Chapter 64 Intervertebral disc diseases
Pathopysiology
1. Trauma/degeneration/stress 2. weakness develops bulging 3. nucleus protrudes laterally or posteriorly 4. pressure on nerve root 5. compression & inflammation 6. pain + radiculopathy ( radiation pain, numbness, tingling, diminished strength)
Nursing diagnosis
Acute pain Impaired physical mobility Knowledge Deficit Imbalanced nutrition Risk for Altered elimination
Herniated intervertebral disk
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.
Diskectomy: Helps maintain bony stability of spine
Another common surgical procedure that may be performed to decompress the nerve root. Microsurgical diskectomy Uses microscope to allow better visual of disk and disk space to aid in the removal of damaged portion of a herniated disk in your spine.
When caring for a patient following a lumbar laminectomy, the nurse should:
Ask the patient to flex the knees and push the heels into the bed during turning
Nursing Management Spinal Surgery: Postoperative Potential Neurovasuclar deficit:
Frequently monitor peripheral neurologic signs. Sensation and movement of extremities Extremity circulation should be assessed by temperature, capillary refill, and pulses. Repeat assessments every 2 to 4 hours during first 48 hours post
Treatment Goal
IMPROVE MOBILITY PHYSICAL THERAPY BEDREST EXERCISE
Nursing Management Spinal Surgery: Postoperative Potential complication: CSF leakage
If spinal canal was entered during surgery, potential for cerebrospinal fluid (CSF) leakage Severe headache or leakage of CSF on dressing should be reported. CSF appears as clear or slightly yellow drainage on dressing.
INTERVERTEBRAL LUMBAR DISK DAMAGE SURGICAL THERAPY
Indicated when Diagnostic tests indicate problem is not responding to conservative treatment Patient is in consistent pain Persistent neurologic deficit
Degenerative disk disease (DDD)
Intervertebral disk is interposed between vertebrae from cervical axis to sacrum.
Summary of clinical manifestation
Low back Pain Radicular Pain Muscle Spasms Reflexes depressed Sensory Deficits- Paresthesias Motor Deficits Postural Deformities
INTERVERTEBRAL LUMBAR DISK DAMAGE COLLABORATIVE CARE
Managed first with at least 4 weeks of conservative therapy Limitation of extremes of spinal movement Brace, corset, or belt Local heat or ice Ultrasound and massage
Clinical manifestation
Most common feature of lumbar disk damage 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.
Percutaneous laser diskectomy
Outpatient surgical procedure Uses tube passed through retroperitoneal soft tissues to lateral border of disk with local anesthesia and aid of fluoroscopy Laser is then used on damaged portion. Minimal blood loss Decreases rehabilitation time
Post Op Nursing Care
Pain Management Maintain proper alignment of spine Assess Respiratory (Risk for Pneumonia/atelactasis) Assess Neurovascular/peripheral vascular system (altered mobility/sensation)
Cervical Disk Disease
Radicular pain radiating into arms and hands, following the pattern of the nerve involved As in lumbar disk damage, reflexes may or may not be present, and there is often weakness of hand grip.
INTERVERTEBRAL LUMBAR DISK DAMAGE CLINICAL MANIFESTATIONS
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. Multiple nerve root compression may be manifested as bowel and bladder incontinence or impotence.
Nursing goals
Relief of pain Improved physical mobility Use of back conservation techniques and proper body mechanics Prevention of post Op complications
Nursing Management Spinal Surgery: Postoperative
Risk for DVT (due to immobility) Assess Genitourinary system (urinary retention) Assess Gastrointestinal (paralytic Ileum) Assess Skin (incision, wound: infected or clean or bloody) Assess complications: Hematoma, Blood loss, CSF leakage, neurologic deficits, DVT/PE
Degenerative disk disease (DDD)
Structural degeneration of lumbar disk Progressive degeneration is normal process of aging. Results in intervertebral disks losing elasticity, flexibility, and shock-absorbing capabilities
Laminectomy
Traditional and most common Surgical excision of part of posterior arch of vertebra to gain access to part of or entire protruding disk to remove it Minimal hospital stay is usually required.
Spinal fusion
When unstable bony mechanism is present Spine is stabilized by creating an ankylosis (fusion) of contiguous vertebrae with a bone graft from patient's fibula or iliac crest or from a donated cadaver bone
INTERVERTEBRAL LUMBAR DISK DAMAGE DIAGNOSTIC STUDIES
X-rays are done to note structural damage. Myelogram, MRI, or CT scan localizes damaged site. electromyogram is a diagnostic test involving the placement of small needles into the muscles to assess the electrical activity of muscle and nerve function
