaryPrimary- 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 thoracicregion

Spinal cord tumors can compress (benign),invade the neural tissue, or cause ischemia to thearea because of vascular obstruction


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B. Common manifestation/complicationsSymptoms depend on the anatomical level of thespinal column, the anatomical location, the type

of tumor and the spinal nerves affectedPain is the most common presenting symptomthat is not relieved by bed restOther symptoms are similar to those found withHNP or spinal cord injury- sensory or motor


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Manifestations thoracic cord tumor Paresis & spasticity of one leg then the other Pain back & chest, not relieved by bedrest;sensory changesBabinski reflex

Bowel (ileus); bladder dysfunction (UMN intype)


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C. Therapeutic interventions

spinal tumorsDiagnostic tests include:

X-ray of the spinal columnMyelogramLumbar puncture with CSF analysis


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Medications spinal tumorsControl pain- narcotic analgesics, may begiven epidural catheter, PCA, NSAIDs Reduce cord edema and tumor size- steroidsdexamethasome (Decadron) high dose for a

few days, then taper off with a Medrol dose pack


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Surgery for spinal cord tumorsLaminectomy to remove or to decrease thesize (decompression laminectomy) of thespinal cord tumor Spinal fusion or the insertion of rods if

several vertebra involved and the column isunstable

Radiation to reduce size and control pain


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D. Nursing assessment specific to cord tumorsHealth history

Pain, motor and sensory changes, bowel and bladder changes, Babinski reflex.

Physical examSimilar to physical assessment for HNP


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E. Pertinent nursing problems/interventions1. Anxiety

Metatastic tumor vs benign spinal cord tumor

Education and support system2. Risk for constipation

From spinal cord compression, narcotics, bed restAdjust fluid and diet


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3. Impaired physical mobilityFrom bed rest and motor involvement

Basic nursing- ROM, etc4. Acute pain

From compression or invasion of tumor Assess and treat

5. Sexual dysfunctionMale sacral reflex ark (S 2,3,4) interferenceSimilar care as discussed with SCI


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6. Urinary retentionReflex arc (S2,3,4) interference can cause neurogenic

bladder as discussed with SCI7. Home care

RehabilitationHome evaluationSupport groups


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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
http://wps.prenhall.com/wps/media/objects/737/755395/intervertebral_disk.pdfhttp://wps.prenhall.com/wps/media/objects/737/755395/intervertebral_disk.pdf


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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 thedermatome 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 andmuscle relaxants around the clock when awake?4. How does a cervical collar help? What else may helprelieve the pain?

5. If the conservative methods did not work, what elsemight the physician have done?6. Why are conservative methods tried for a period of time rather than immediate surgery?


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7. Where is the posterior/anterior nerve root?8. Where is the lamina? 9. Would the Dr use theanterior or posterior surgical route to get to her disk?


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LeMone Blackboard: Media Links

http://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.html

http://www.spine-health.com/
http://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.htmlhttp://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.htmlhttp://www.spine-health.com/http://www.spine-health.com/http://www.spine-health.com/http://www.spine-health.com/http://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.htmlhttp://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.htmlhttp://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.htmlhttp://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.html

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Neurosensory HNP,Spinal Tumors