HERNIATED NUCLEUS POLPOSUS (Herniated disk or Slipped disk) I.

Definition: A dysfunction of the spine wherein the nucleus polposus (soft central portion of the intervertebral disk) is squeezed out of place and herniate (protrude) through the annulus fibrosus into the vertebral canal where it places pressure on the nearby nerves (spinal nerve root). II. Prevalence: 1-3% (3.1% of men and 1.3% of women) -U.K. based III. Classification: IV. Pathophysiology: 1. Risk Factors: middle-aged and old-aged ( ) men involved in strenuous physical activity congenital condition that affect size of lumbar spinal canal 2. Predisposing Factors: lifting while in flexed position slipping or falling on the buttocks or back suppressing a sneeze degenerative processes that causes nucleus polposus to dry out and lose elasticity. osteoarthritis, ankylosing spondylitis 3. Etiology: trauma + effects of aging + degenerative disorders of spine sitting or bending forward = anterior side (stomach side) and nucleus polposus get pressed = annulus fibrosis is tightly stretched and thinned = rupture of confining membrane = movement of nucleus polposus to spinal canal = pressing against spinal nerves = pain + other s/sx
Tear in the disc ring may result in the release of inflammatory chemical mediators which may directly cause severe pain, even in the absence of nerve root compression. Mutation in genes

4. Signs & Symptoms (Depends on location of Herniation and types of soft tissue involved) Numbness or paresthesia Pain (most often occurs on ONE SIDE OF THE BODY):

a. Lumbar herniated disc - SHARP PAIN in one part of leg, hip, or buttocks + numbness in other parts (back of the calf or sole of foot) + weakness on affected leg b. Cervical herniated disc - pain when moving NECK, deep pain near or over the shoulder blade, or pain that radiates to the upper arm, forearm, or fingers. *Pain starts slowly, and may get worse: a. after standing or sitting b. at night c. when sneezing, coughing, or laughing d. when bending backwards or walking Muscle weakness: difficulty lifting leg or arm, standing on toes on one side, squeezing tightly one of your hands Diminished or absent knee and ankle reflexes

5. Complications long-term back pain paralysis or paresthesia in the legs or feet loss of bowel and bladder function Permanent spinal cord injury (very rare) Cauda equine Syndrome V. Diagnostic Tests Diagnostic Test Description Pre-procedure Nursing Responsibilites >Inform if pregnant >Remove all jewelry Post-procedure Nursing Responsibilites >Determine results and notify HCP of any abnormalities >Determine results and notify HCP of any abnormalities

Spine X-ray

X-ray of the vertebrae to rule out other causes of back or neck pain Spine MRI or Spine Computed CT tomography of the spine and surrounding tissues to show spinal canal compression by herniated disk Electromyelography Test that checks the (EMG) health of the muscles and the nerves to determine the exact nerve root involved.

>Remove all jewelry or other metal objects

>Avoid using any creams or lotions on the day of the test >Wait in a warm room (body temp can affect result of test)

>Control bleeding (minimal) >Manage infection at the electrode sites (minimal risk)

Nerve Conduction Velocity Test

Test of speed of electrical signals through nerve to diagnose nerve damage or destruction

Myelogram

Radiologic examination that uses a contrast medium to determine pathology of the spinal cord including the size and location of disk herniation.

>Maintain normal body temp (low body tem slows nerve conduction) >Inform doctor if pt. have a cardiac defibrillator or pacemaker >Orient pt. that impulse may feel like an electric shock >Omit meal prior to procedure >Ensure that client is well hydrated >Administer enemas or laxatives as ordered >Administer prescribed pretest medications

>Obtain result and consult physician for interpretation. >Collaborate with health care team for management if there are abnormal results.

>Prevent infection >Avoid strenuous activity and heavy lifting >Keep headselevated at least 30 for specific # of hrs.

VI. Nursing Management VII. Medical Management Treatment Conservative Treatment Description Mainly avoiding painful positions, following planned exercise and pain-medication regimen. Nursing Responsibilities Assist pt. in performing exercises, administer ordered medications, provide nonpharmacologic measures to relieve pain

VIII. Surgical Management Procedure Discectomy Description Surgical removal of the herniated disc material that presses on a nerve root or the spinal cord: to relieve nerve compression. Nursing Responsibilities >Provide information about injury and treatment needs. >Maximize respiratory function >Prevent further injury to spinal cord >Promote mobility/independence as indicated >Prevent or minimize complications >Support psychological adjustment of client/SO Pre-op: Demonstrate and ask client to practice deep breathing, log rolling, and leg exercises.

Laminectomy

Spine ope1-3ration to remove the portion of the

vertebral bone called lamina to relieve spinal stenosis or nerve compression

Post-op: >Turn pt q 2 >Assess V/S q 2 >Assess for pain, hematoma formation, leakage of CSF, nerve root injury, urinary retention >Increase mobility as prescribed Post-op: (Cervical Laminectomy) >Elevate head of bed slightly >Position a small pillow under neck >Maintain the position of the cervical collar. Post-op: (Lumbar Laminectomy) >Keep the bed flat or elevate HOB slightly >Place a small pillow under the head >Place a small pillow under the knees

IX. References: Borenstein, S. et. al. (2004). Low back and neck pain: Comprehensive Diagnosis and Management, 3rd ed. Doenges, M. et. al. (2006). Nursing Care Plans, Edition 7. Porth, C. (1998). Pathophysiology: Concepts of Altered Health States, 5 th ed. http://en.wikipedia.org (2011). Spinal Disk Herniation. http://www.ncbi.nlm.nih.gov/pubmedhealth (2011). Herniated disk. A.D.A.M., Inc. http://www.mayoclinic.com (2010). Herniated Disk.