Low Back Pain

Acute Low Back Pain is:

Acute back pain is a pain that last 4 weeks or less. Acute low back pain is usually associated with some type of activity that causes undue stress (often hyperflexion) on the tissues of the lower back. E.g. Heavy lifting, overused of back muscle while working on the yard, sports injury.

Patient's teaching Don't s

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

Bone Graft Surgery Nursing Implications

Longer recovery time for patients who have bone graft Rigid orthosis is often used when patient is immobilized. Nurse will need to teach patient preferred way to put on and take off brace by logrolling in bed or by sitting or standing positions. Nurse to verify preferred method with physician.

Multiple nerve root compression may be manifested as:

as bowel and bladder incontinence or impotence. This condition is a medical emergency.

Proper Technique To Turn and Position Patients Post Op is:

-Logroll patient when turning -Pillows under thighs of each leg when supine and between legs when side-lying Patient often fears turning or any movement that increases pain. Offer reassurance that proper technique is being used. Sufficient staff should be available to move patient without undue pain or strain on staff and patient.

Nursing Assessment Objective Data

1) Observe for guarded movement 2) Neurologic- depressed or absent achilles tendon reflex or patellar tendon reflex; positive leg raising test, positive crossover straight-leg raising test, positive Trendelenburg test 3-Musculoskeletal- Tense, tight paravertebral muscles on palpation, decrease range of motion of the spine. 4- Diagnostic finding- CT scan MRI Determination of nerve root impingement on electromyography

Nursing Assessment (Subjective data)

1) Past medical history- Have he/she ever had a acute or chronic lumbosacral trauma, degenerative disc disease, osteoarthritis, obesity 2) What type of medications- Opiods, nonopiods analgesics, muscle relaxants, NSAIDS, corticosteroids, and OTC medications 3)Surgeries or other past treatments (e.g previous back surgery, epidural corticosteoid injections). 4)Health patterns- -Smoking, lack of exercise, obesity, poor posture, muscle spasms, activity intolerance, constipation, interrupted sleep 5)Cognitive perception- Is the pain in back, buttocks or legs associated with walking, turning, coughing, straining, leg raising; is there any tingling or numbness of the feet or toes. 6- Occupation- Does he/she required to do heavy lifting, use of equipment that emits vibrations or extended driving.

Low Back Pain of Musculoskeletal Origin Includes:

1)Acute lumbosacral strain 2)Instability of the lumbosacral bony mechanism 3)Osteoarthritis 4)Degenerative disc disease 5)Herniation of an intervertebral disc.

Structural Degeneration of the Disc is Often Caused by:

1-Degenerative Disc Disease( DDD) - Is a normal process of aging and results in the intervertebral disc losing their elasticity, flexibility and shock absorbing capabilities. 2) Herniated Disc- or slipped disc, is a condition in which a spinal disc herniates and bulges outward between the vertebrae.

Treatment (Drug Therapy)

1-NSAIDS 2-Short term use of opiods 3-Analgesics 4-Muscle relaxant 5-Antiseizure drugs 6-antidepressants 7-Epidural corticosteoids injections

Surgical Procedure- Diskectomy

A diskectomy is another common type of surgical procedure that may be performed to decompress the nerve root. Microsurgical diskectomy is a version of the standard diskectomy in which the surgeon uses a microscope to allow better visualization of the disk and disk space during surgery to aid in removal of the damaged portion. This helps maintain the bony stability of the spine.

Positive Straight Leg Raise Means:

A positive (abnormal) test means that one or more of the nerve roots leading to the sciatic nerve may be compressed or irritated.

Patients Should Avoid

Activities that aggravate pain: Lifting Bending Twisting Prolonged sitting (Most cases improve in 2 weeks).

GU Disturbances Post OP

Adequate bladder emptying may be altered because of activity restrictions, opioids, or anesthesia. If allowed by the surgeon, encourage men to dangle the legs over the side of the bed or stand to urinate. Patients should use the commode or ambulate to the bathroom when allowed, to promote adequate emptying of the bladder. Ensure that privacy is maintained. Clarify whether the patient can be allowed up to ambulate to the bathroom without the corset or brace. Intermittent catheterization or an indwelling catheter may be necessary for patients who have difficulty urinating.

