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Module 8 Neurosensory : Herniated Disc and Spinal Cord tumors

Module 8 Neurosensory : Herniated Disc and Spinal Cord tumors. Spinal Cord Anatomy. spinal cord anatomy. Spinal Cord Anatomy. Pathophysiology /Etiology. Function of disc is to allow for mobility of the spine and act as shock absorber. Pathophysiology /Etiology.

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Module 8 Neurosensory : Herniated Disc and Spinal Cord tumors

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  1. Module 8 Neurosensory: Herniated Disc and Spinal Cord tumors

  2. Spinal Cord Anatomy • spinal cord anatomy

  3. Spinal Cord Anatomy

  4. Pathophysiology/Etiology • Function of disc is to allow for mobility of the spine and act as shock absorber

  5. Pathophysiology/Etiology • Located between vertebral bodies • Composed of nucleus pulposus a gelatinous material surrounded by annulus fibrosis- a fibrous coil

  6. Pathophysiology/Etiology • Spinal nerves come out between vertebra

  7. Herniated Disc • Herniated nucleus pulposus, slipped disc, ruptured disc • HNP- annulus becomes weakened/torn and the nucleus pulpsusherniates through it. Risk Factors- • Standing erect- cumulative effect and daily stress • Aging changes in disc and ligaments, osteoarthritis • Poor body mechanics • Overweight • Trauma

  8. Common Manifestations/Complications • HNP compresses • Spinal nerve (sensory or motor component) as it leaves the spinal cord • Or the cord itself- the white tracts within the cord- rare

  9. Common Manifestations/Complications • Sensory root or nerve of the spinal nerve is usually affected resulting in sensory symptoms- pain, parenthesis, or loss of sensation • Motor root or nerve may be affected which results in motor symptoms- paresis or paralysis • Manifestations depend on what nerve root, spinal nerve is being compressed– which dermatomes • Radiculopathy- pathology of the nerve root

  10. Common Manifestations/Complications Lumbar HNP • Most common site for HNP is L4-5 disc- the 5th lumbar nerve root • Most common is the posterior sensory nerve or root compressed • Classic symptoms- low back sciatica pain. The pain increases with increase in intrathorasic pressure • herniated disc L4-L5

  11. Other Symptoms Lumbar HNP: • Postural changes • Urinary/male sexual function changes • Paresis or paralysis • Foot drop • Paresthesias • Numbness • Muscle spasms • Absent cord reflexes

  12. Common Manifestations/Complications Cervical HNP C5-C6 disc- affects the 6th cervical nerve root • Pain- neck, shoulder, anterior upper arm to thumb • Absent/diminished reflexes to the arm • Motor changes- paresis or paralysis • Sensory- paresthesias or pain • Muscle spasms

  13. Therapeutic Interventions- Diagnostic Tests • X-ray identify deformities and narrowing of disk space • CT/MRI • Mylogram p1336 • Nerve conduction studies (EMG) to detect electrical activity of skeletal muscles

  14. Treatment- Conservative • Bed rest with firm mattress; log roll; side lying position with knees bent and pillow between legs to support legs • Avoid flexion of the spine- brace/corset, cervical collar to provide support • Medications- nonnarcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodics and tranquilizers

  15. Treatment- Conservative • Heat/cold therapy to decrease muscle spasms • Break the pain-spasm-pain cycle • Ultrasound, massage, relaxation techniques • Progressive mobilization with approved exercise program –includes abdominal/thigh strengthening • Teaching good body mechanics • Weight loss • TENS unit

  16. Treatment- Surgery • Laminectomy- removal of a portion of the lamina to relieve pressure and to get to the herniated nucleus pulposus that is protruding out • herniated disc repair

  17. Treatment- Surgery • Spinal fusion removes most of the disc and replaces it with bone usually from the patient iliac crest • Flexibility is lost at the site- requires longer hospital stay • spinal fusion

  18. Treatment- Surgery • Foraminotomy • Enlargement of the bony overgrowth at the opening which is compressing the nerve • Microdiskectomy • Use of electron microscope through a small incision to remove a portion of the HNP that is displaced • If cervical HNP, usually use the anterior approach in the neck

  19. Prevention of HNP • Back school approach- • Causes of HNP • Learn how to prevent • Good body mechanics • Exercises to strengthen leg and abdominal muscles • Change in life-style or occupation

  20. Nursing Assessment Specific to HNP Health History • Assess for risk factors- • The cumulative effect of standing erect and daily stress • Aging changes in disc/ligaments • Poor body mechanics • Overweight • Trauma • Employment • History of pain and other neuro changes

  21. Nursing Assessment Specific to HNP Physical Exam • Use similar methods to assess as utilized SCI • Muscle strength and coordination • Sensation- sharp/dull of paperclip using dermatome as reference • Pain evaluation- pain scale • Pre/Post-op assessment

  22. Post-Op Assessment for HNP • Sensory/motor assessment- care not to injure op site • Assess for CSF drainage or bleeding from op site • Encourage turn (log roll, cough, deep breath) • Assess for postural hypotension, especially if client was on bed rest for several days/weeks prior to surgery

