Back Problems

disc herniation

-Disc consists of outer annulus fibrosus, composed of strong fibrocartilage, and an inner nucleus pulposus, composed of loose fibers in a protein gel. -A herniated intervertebral disc occurs when the annulus fibrosus is damaged, allowing protrusion of the nucleus pulposus through the defect -Most common sites of disc herniation: --Lumbar region between L4, L5, and S1 --Neck region between C5, C6, and C7 -Pressure on the nerve root causes changes in motor and sensory function. -May occur gradually because of degenerative changes such as osteoarthritis or ankylosis spondylitis -May occur abruptly as a result of trauma such as lifting a heavy object or being in a motor vehicle crash -Aging causes loss of fluid content in the nucleus pulposus and increased susceptibility to tears in the annulus fibrosus, which increases risk of herniation.

Common presentation- scoliosis

-Evident in the thoracic, lumbar, or thoracolumbar region of the spine. -A right thoracic curve is the most common. -Curvature is graded: --10-20°: mild --20-40°: moderate -->40°: severe -->100°: life threatening -Classifications: --Nonstructural: Spine bends to compensate for poor posture, different leg lengths, or other physical condition; corrected by alleviating the cause. --Structural: Curve is caused by deformities of spinal bones.

medications used by clients with herniated discs

-NSAIDs -Opioids for severe pain and postsurgical pain -Antispasmodics to reduce muscle spasms -Treatment of neuropathic pain with gabapentin, pregabalin, or duloxetine -Epidural injection of corticosteroids to reduce inflammation and pain.

Congenital scoliosis

-Occurs during fetal development and is present at birth. -Can be an isolated finding or associated with heart and kidney problems. -Incomplete formation or separation of the vertebrae during fetal development

Neuromuscular scoliosis

-Occurs in the setting of abnormal innervation to the muscles surrounding the vertebra, as in cerebral palsy or spinal cord injury. -Resulting abnormal forces on the vertebral column lead to curvature. -Caused by medical conditions that affect the nerves and muscles (e.g., cerebral palsy, muscular dystrophy, or spinal cord injury)

L4 to L5 s/s

-Pain in hip, lower back, posterolateral thigh, anterior leg, dorsal surface of the foot and great toe -Sciatica: pain, burning, tingling, and numbness radiating across buttocks and into leg and into knee or foot -Muscle spasms -Paresthesia over the lateral leg and web of great toe -Possible cauda equina syndrome (CES): compression of nerve roots of cauda equina -Bowel and bladder incontinence -Lower-extremity paralysis

L5 to S1 s/s

-Pain in midgluteal region, posterior thigh, calf to heel, plantar surface of the foot to the fourth and fifth toes -Paresthesia in the posterior calf and lateral heel, foot, and toes -Difficulty walking on toes

Cervical region s/s

-Pain in neck, shoulder, anterior upper arm, radial area of forearm, and thumb -Paresthesia of the forearm, thumb, forefinger, and lateral arm -Stiff neck -Decreased biceps and supinator reflex -Triceps reflex normal to hyperactive

nursing dx- back problems

-Potential for injury related to altered mobility Impaired mobility related to pain, as a result of surgery, or while wearing brace -Alterations in skin integrity related to surgical wound or pressure areas under brace -Alterations in role performance related to lost work with disc pain and reluctance to be in the presence of peers wearing scoliosis brace -Increased risk for infection in postsurgical clients -Increased anxiety related to treatment and prognosis -Potential for noncompliance with therapeutic regimen, particularly for clients with a Milwaukee brace -Potential for enhanced wellness through encouragement, support, and effective intervention -Potential for enhanced knowledge regarding treatment and prognosis.

Herniated disc-life span

-Rare in children but may occur as a result of trauma to the vertebral column -Common at ages 35-45 -Less likely in older adults because the fluid in the nucleus pulposus is diminished and less likely to protrude

implementation- back problems

-Teaching proper body mechanics and appropriate exercise -Explaining diagnostic tests and treatment options -Monitoring vital signs and performing wound and skin checks post surgery as ordered or per unit policy -Positioning and turning the client in bed to facilitate support of joints and proper alignment -Assessing the postsurgical client for activity tolerance and neuromuscular status -Assisting with range of motion exercises -Encouraging the use of incentive spirometer, coughing, and deep breathing -Administering analgesics and antispasmodics as ordered -Teaching proper use of medications -Teaching nonpharmacologic coping techniques for pain management -Referring the client for counseling for frustration, depression, or anxiety -Teaching about the use and care of braces and assistive devices.

planning- back problems

-The client will remain free from, or note improvement in, motor and neurologic deficits. -The client will remain free from injury. -The client will maintain skin integrity or demonstrate wound healing according to the expected postsurgical course. -The client will not exhibit signs of infection. -The client will rate pain at acceptable levels on a pain scale. -The client will verbalize understanding of medications, procedures, treatment, and follow-up. -The client will report wearing the brace for the prescribed duration. -The client will experience decreased anxiety. -The client will verbalize feelings about role performance and relationships with co-workers and peers.

non-pharm scoliosis

-reevaluation every 3-6 months for mild curvatures (less than 20°) -braces for moderate curvatures (25-45°). The thoracolumbar sacral orthosis (TLSO) --contoured to conform to the body --most common and used as first-line treatment in clients over the age of 10 who are still growing and do not have congenital or neuromuscular scoliosis and to maintain stability post surgery. The Milwaukee (full torso) brace --wider and has a neck ring, which holds the head in position with front and back supports. --cumbersome, and client compliance may be an issue --only when the TLSO is insufficient, such as for curvatures involving the cervical spine -Braces should be worn 13-14 hours per day -Efficacy increases proportionally to the time they are worn.