Post Op Nursing Care

After vertebral disc surgery, postoperative nursing intervention mainly focus on maintaining proper body alignment of the spine until it has healed. Depending on the type and extent of surgery, patient may be able -To dangle legs at side of the bed -To stand -To ambulate first day after surgery

Herniated Disc

An acute herniated intervertebral disk (slipped disk) can be the result of natural degeneration with age or repeated stress and trauma to the spine. The nucleus pulposus first may bulge and then it can herniate, placing pressure on nearby nerves. The most common sites of rupture are the lumbosacral disks, specifically L4-5 and L5-S1. Disk herniation may also occur at C5-6 and C6-7. Disk herniation may be the result of spinal stenosis, in which narrowing of the spinal canal creates bulging of the intervertebral disk.

Nursing Consideration Post Op

Because the spinal canal may be entered during surgery, there is a potential for cerebrospinal fluid (CSF) leakage. Immediately report severe headache or leakage of CSF on the dressing. CSF appears as clear or slightly yellow drainage on the dressing. It has a high glucose concentration and is positive for glucose when tested on a dipstick (Note the amount and color of drainage).

Chronic Low Back Pain is Caused By:

Degenerative disk disease Lack of physical exercise Prior injury Obesity Structural and postural abnormalities Systemic disease

Risk Factors for Low Back Pain are:

Lack of muscle tone Excess body weight Poor posture Cigarette smoking Stress Pregnancy Prior compression fractures of the spine. Jobs that requires repetitive heavy lifting, vibration(e.g. jackhammer operator) and sitting for a long period of time.

Diagnostic Tests: Acute Low Back Pain

Few definitive diagnostic abnormalities with paravertebral muscle strain One test is straight-leg raise. Positive for disk herniation when radicular pain occurs. MRI and CT not done unless trauma or systemic disease is suspected

Nursing Consideration Post Op (cont)

Frequently monitor patient's peripheral neurologic signs such as: 1)Movement of the arms and legs 2)Assessment of sensation (should be unchanged when compared with pre-op status). 3-Assessment should be repeated every 2 to 4 hours during the first 48 hours after surgery and compared with the pre-op assessment. 4-Paresthesias, such as numbness and tingling, may not be relieved immediately after surgery. 5-Document any new muscle weakness or paresthesias, and report this to the surgeon immediately. 6-Assess extremity circulation by temperature, capillary refill, and pulses.

Ambulatory and Home Care

Goal is to make an episode of acute low back pain an isolated incident. If lumbosacral mechanism is unstable, repeated episodes can be anticipated. The lumbosacral spine may be unable to meet the demands placed on it without strain because of factors such as obesity, poor posture, poor muscular support, advancing age, or local trauma. Intervention is aimed at strengthening the supporting muscles with exercise. A corset limits extremes of movement and may be useful in decreasing pain and the use of pain medication. If the strain is work related, occupational counseling may be necessary. The frustration, pain, and disability imposed on the patient with low back pain require your emotional support and understanding care.

Medications

If the acute muscle spasms and accompanying pain are not severe and debilitating, the patient may be treated on an outpatient basis with a combination of the following: (1) analgesics, such as NSAIDs. (2) muscle relaxants (e.g., cyclobenzaprine [Flexeril]) 3)Tricyclic antidepressants Serotonin reuptake inhibitors Both have been shown to improve chronic symptoms.

Patient Teaching

Instruct patient in proper body mechanics and to avoid sitting for prolonged periods of time. Encourage activity such as : Walking -Lying down -Shifting weight from one foot to the other when standing -Lifting is usually restricted in the postoperative period following spinal surgery. -The patient should learn to mentally think through an activity before starting any potentially injurious task such as bending or stooping. -Any twisting movement of the spine is contraindicated. -The thighs and knees, rather than the back, should be used to absorb the shock of activity and movement. -Firm mattress or bed board is essential.

Intervention is aimed at

Intervention is aimed at strengthening supporting muscles with exercise.

Intervertebral Disk Disease

Is a condition that involves the deterioration, herniation, or other dysfunction of the vertebral disc.

Low Back Pain

Is most often due to a musculoskeletal problem. It may be experienced as a localized or diffuse.

The Goal of Nursing Management is To:

Is to make an episode of acute low back pain an isolated incident. If lumbosacral mechanism is unstable, repeated episodes can be anticipated. The lumbosacral spine may be unable to meet the demands placed on it without strain because of factors such as obesity, poor posture, poor muscular support, advancing age, or local trauma.

Low Back Pain is Most Common in:

Lumbar region due to: 1-Bears most of the weight of body 2-Is the most flexible region of the spinal column 3-Contains nerve roots that are vulnerable to injury or disease 4-Has an inherently poor biomechanical structure

Acute low back Pain Treatment

Massage and back manipulation Alternating use of heat and cold compresses Opioid analgesics for severe pain Severe back pain may require a brief period (1 to 2 days) of rest at home, but most persons do better with continuation of their regular activities. Prolonged bed rest should be avoided.

