low back pain

Osteoarthritis (OA)

of lumbar spine is found in patients over 50. Chronic back pain in younger patients with OA usually involves thoracic or lumbar spine. Discomfort is ↑ following periods of inactivity. Particularly on awakening or after long periods of sitting

subjective data cont

Activity intolerance Constipation Interrupted sleep Pain in back, buttocks, or legs associated with walking, turning, straining, coughing, leg raising Numbness or tingling of legs, feet, toes Occupation requiring heavy lifting, vibrations, or extended driving Change in role within family structure due to inability to work and provide income

INTERVERTEBRAL LUMBAR DISK DAMAGE ETIOLOGY AND PATHOPHYSIOLOGY

Acute herniated intervertebral disk Slipped disk Can be result of Natural degeneration with age Repeated stress or trauma to spine Disk may first bulge and then herniate, placing pressure on nerves. Most common ruptures at lumbosacral disks

Etiology & pathophysiology of lower back pain

Acute lower back pain Chronic lower back pain Treatment: Collaborative Care Herniated Intervertebral Disk Etiology & pathophysiology Collaborative Care/Surgery

Low back pain most often due to musculoskeletal problems

Acute lumbosacral strain Instability of lumbosacral bony mechanism Osteoarthritis of lumbosacral vertebrae Degenerative disk disease Herniation of intervertebral disk

Diskectomy

Another common surgical procedure Microsurgical diskectomy Uses microscope to allow better visual of disk and disk space to aid in the removal of damaged portion Helps maintain bony stability of spine

health promotion Some Don'ts

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

Subjective data

Acute or chronic lumbosacral strain/ trauma Osteoarthritis History degenerative disk disease? Obesity Use of opioid and nonopioid analgesics, muscle relaxants, nonsteroidal anti-inflammatory drugs, corticosteroids Use of over-the-counter remedies Previous back surgery, epidural or corticosteroid injections Smoking Lack of exercise Poor posture Muscle spasms

Nursing Diagnoses

Acute pain Chronic pain Impaired physical mobility Ineffective coping Ineffective self-health management

Etiology and Pathophysiology

Affects most adults at least once 45% of sufferers seek medical attention Low back pain is common and has probably affected 70% to 85% of adults at least once during their lifetime In persons younger than age 45, low back pain is responsible for many lost working hours

Treated on an outpatient basis if acute muscle spasms and pain are not severe and debilitating

Analgesics Muscle relaxants Massage and back manipulation Alternating use of heat and cold compresses Opioid analgesics for severe pain

Nursing Implementation Health Promotion

As a role model, nurse should use proper body mechanics at all times. Primary consideration when teaching patients transfer and turning techniques Assess patient's use of body mechanics, and offer advice when activities could produce back strain.

Lasts 6 weeks or less

Associated with some type of activity that causes undue stress on tissues of lower back Symptoms often do not appear at time of injury but develop later because of gradual ↑ in paravertebral muscle spasms

Low back pain common because lumbar region

Bears most of the weight of body Is the most flexible region of the spinal column Contains nerve roots that are vulnerable to injury or disease Has an inherently poor biomechanical structure

Surgical interventions may be indicated for patients

With severe chronic low back pain Who do not respond to conservative care Who have neurological deficits

Lasts longer than 3 months or is a repeated incapacitating episode

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

Nursing Management Spinal Surgery: Postoperative

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 Logroll patient when turning Pillows under thighs of each leg when supine and between legs when side-lying

Surgical Management

Discectomy Laminectomy Spinal fusion Alternative procedures

Nursing Management Spinal Surgery: Postoperative compresses the spine

Encourage Walking Lying down Shifting weight from one foot to the other when standing

Nursing Implementation 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. Intervention is aimed at strengthening supporting muscles with exercise. Corset limits extremes of movement. Persistent use of poor body mechanics may result in repeated episodes. Frustration, pain, and disability require emotional support and understanding.

objective data

Guarded movement Depressed or absent Achilles tendon reflex Patellar tendon reflex Positive straight-leg raise test Positive crossover straight-leg test Positive Trendelenburg test Decreased range of motion of spine Tense, tight paravertebral muscles on palpation Localization of site of lesion or disorder on myelogram CT scan MRI Determination of nerve root impingement on electromyography

Planning/Overall goals

Have satisfactory pain relief. Avoid constipation secondary to medication and immobility. Learn back-sparing practices. Return to previous level of activity within prescribed restrictions.

Spinal Surgery: Postoperative RISKS

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. Paralytic ileus, interference with bowel function may occur for several days and may manifest as nausea, abdominal distension, 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) may aid in relieving and preventing constipation.

Several risk factors

Lack of muscle tone Excess body weight Poor posture Cigarette smoking Stress

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

Treatment regimens (Cont.)

Mild analgesics to decrease pain and stiffness Integral to daily comfort Weight reduction Sufficient rest periods Local heat and cold application Exercise and activity throughout day Keep muscle and joints mobilized Tricyclic antidepressants & Serotonin reuptake inhibitors Both have been shown to improve chronic symptoms.

INTERVERTEBRAL LUMBAR DISK DAMAGE CLINICAL MANIFESTATIONS

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. 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.

Low Back Pain Collaborative Care

Most persons do better with continuation of their regular activities. All patients should avoid activities that aggravate pain: Lifting Bending Twisting Prolonged sitting Most cases improve in 2 weeks (if pain is acute).

Post-op care

Neurologic assessment Check voiding Check dressing (clear drainage) Donor site - if fusion Move in correct position Routine Discharge Teaching, getting patient ready to manage recovery at home

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 Management Spinal Surgery: Postoperative

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. 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 and possible muscle relaxants

Health Promotion dos

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 25-cm-high pillow under knees to flex hips and knees

Nursing Implementation Acute Intervention

Primary nursing responsibilities Assist patient to maintain activity limitations. Promote comfort. Educate patient about health problem. Educate patient on appropriate exercises. Use analgesics, NSAIDs, muscle relaxants, and thermotherapy while avoiding bed rest

Associated with low back pain

Prolonged periods of seating Repetitive heavy lifting Vibration

Treatment regimens for chronic back pain

Reduction in pain associated with daily activities Formal back pain program Ongoing medical care Rest and local heat application when cold, damp weather aggravates back pain

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.

Pre-op care

What to expect post-op Sensations Brace if fusion Positioning Flat bed rest for a few days Log rolling Straight back chair No prolonged sitting or standing

Spinal fusion

When unstable bony mechanism is present Spine is stabilized by creating a fusion of contiguous vertebrae with a bone graft from patient's fibula or iliac crest or from a donated cadaver bone Metal fixation with rods, plates, or screws Provides stability and decreases vertebral motion