Juvenile idiopathic scoliosis- lifespan

3 to 9 years Symptoms similar to adolescent scoliosis Likely to require surgical correction of the curvature

disc herniation-risk factors

Age between 30 and 50 Being overweight Frequent heavy lifting Frequent bending and twisting Previous back problems Smoking Genetic factors such as male gender Above-average height History of bone disorders or degenerative disc disorders

Infantile idiopathic scoliosis-lifespan

Birth to 3 years More common in boys of European descent May resolve spontaneously.

Scoliosis sx

Clients affected by scoliosis with a Cobb angle > 50 degrees who have stopped growing and whose spinal curvatures have not responded to conservative treatment are candidates for surgery. Surgery involves fusion of vertebrae and insertion of metal rods on either side of the spine, held together by hooks, screws, and wires.

disc herniation- prevention

Exercise Smoking cessation Correct posture Managing weight Stretching before exercise Using proper body mechanics

assessment-back problems

Health history --History of scoliosis or back injury --Family history of scoliosis --Description of pain and symptoms --Previous back surgeries --Occupational and recreational activities --Medications Physical examination --Scoliosis screening --Muscle strength --Coordination --Gait --Posture --Reflexes

non-pharm herniated discs

Heat-Dilates blood vessels, increasing circulation and oxygen to the area to facilitate healing of damaged tissues. May be alternated with cold. Cold-Reduces inflammation by decreasing blood flow to the area. May be alternated with heat. Low-impact exercise-Strengthens surrounding structures, improves stability, maintains circulation Intradiscal electrothermal therapy-An electrified needle is inserted into the disc and heated to thicken and seal the defect. Chiropractic-Adjusts the position of the spine and surrounding structures, possibly reversing the protrusion of the nucleus pulposus Massage-Relieves muscle tension and spasms, maintains flexibility of the joints Weight reduction-Reduces stress on the spinal column

Herniated disc sx

Laminectomy removes the lamina (the part of the vertebra that covers the spinal canal), enlarging the space and reducing pressure. Laminotomy removes only part of the lamina. Discectomy removes all or part of the herniated disc. Spinal fusion joins two or more vertebrae to reduce motion between them and thus reduce pain. Artificial disc surgery replaces the damaged disc with an artificial one to maintain mobility in the spinal column. Laser surgery vaporizes a portion of the herniated disc to relieve pressure on nerves.

Scoliosis

Lateral (sideways) curvature of the spine Idiopathic in 80-85% of cases2 Idiopathic cases may be the result of abnormal force exerted on the spine by surrounding connective tissues and muscles.

Scoliosis meds

Mild pain can usually be alleviated by over-the-counter analgesics. Postsurgical clients may require prescription NSAIDs or opiates.

Herniated disc dx

Mobility tests --Straight-leg-raise --Gait evaluation --Reflexes --Muscle strength tests Imaging tests --CT --MRI --Myelogram: dye injected into the spinal fluid and visualized on x-ray to identify areas of increased pressure on the spinal cord Electromyo-gram and nerve conduction studies --Electromyogram measures electrical activity of muscles. --Nerve conduction studies measure speed and strength of nerve impulses and may identify nerve damage. Blood tests --Complete blood count --Erythrocyte sedimentation rate --C-reactive protein --HLA-B2710

Adolescent idiopathic scoliosis- lifespan

Most common, occurring between the ages of 10 and 19 Most common in girls Progression more likely in children with large curves

Scoliosis s/s

Musculoskeletal --One shoulder higher than other --Uneven hips --Projecting scapula --Asymmetry of the shoulders, scapula, and waist crease --Prominence of the thoracic ribs or paravertebral muscles on forward bending --Lateral curvature and vertebral rotation on posteroanterior x-rays Pain --Usually present in the lumbar region --Can be caused by pressure on the ribs or the crest of the ilium Respiratory --Shortness of breath because of diminished chest expansion --Pneumonia in severe scoliosis

Scoliosis dx

Physical examination --Client stands with arms relaxed and hanging freely at the sides while the examiner evaluates for shoulder symmetry, scapulae, waist creases, and arm length. --Client bends forward (Adams test) while the examiner observes for prominence of the thoracic ribs or vertebral muscles. --Examiner may use scoliometer to measure rib hump while client is in forward-bend position. --Client stands straight while the examiner views the side of the body for thoracic rounding or lumbar swayback. Upright posteroanterior and lateral x-rays --Degree of curvature is measured on the x-ray using the Cobb method, in which lines are drawn from the ends of the vertebrae at the upper and lower limits of the curvature. The angle at their intersection is called the Cobb angle. --The degree of vertical rotation is determined by the Nash-Moe method, which measures the degree of rotation of the vertebra in the apex of the curve.

Adult idiopathic scoliosis- lifespan

Present from childhood or the result of aging May result from injury or degenerative changes in the spine More commonly involves the entire vertebral column Pain in back and legs more common

Scoliosis-risk factors

Risk greatest during growth spurts in adolescence, between the ages of 9 and 15 Female gender5 Neuromuscular disorders Family history of scoliosis

Scoliosis-prevention

There is no known method of prevention.