Herniated

Nucleus Pulposus

Alternative Names
Lumbar radiculopathy; Cervical radiculopathy; Herniated intervertebral disk; Prolapsed intervertebral disk; Slipped disk; Ruptured disk

Definition of Herniated Nucleus Pulposus:

A herniated nucleus pulposus is a slipped disk along the spinal cord. The condition occurs when all or part of the soft center of a spinal disk is forced through a weakened part of the disk.

Definition of Herniated nucleus pulposus:

Displacement of the central area of the disc (nucleus) resulting in impingement on a nerve root.

The four stages to a herniated disc include:

Disc Degeneration: chemical changes associated with aging causes discs to weaken, but without a herniation.

The four stages to a herniated disc include:

1.Disc Degeneration: chemical changes associated with aging causes discs to weaken, but without a herniation.

The four stages to a herniated disc include:

2. Prolapse: the form or position of the disc changes with some slight impingement into the spinal canal. Also called a bulge or protrusion.

The four stages to a herniated disc include:

3. Extrusion: the gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc.

The four stages to a herniated disc include:

4. Sequestration or Sequestered Disc: the nucleus pulposus breaks through the annulus fibrosus and lies outside the disc in the spinal canal (HNP).

INCIDENCE RATE
Most herniation takes place in the lower back (lumbar area) of the spine. Lumbar disk herniation occurs 15 times more often than cervical (neck) disk herniation, and it is one of the most common causes of lower back pain. The cervical disks are affected 8% of the time and the upper-to-mid-back (thoracic) disks only 1 - 2% of the time.

 Nerve roots (large nerves that branch out from the spinal cord) may become compressed resulting in neurological symptoms, such as sensory or motor changes. Disk herniation occurs more frequently in middle aged and older men, especially those involved in strenuous physical activity. Other risk factors include any congenital conditions that affect the size of the lumbar spinal canal.

Predisposing FACTORS

Advanced age History of back trauma Male Congenital conditions

Precipitating FACTORS

Sedentary lifestyle Sitting without lumbar support Cigarette smoking Chronic coughing Strenuous activities

MANIFESTATIONS
SYMPTOMS OF HERNIATED LUMBAR DISK Muscle spasm Muscle weakness or atrophy in later stages Pain radiating to the buttocks, legs, and feet Pain made worse with coughing, straining, or laughing Severe low back pain Tingling or numbness in legs or feet

MANIFESTATIONS
SYMPTOMS OF HERNIATED CERVICAL DISK
Arm muscle weakness Deep pain near or over the shoulder blades on the affected side Neck pain, especially in the back and sides Increased pain when bending the neck or turning head to the side Pain radiating to the shoulder, upper arm, forearm, and rarely the hand, fingers or chest Pain made worse with coughing, straining, or laughing Spasm of the neck muscles

Complications: Long-term back pain Loss of movement or sensation in the legs or feet Loss of bowel and bladder function Permanent spinal cord injury (very rare)

Signs and tests:

A physical examination and history of pain may be all that is needed to diagnose a herniated disk. A neurological examination will evaluate muscle reflexes, sensation, and muscle strength. Often, examination of the spine will reveal a decrease in the spinal curvature in the affected area.

Signs and tests:

Leg pain that occurs when you sit down on an exam table and lift your leg straight up usually suggests a herniated lumbar disk.

Signs and tests:

A foraminal compression test of Spurling is done to diagnose cervical radiculopathy. For this test, you will bend your head forward and to the sides while the health care provider provides slight downward pressure to the top of the head. Increased pain or numbness during this test is usually indicative of cervical radiculopathy.

DIAGNOSTIC STUDIES
EMG may be done to determine the exact nerve root that is involved. (Electromyography (EMG) is a technique for evaluating and recording the activation signal of muscles. EMG is performed using an instrument called an electromyograph, to produce a record called an electromyogram. An electromyograph detects the electrical potential generated by muscle cells when these cells are both mechanically active and at rest. The signals can be analyzed in order to detect medical abnormalities or analyze the biomechanics of human or animal movement.)

DIAGNOSTIC STUDIES
Nerve conduction velocity test may also be done. (nerve conduction study (NCS) is a test commonly used to evaluate the function, especially the ability of electrical conduction, of the motor and sensory nerves of the human body. Nerve conduction studies are used mainly for evaluation of paresthesias (numbness, tingling, burning) and/or weakness of the arms and legs.)

DIAGNOSTIC STUDIES
Myelogram may be done to determine the size and location of disk herniation. (Myelography is a type of radiographic examination that uses a contrast medium to detect pathology of the spinal cord, including the location of a spinal cord injury, cysts, and tumors. The procedure often involves injection of contrast medium into the cervical or lumbar spine, followed by several X-ray projections.)

DIAGNOSTIC STUDIES

Spine MRI or spine CT will show spinal canal compression by the herniated disk. Spine x-ray may be done to rule out other causes of back or neck pain. However, it is not possible to diagnosis herniated disk by spinal x-ray alone.

MANAGEMENT

The main treatment for a herniated disk is a short period of rest with pain and anti-inflammatory medications, followed by physical therapy. Most people who follow these treatments will recover and return to their normal activities. A small number of people need to have further treatment, which may include steroid injections or surgery.

MEDICATIONS

Nonsteroidal anti-inflammatory medications (NSAIDs) and narcotic pain killers will be given to people with a sudden herniated disk caused by some sort of injury (such as a car accident or lifting a very heavy object) that is immediately followed by severe pain in the back and leg.

MEDICATIONS

NSAIDs are used for long-term pain control, but narcotics may be given if the pain does not respond to anti-inflammatory drugs.

MEDICATIONS

Muscle relaxants are usually given if the patient has back spasms. On rare occasions, steroids may be given either by pill or directly into the blood through an IV.

MEDICATIONS

Steroid injections into the back in the area of the herniated disk can help control pain for several months. Such injections reduce swelling around the disk and relieve many symptoms. Spinal injections are usually done on an outpatient basis, using x-ray or fluoroscopy to identify the area where the injection is needed.

SURGERY

Diskectomy - removes a
protruding disk. This procedure requires general anesthesia (asleep and no pain) and 2 - 3 day hospital stay.

SURGERY

Microdiskectomy - a procedure removing fragments of nucleated disk through a very small opening.

SURGERY

Chemonucleolysis - involves
the injection of an enzyme (called chymopapain) into the herniated disk to dissolve the protruding gelatinous substance. This procedure may be an alternative to diskectomy in certain situations.

NURSING DIAGNOSIS

Pain acute/chronic related to injuring agents, nerve compression, muscle spasm Impaired physical mobility related to pain and discomfort Fatigue related to inability to maintain usual routines, compromised concentration

NURSING DIAGNOSIS

Ineffective coping related to situational crisis Knowledge deficit regarding condition, prognosis, and treatment related to lack of knowledge

NURSING RESPONSIBILITIES

1. Reduce back stress, muscle spasm, and pain. 2. Promote optimal functioning. 3. Support patient/SO in rehabilitation process.

NURSING RESPONSIBILITIES
4. Provide information concerning condition/prognosis and treatment needs. 5. Discharge plan DRG projected mean length of inpatient stay: 4.96.5 days considerations: May require assistance with transportation, self-care, and homemaker/maintenance tasks Refer to section at end of plan for postdischarge considerations.

LIFESTYLE CHANGES

Any extra weight being carried by an individual, especially up front in the stomach area, will make back pain worse. Diet and exercise are crucial to improving back pain in overweight patients.

Prevention

Safe work and play practices, proper lifting techniques, body mechanics and weight control may help to prevent back injury in some people.

Thanks!