  23. Post-op Assessment for HNP • If Anterior Cervical- • Assess injury to the carotid, esophagus, trachea, laryngeal nerve (speech- hoarseness) • Assess respiration, neck size, swallowing and speech • If Post-Op Lumbar- • Assess bowels sounds, voiding. • Minimize stress of post-op site- flat with pillow between knees, log roll, etc

  24. Nursing Problems/Interventions 1. Acute Pain • Post surgery the individual may have similar pain as pre-op due to lack of resiliency of the spinal nerves to ‘bounce’ back quickly • Donor site (illiac crest) may cause more pain than laminectomy • Individual may be in a pain-spasm-pain cycle, therefore may need both antispasmodic as well as analgesic

  25. 2. Chronic Pain • Surgery may not relieve pain • Nonpharmalogical methods to control pain • Pain clinic

  26. 3. Constipation • As a result of bed rest and decreased mobility and fear of pain with straining of stool • Constipation prevention methods– fluids, diet, etc

  27. 4. Home Care • When riding in a car, take frequent stops to move and stretch • Prevention– Back school approach • May have to deal with pain as a chronic condition • May need to make life/job changes

  28. Spinal Cord Tumors Patho- Normal Cord & Cord Tumors • CNS is made up of neural tissue (neurons) and support tissue (glial) • These tissues undergo changes and result in spinal cord tumors • Blood vessels and bone (vertebra) also can be part of the tumor

  29. Classification of Spinal Cord Tumors by Anatomical Area • Intramedullary- arise from neural tissues of the spinal cord • Extramedullary- arise from tissues outside the spinal cord may be benign or malignant • Intradural-from the nerve roots or meninges in subarachnoid space • Extradural- from the epidural tissue or vertebra

  30. Classification of Spinal Cord Tumors by Origin • Primary- originating in the spinal cord or meninges that is not relieved by bed rest • Secondary- metastases from other parts of the body

  31. Spinal Cord Tumors • Most spinal cord tumors are found in the thoracic region • Spinal cord tumors can compress (benign), invade the neural tissue, or cause ischemia to the area because of vascular obstruction

  32. Common Manifestations/Complications • Symptoms depend on the anatomical level of the spinal column, the anatomical location, the type of tumor and the spinal nerves affected • Pain that is not relieved by bed rest is the most common presenting symptom • Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor

  33. Common Manifestations/Complications • Manifestations of thoracic cord tumor • Paresis & spasticity of one leg then the other • Pain back & chest, not relieved by bedrest • Sensory changes • Babinski reflex • Bowel (ileus); bladder dysfunction (UMN in type)

  34. Therapeutic Interventions • Diagnostic tests include: • X-ray of the spinal column • Myelogram • Lumbar puncture with CSF analysis

  35. Therapeutic Interventions • Medications spinal tumors • Control pain- narcotic analgesics, may be given epidural catheter, PCA, NSAID’s • Reduce cord edema and tumor size- steroids dexamethasome (Decadron) high dose for a few days, then taper off with a Medrol dose pack

  36. Therapeutic Interventions • Surgery for spinal cord tumors • Laminectomy to remove or to decrease the size (decompression laminectomy) of the spinal cord tumor • Spinal fusion or the insertion of rods if several vertebra involved and the column is unstable • Radiation to reduce size and control pain

  37. Nursing Assessment • Health history • Pain, motor and sensory changes, bowel and bladder changes, Babinski reflex. • Physical exam • Similar to physical assessment for HNP

  38. Nursing Problems/Interventions • 1. Anxiety • Metatastic tumor vs benign spinal cord tumor • Education and support system • 2. Risk for constipation • From spinal cord compression, narcotics, bed rest • Adjust fluid and diet

  39. Nursing Problems/Interventions • 3. Impaired physical mobility • From bed rest and motor involvement • Basic nursing- ROM, etc • 4. Acute pain • From compression or invasion of tumor • Assess and treat • 5. Sexual dysfunction • Male sacral reflex ark (S 2,3,4) interference • Similar care as discussed with SCI

  40. Nursing Problems/Interventions • 6. Urinary retention • Reflex arc (S2,3,4) interference can cause neurogenic bladder as discussed with SCI • 7. Home care • Rehabilitation • Home evaluation • Support groups

  41. Nursing Care Plan: A Client with a Ruptured Intravertebral Disc http://wps.prenhall.com/wps/media/objects/737/755395/intervertebral_disk.pdf

  42. Added Critical thinking questions Nursing Care Plan: A Client with Ruptured Intervertebral Disc • 1. If Marees’ C6-C7 disk is herniated, where does the dermatome for C7 spinal nerve supply? • 2. Is Marees’ anterior or posterior nerve root being compressed by the herniation? • 3. Why is Maree Ivans prescribed both analgesics and muscle relaxants around the clock when awake? • 4. How does a cervical collar help? What else may help relieve the pain? • 5. If the conservative methods did not work, what else might the physician have done? • 6. Why are conservative methods tried for a period of time rather than immediate surgery?

  43. 7. Where is the posterior/anterior nerve root?8. Where is the lamina? 9. Would the Dr use the anterior or posterior surgical route to get to her disc?

  44. LeMone Blackboard: Media Links http://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.html http://www.spine-health.com/

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