Why Does Low Back Pain Occur?

Most common cause of low back pain is muscle strain due to: -deconditioning -trauma- overloaded (e.g. lifting something heavy). -

Pharmacological Treatment Post Op

Most patients will require opioids for 24 to 48 hours. Preferred method is patient-controlled analgesia (PCA). Once fluids are being taken, switch to oral drugs(e.g. Vicodin or Percocet) and possible muscle relaxants(e.g. Valium ).

Loss of sphincter tone or bladder tone may indicate

Nerve damage Monitor for incontinence or difficulty evacuating the bowel or bladder, and report findings immediately.

Symptoms of Acute Back Pain

Often do not appear at the time of injury but develop later(Within 24hr) because of gradual increase in pressure on the nerve by an intervertebral disc.

Conservative treatment

Once Symptoms subside, back strengthening exercises are begun twice a day and encouraged for a lifetime. Teach the patient proper body mechanics. Discourage extremes of flexion and torsion.

Degenerative Disc Disease is Associated With:

Osteoarthritis of the spine and stress placed on the vertebrae.

GI Disturbances Post OP

Paralytic ileus and interference with bowel function may occur for several days and may manifest as nausea, abdominal distention, and constipation. Assess whether the patient is passing flatus, has bowel sounds in all quadrants, and has a flat, soft abdomen. Stool softeners (e.g., docusate [Colace]) may aid in relieving and preventing constipation.

Treatment

Patients with suspected disc damage is usually first managed with conservative therapy, this includes: 1)limitation of extremes of spinal movement (brace, corset, or belt) 2)local heat or ice, 3)Ultrasound and massage, traction, and transcutaneous electrical nerve stimulation (TENS).

Patient Teaching Do's

Prevent lower back from straining forward by placing a foot on a step or stool during prolonged standing Maintain appropriate body weight 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 Exercise 15 minutes in the morning and evening regularly Use local heat and cold application Use a lumbar roll or pillow for sitting

Chronic Low Back Pain: Medications

Relief of pain and and stiffness with: -Mild analgesic (e.g NSAIDS) Other treatment regimens: -Tricyclic antidepressants -Serotonin reuptake inhibitors Both have been shown to improve chronic symptoms. -Gabapentin (Neurontin)

Surgical Therapy

Surgery for a damaged disk is generally indicated when diagnostic tests indicate that the problem is not responding to conservative treatment, and the patient is in consistent pain and/or has a persistent neurologic deficit.

Surgical Procedures- Laminectomy.

The most common and traditional surgical procedure for lumbar disk disease is a laminectomy. It involves the surgical excision of part of the posterior arch of the vertebra (referred to as the lamina) to gain access to part of or the entire protruding disk to remove it. A minimal hospital stay is usually required after the procedure.

Lumbar Disc Disease Manifestation

The most common manifestation is low back pain Indications of disk herniation: Radicular pain that radiates down buttock and below knee Along distribution of sciatic nerve Straight-leg raising-test may be positive. Reflexes may be depressed or absent, depending on the spinal nerve root involved Back or leg pain may be reproduced by raising leg and flexing foot at 90 degrees. Paresthesia or muscle weakness in legs, feet, or toes may be reported

Diffuse Back Pain

The pain is spread over a larger area and comes from deep tissue layers.

Localized Back Pain

The person feels soreness or discomfort when they or someone else palpate or press on a specific area of the lower back.

Primary nursing responsibilities

The primary nursing responsibilities in acute low back pain are to assist the patient to maintain activity limitations, promote comfort, and educate the patient about the health problem and appropriate exercises. Educate patient about health problem. Educate patient on appropriate exercises. Use analgesics, NSAIDs, muscle relaxants, and thermotherapy while avoiding bed rest.

Straight Leg Raise

The straight leg raise, also called Lasègue's sign, Lasègue test or Lazarević's sign, is a test done during the physical examination to determine whether a patient with low back pain has an underlying herniated disk, often located at L5 (fifth lumbar spinal nerve).

Nursing Intervention with Lumbar Fusion

When a patient has had a lumbar fusion, place a pillow under the thighs of each when supine and between the legs when in side-lying position to provide comfort and ensure alignment.

Diagnostic Studies

X-Ray done to detect any structural defect. Myelogram, MRI, or CT scan are helpful in localizing the damage site. Epidural venogram or diskogram may be necessary if other methods of diagnosis are unsuccessful. EMG of the extremities can be done to determine the severity of the nerve irritation, or to rule out other pathologic conditions (e.g. peripheral neuropathy).