Exam 3 - Degenerative Disc Disease

Postop for spinal fusion

-Additional nursing responsibilities are required if the patient has also had a spinal fusion. -Because a bone graft is usually involved, the postoperative healing time is prolonged compared with that for a laminectomy. -Limited activity over an extended time may be necessary. -A rigid orthosis (thoracic-lumbar-sacral orthosis or chair-back brace) is often used during this period.

Postop - CSF

-Because the spinal canal may be entered during the surgical procedure, there is potential for cerebrospinal fluid (CSF) leakage. -Immediately report a severe headache or leakage of CSF on the dressing.

Drug therapy

-Drug therapy includes nonsteroidal antiinflammatory drugs (NSAIDs), short-term opioids, antidepressants, and muscle relaxants. -Epidural corticosteroid injections may be effective in reducing inflammation and relieving acute pain.

Postop - Neuro

-Frequently monitor the peripheral neurologic signs of the patient after spinal surgery. -Movement of arms and legs and assessment of sensation should be unchanged when compared with preoperative status. -Paresthesias, such as numbness and tingling, may not be relieved immediately after surgery. -Document any new muscle weakness or paresthesias and report them to the surgeon.

Postop cervical spine care

-If surgery is done on the cervical spine, be alert for symptoms of spinal cord edema such as respiratory distress and a worsening neurologic status of the upper extremities. -After surgery, the patient's neck may be immobilized in either a soft or hard cervical collar.

Postop assessement of donor site for bone graft

-In addition to the primary surgical site, regularly assess the donor site for the bone graft. -The donor site usually causes greater postoperative pain than the fused area. -A pressure dressing is applied to the donor site to prevent excessive bleeding. -If the donor site is the fibula, neurovascular extremity assessments are a postoperative nursing responsibility.

Postop activity

-Instruct the patient to avoid sitting or standing for prolonged periods. -Encourage activities that include walking, lying down, and shifting weight from one foot to the other when standing. -The patient should learn to 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. -A firm mattress or bed board is essential.

What do intervertebral discs do? What is degenerative disc disease (DDD)?

-Intervertebral discs separate the vertebrae of the spinal column and provide shock absorption for the spine. -Structural degeneration of discs is often caused by degenerative disc disease (DDD) -This progressive degeneration is a normal process of aging and results in the intervertebral discs losing their elasticity, flexibility, and shock-absorbing capabilities. -Thinning of the discs occurs as the nucleus pulposus (gelatinous center of the disc) starts to dry out and shrink. -These changes limit the ability of the discs to distribute pressure loads between the vertebrae, which can cause progressive, structural deterioration.

What 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 or all of the protruding disc to remove it. -A minimal hospital stay is usually required.

What are clinical manifestations of cervical disc disease?

-Pain often radiates into the arms and hands, following the pattern of the nerve involved. -Similar to lumbar disc disease, reflexes may or may not be present, and there is often weakness of the handgrip.

Postop - Elimination

-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 sodium [Colace]) may aid in relieving and preventing constipation. -Adequate bladder emptying may be altered because of activity restrictions, opioids, or anesthesia. -Patients should use the commode or ambulate to the bathroom when allowed to promote adequate emptying of the bladder. -Intermittent catheterization or an indwelling catheter may be necessary for patients who have difficulty urinating.

Postop - meds

-Postoperatively, most patients will require opioids, such as morphine, IV for 24 to 48 hours. Patient-controlled analgesia (PCA) allows for optimal analgesic levels and is the preferred method of continued pain management during this time. -Once fluids are being taken, the patient may be switched to oral drugs such as acetaminophen with codeine, hydrocodone (Vicodin), or oxycodone (Percocet). Diazepam (Valium) may be prescribed for muscle relaxation.

When is surgical therapy for a damaged disc generally indicated?

-Surgery for a damaged disc 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.

What are clinical manifestations of lumbar disc disease?

-The most common manifestation is low back pain. -Radicular pain that radiates down the buttock and below the knee along the distribution of the sciatic nerve generally indicates disc herniation. -The straight-leg raise test may be positive indicating nerve root irritation. -Back or leg pain may be reproduced by raising the leg and flexing the foot at 90 degrees. -Reflexes may be depressed or absent, depending on the spinal nerve root involved. -Paresthesia or muscle weakness in the legs, feet, or toes may occur. -Multiple nerve root (cauda equina) compression may be manifested as bowel or bladder incontinence or impotence. -This condition is a medical emergency.

