Ch. 63: lower back pain

Nursing Management Spinal Surgery: Postoperative

-Frequently assess peripheral neurologic signs -Every 2 to 4 hours during first 48 hours post surgery -Compare with preoperative status ( movement should be equal to preop, report any newparesthesias/muscle weaknesses to surgeon) -Assess circulation (temp, capillary refill, pulses)

Ambulatory and Home Care

-Goal is to make an episode of acute low back pain an isolated incident -Patient teaching imperative -Occupational counseling -Emotional support

Nursing Assessment:Objective Data

-Guarded movement -Depressed or absent Achilles tendon or patellar reflex + Straight leg raise test + Crossover straight leg test + Trendelenburg test -Tense, tight paravertebral muscles -↓ Range of motion in spine

Intervertebral Disc Disease:Surgical Therapy

-Indicated when: *Conservative treatment fails *Radiculopathy worsens *Loss of bowel or bladder control *Constant pain *Persistent neurologic deficit

Intervertebral Disc Disease:Etiology and Pathophysiology

-Intervertebral discs separate vertebrae and help absorb shock -Disease involves deterioration, herniation, or other dysfunction -Involves all levels

Low back pain common because lumbar region

-Bears most of body weight -Is most flexible -Contains nerve roots -Has poor biomechanical structure

The causes of low back pain of musculoskeletal origin include:

(1) acute lumbosacral strain, (2) instability of the lumbosacral bony mechanism (3) osteoarthritis of the lumbosacral vertebrae (4) degenerative disc disease, and (5) herniation of an intervertebral disc.

Intradiscal electrothermoplasty (IDET)

* Minimally invasive outpatient procedure * Needle inserted into affected disc * Wire threaded into disc and heated → denervates nerve fibers *The heat also partially melts the annulus fibrosus. This causes the body to generate new reinforcing proteins in the fibers of the annulus.

Referred Pain

- "felt" or perceived in the lower back, but the source of the pain is another location (e.g., kidneys, lower abdomen).

Low Back Pain

- Affects ~80% of adults in United States at least once - Second only to headache as most common pain complaint - Leading cause of job-related disability - Major contributor to missed work days

Do Not

- Lean forward without bending knees - Lift anything above level of elbows - Stand in one position for prolonged time - Sleep on abdomen or on back or side with legs out straight - Exercise without consulting health care provider if having severe pain

Etiology and Pathophys

- Most often due to musculoskeletal problem - localized: soreness/discomfort when a specific area of the lower back is palpated/pressed - diffused: occurs over a larger area and comes from deep tissue - Radicular pain: caused by irritation of a nerve root - Referred Pain: source of pain is another location

Nursing Management Spinal Fusion: Postoperative

- Regularly assess bone graft donor site *Posterior iliac crest (most commonly used donor site) *Fibula - Usually more painful than fusion area - Pressure dressing - Neurovascular assessments if fibula is donor site

Radicular pain

- caused by irritation of a nerve root. Radicular pain is not typically isolated to a single location, but instead radiates or moves along a nerve distribution. Sciatica is an example of radicular pain.

Risk factors associated with low back pain include:

- lack of muscle tone and excess body weight, pregnancy, stress, poor posture, cigarette smoking, prior compression fractures of the spine, spinal problems since birth, and a family history of back pain.

Degenerative disc disease (DDD)

- loss of elasticity, flexibility, & shock-absorbing capabilities - disc becomes thinner at nucleus pulposus dries out, load is shifted to annulus fibrosus and progressive pulposus seeps out (herniates)

Interprofessional Care

-Back-strengthening exercises *Twice a day *Encouraged for a lifetime -Teach good body mechanics -Avoid extremes of flexion and torsion -Most patients heal in 6 months

Artificial disc replacement

-Charité or Prodisc-L disc for lumbar DDD -Prestige cervical disc system -Surgically placed in spine through small incision after damaged disc is removed -Allows for movement at level of implant

Conservative Therapy

-Drug therapy to manage pain includes NSAIDs, short-term use of corticosteroids, opioids, analgesics, muscle relaxants, antiseizure drugs, and antidepressants. -Epidural corticosteroid injections may reduce inflammation and relieve acute pain. -However, if the underlying cause remains, pain tends to recur.

do:

-Exercise 15 minutes in the morning and evening regularly -Carry light items close to body -Use local heat and cold application -Use a lumbar roll or pillow for sitting -Begin exercises with 2- or 3-minute warm-up period

Occupational risk factors

-Jobs that require repetitive heavy lifting, vibration (such as a jackhammer operator), and extended periods of sitting are also associated with low back pain. -Health care personnel who perform direct patient care activities are at high risk for the development of low back pain. -Lifting and moving patients, excessive bending or leaning position, and frequent twisting can result in low back pain that causes lost time and productivity and/or disability.

Acute low back pain

-Lasts 4 weeks or less -Caused by trauma or undue stress -Symptoms usually appear within 24 hours -Muscle ache to shooting/stabbing pain -Limited flexibility/ROM -Inability to stand upright

Chronic Low Back Pain

-Lasts longer than 3 months or involves a repeated incapacitating episode -Often progressive Various causes -Degenerative or metabolic disease -Weakness from scar tissue -Chronic strain -Congenital spine problems

Possible Diagnostic Findings

-Lesion or disorder on myelogram, CT scan, or MRI -Nerve root impingement on electromyography (EMG)

Conservative Therapy

-Limitation of movement -Local heat or ice -Ultrasound and massage -Skin traction -Transcutaneous electrical nerve stimulation (TENS)

Intervertebral Disc Disease:Clinical Manifestations

-Low back pain most common -Radicular pain -+ Straight leg raise (indicates nerve root irritation) -↓ or absent reflexes -Paresthesia -Muscle weakness