What is involved in conservative therapy for a pt with intervertebral disc disease?

-The patient with suspected disc damage is usually managed first with conservative therapy. -This includes limitation of extremes of spinal movement (brace/corset/belt), local heat or ice, ultrasound and massage, traction, and transcutaneous electrical nerve stimulation (TENS). -Drug therapy includes nonsteroidal antiinflammatory drugs (NSAIDs), short-term opioids, antidepressants, and muscle relaxants. -Epidural corticosteroid injections may be effective in reducing inflammation and relieving acute pain. -Once symptoms subside, back-strengthening exercises are begun twice per day and are encouraged for a lifetime. -Teach the patient the principles of good body mechanics. -Extremes of flexion and torsion are strongly discouraged. -Most patients heal with a conservative treatment plan after 6 months.

What is interspinous process decompression system (X Stop)?

-This device is made of titanium and fits onto a mount that is placed on vertebrae in the lower back. -The device works by lifting the vertebrae off the pinched nerve. -The X Stop is used in patients with pain due to lumbar spinal stenosis.

What is a herniated disc? What is it the result of? Where are the most common sites of rupture?

-When there is structural damage to the disc, the nucleus pulposus may seep through a torn or stretched annulus. -This is called a herniated disc (slipped disc), a condition in which a spinal disc herniates and bulges outward between the vertebrae. -A herniated disc can be the result of natural degeneration with age or repeated stress and trauma to the spine. -The nucleus pulposus may first bulge and then it can herniate, placing pressure on nearby nerves. -The most common sites of rupture are the lumbosacral discs, specifically L4-5 and L5-S1. -Disc herniation may be the result of spinal stenosis, in which narrowing of the spinal canal creates a bulging of the intervertebral disc.

What is radiofrequency discal nucleoplasty?

-in which a special radiofrequency probe is inserted into the disc and generates energy that breaks up the molecular bonds of the gel in the nucleus

Artificial disc replacement surgery for patients with DDD

-includes the use of the Charité disc for lower disc damage and the Prestige cervical disc system.

What is intradiscal electrothermoplasty (IDET)?

-is a minimally invasive outpatient procedure that may help in treating back and sciatica pain. -It involves the insertion of a needle into the affected disc with the guidance of an x-ray. -The wire is heated, which denervates the small nerve fibers that have grown into the cracks and invaded the degenerating disc.

What is a percutaneous laser diskectomy?

-is an outpatient surgical procedure that is done by using fluoroscopy and passing a tube through retroperitoneal soft tissues to the lateral border of the disc. -A laser is then used on the damaged portion of the disc.

What is 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 disc to aid in the removal of the damaged portion.

Postop vertebral disc surgery interventions

-mainly focus on maintaining proper alignment of the spine until healing has occurred. -Depending on the type and extent of surgery and the surgeon's preference, the patient may be able to dangle the legs at the side of the bed, stand, or even ambulate the same day of surgery. -When a patient has had a lumbar fusion, place pillows under the thighs of each leg when supine and between the legs when in the side-lying position to provide comfort and ensure alignment. -The patient often fears turning or any movement that increases pain. -Offer reassurance to the patient that the proper technique is being used to maintain body alignment.

What is a spinal fusion?

-may be performed if the spine is unstable. -The spine is stabilized by creating an ankylosis (fusion) of contiguous vertebrae with a bone graft from the patient's fibula or iliac crest or from donated cadaver bone. -Metal fixation with rods, plates, or screws may be implanted. -A posterior lumbar interbody fusion may be performed to provide extra support for bone grafting or a prosthetic device. -Bone morphogenetic protein (BMP), a genetically engineered protein, may be used to stimulate bone growth of the graft in spinal fusions.

Postop med

Diazepam (Valium) may be prescribed for muscle relaxation.

What is intervertebral disc disease?

Intervertebral disc disease is a condition that involves the deterioration, herniation, or other dysfunction of the intervertebral discs. Disc disorders can involve the cervical, thoracic, and lumbar spine.

What diagnostic studies can be done for intervertebral disc disease?

■ X-rays are done to detect any structural defects. ■ A myelogram, MRI, or CT scan is helpful in localizing the damaged site. ■ An epidural venogram or diskogram may be necessary if other methods of diagnosis are unsuccessful. ■ An electromyogram (EMG) of the extremities can be performed to determine the severity of nerve irritation or to rule out other pathologic conditions such as peripheral neuropathy.