Nursing Management:Vertebral Disc Surgery

-Maintain proper alignment -Allowed activity varies -Post lumbar fusion -Pillows under thighs when supine -Between legs when side-lying -Reassure patient

tx of chronic back pain

-Manage the patient's pain and stiffness with mild analgesics, such as -NSAIDs, is imilar to those recommended for acute low back pain. integral to the daily comfort of the individual with chronic low back pain. -Antidepressants (e.g., duloxetine [Cymbalta]) may help with pain management and sleep problems. -The antiseizure drug gabapentin (Neurontin) may improve walking and relieve leg symptoms

Minimally invasive treatments

-Minimally invasive treatments, such as epidural corticosteroid injections and implanted devices that deliver pain medication, may be used for patients with chronic low back pain that fails to respond to the usual therapeutic options. -Surgical intervention may be indicated in patients with severe chronic low back pain who receive no benefit from conservative care and/or have continued neurologic deficits. Specific surgical interventions will be discussed after intervertebral disc disease.

Nursing Management Spinal Surgery: Postoperative

-Monitor GI and bowel function -Administer stool softeners -Monitor and assist with bladder emptying -Loss of tone may indicate nerve damage -Notify surgeon immediately if bowel or bladder incontinence

Treat as outpatient if not severe..

-NSAIDs, muscle relaxants -Massage -Back manipulation -Acupuncture -Cold and hot compresses -Severe pain: corticosteroids, opioids

Spinal stenosis

-Narrowing of spinal canal -Acquired conditions -Osteoarthritis most common -Rheumatoid arthritis, tumors, Paget's disease, trauma -Inherited conditions -Congenital spinal stenosis -Scoliosis

Radiofrequency discal nucleoplasty (coblation nucleoplasty)

-Needle inserted similar to IDET -Radiofrequency probe generates energy → breaks up nucleus pulposus -Up to 20% of nucleus is removed -Decompresses disc

Nursing Management:Spinal Surgery: Postoperative

-Opioids for 24 to 48 hours -Patient-controlled analgesia (PCA) (preferred method of continuous pain) -Switch to oral drugs when able -Muscle relaxants (Diazepam-Valium) -Assess and document pain intensity, and pain management effectiveness

Spinal stenosis - lumbar

-Pain in low back and radiates to buttock and leg -↑ With walking/ prolonged standing -Numbness, tingling, weakness, heaviness in legs and buttocks -Pain ↓ when bends forward or sits down -In most cases the stenosis slowly progresses.

Cervical disc disease

-Pain radiates to arms and hands. -↓ Reflexes and handgrip -May include shoulder pain and dysfunction

Nursing Management Spinal Surgery: Postoperative

-Potential for cerebrospinal fluid (CSF) leakage -Monitor for and report severe headache or leakage of CSF -Clear or slightly yellow drainage on dressing -+ For glucose

do

-Prevent lower back from straining forward by placing a foot on a step or stool during prolonged standing -Maintain appropriate body weight

Nursing Management Spinal Fusion: Postoperative

-Prolonged limited activity -Rigid orthosis (thoracic-lumbar-sacral orthosis or chairback brace) *Verify and teach how to apply -Cervical spine *Observe for spinal cord edema *Immobilize neck

Health promotion

-Proper body mechanics -"Back School" -Appropriate body weight -Proper sleep positioning -Firm mattress Stop smoking

Teaching regarding activity

-Proper body mechanics -Avoid prolonged sitting or standing. -Encourage walking, lying down, shifting weight -No lifting, twisting -Use thighs and knees to absorb shock -Firm mattress or bed board

Radiculopathy

-Radiating pain -Numbness -Tingling -↓ Strength and/or range of motion -Osteoarthritis

overall goals

-Satisfactory pain relief (<4 on 10 point scale) -Return to previous level of activity -Correct performance of exercises -Adequate coping -Adequate self-help management

Multiple nerve root (cauda equina) compression

-Severe low back pain -Progressive weakness -Increased pain -Bowel and bladder incontinence -Medical emergency (requires surgical decompression)

DO:

-Sleep in a side-lying position with knees and hips bent -Sleep on back with a lift under knees and legs or back with 10-inch-high pillow under knees to flex hips and knees -Tell patients to avoid sleeping in a prone position because this produces excessive lumbar lordosis, placing excessive stress on the lower back.

Spinal fusion

-Spine is stabilized by creating an ankylosis (fusion) of contiguous vertebrae -Uses a bone graft from patient's fibula or iliac crest (autograft) or from a donated cadaver bone (allograft) -Metal fixation can add to stability -Bone morphogenetic protein (BMP) to stimulate bone grown of graft

Few definitive diagnostic abnormalities

-Straight-leg raising test -Positive for disc herniation when radicular pain occurs -MRI and CT scan only for trauma or suspected systemic disease

Laminectomy

-Surgically remove disc through excision of part of vertebra

Diskectomy

-The surgeon uses a microscope for better visualization of the disc and disc space to aid in the removal of the damaged portion -Surgically decompress nerve root -Microsurgical or percutaneous technique

Interspinous process decompression system (X Stop)

-Titanium →fits into mount placed on vertebrae -To treat lumbar spinal stenosis -Lifts vertebrae off pinched nerve

Chronic Low Back Pain:Interprofessional Care

-Weight reduction -Sufficient rest periods -Local heat and cold application -Physical therapy -Exercise and activity throughout day -Complementary and alternative therapies -Back School

Intervertebral Disc Disease:Diagnostic Studies

-X-rays -Myelogram, MRI, or CT scan -Epidural venogram or discogram -EMG (determines severity of nerve irritation/rules out other conditions such as peripheral neuropathy)