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Neurosensory: Herniated Disk and Spinal Cord tumors

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Neurosensory: Herniated Disk and Spinal Cord tumors Marnie Quick RN, MSN, CNRN – PowerPoint PPT presentation

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Title: Neurosensory: Herniated Disk and Spinal Cord tumors


1
Neurosensory Herniated Disk and
Spinal Cord tumors
  • Marnie Quick RN, MSN, CNRN

2
A. Pathophysiology/etiologyNormal spine as
related to herniated disk
  • Herniated nucleus pulposus, slipped disk,
    ruptured disk
  • Function of disk is to allow for mobility of the
    spine and act as shock absorber
  • Located between vertebral bodies
  • Composed of nucleus pulposus a gelatinous
    material surrounded
  • By annulus fibrosis- a fibrous coil

3
Spinal nerves come out between vertebra from the
reflex ark in the spinal cord
4
Causes of degenerative disease Video of diff
causes http//www.spineandscoliosis.com/subject.p
hp?pnspinal-conditions
5
HNP- Herniated Nucleus Pulpsus
  • HNP- annulus becomes weakened/torn and the
    nucleus pulpsus herniates through it.
  • HNP compresses
  • Spinal nerve (sensory or motor component) as it
    leaves the spinal cord
  • Or the cord itself- the white tracks within the
    cord- rare

6
Risk factors developing herniated disk
  • Standing erect- cumulative effect and daily
    stress
  • Aging changes in disc and ligaments,
    osteoarthritis
  • Poor body mechanics
  • Overweight, sedentary life style
  • Smoking
  • Trauma

7
  • 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
  • Video http//www.spineandscoliosis.com/subject.ph
    p?pnanimate-lumradsciatica

8
Common manifestations/complications
Lumbar HNP
  • A common site is L4-5 disc- the 4th lumbar nerve
    root
  • Most common is posterior sensory nerve or root
    compressed
  • Classic symptoms- low back sciatica pain. The
    pain increases with increase in intrathorasic
    pressure- sneezing, straining, coughing
  • Other symptoms- postural changes, urinary, male
    sexual function, paresis/paralysis, foot drop,
    paresthesias, numbness, muscle spasms, BB
    incontinence, cord reflexes decreasedgtabsent

9
Common manifestations/complications
Cervical HNP
  • C5-C6 disk- 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- may cause pain and set up a
    pain-spasm-pain cycle.

10
Collaborative Care Diagnostic tests
  • X-ray identify deformities and narrowing of disk
    space
  • CT/MRI
  • Mylogram- picture gt
  • Diskogram
  • Nerve conduction studies (EMG) to detect
    electrical activity of skeletal muscles

11
Collaborative Care
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. Avoid smoking
  • Heat/cold therapy to decrease muscle spasms
  • Break the pain-spasm-pain cycle with meds
    (antispasmodics/pain meds)

12
Treatment- Conservative
  • Intermittent skin traction (cervical/pelvic)
  • Ultrasound, massage, relaxation techniques
  • TENS unit (Transcutaneous electrical nerve
    stimulation)
  • Progressive mobilization with approved exercise
    program includes abdominal/thigh strengthening
  • Teaching good body mechanics
  • Weight loss

13
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
  • IDET or Percutanecus Disc Nucluoplasty View
    video below
  • http//www.spineandscoliosis.com/subject.php?
    pnanimate-nucleoplasty

14
Treatment- Surgery
  • Spinal fusion removes most of the disk and
    replaces it with bone usually from the patient
    iliac crest. View video
  • http//www.spineandscoliosis.com/subject.ph
    p?pnanimate-spinalfusion
  • Videos of Lumbar inter-Body Fusion with
    cage
  • http//www.spineandscoliosis.com/subject.ph
    p?pnanimate-alifmesh
  • http//www.spineandscoliosis.com/subject.ph
    p?pnanimate-ibf
  • Flexibility is lost at the site- requires longer
    hosp stay

15
Treatment- Surgery
  • Foraminotomy is enlargement of the bony
    overgrowth at the opening which is compressing
    the nerve. View video on Foraminotomy
    http//www.spineandscoliosis.com/subject.php?pnan
    imate-cervpostfor
  • Microdiskectomy is 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

16
Charite disk View Video on artificial disks
http//www.spineandscoliosis.com/subject.php?pnan
imate-cervartificialdisc
17
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

18
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

19
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

20
Post-op assessment from HNP
  • NVS sensory/motor- care not to injure op site
  • Assess for CSF drainage or bleeding from op site
  • Encourage turn (log roll, cough, deep breath)
  • If anterior cervical- assess injury to the
    carotid, esophagus, trachea, laryngeal nerve
    (speech- hoarseness)- assess respiration, neck
    size, swallowing and speech

21
  • If post-op lumbar- assess bowels sounds, voiding.
    Minimize stress of post-op site- flat with pillow
    between knees, log roll, etc
  • Assess for postural hypotension, especially if
    ind was on bed rest for several days/weeks prior
    to surgery

22
Pertinent nursing problems/interventions 1.
Acute pain
  • Bedrest medication (analgesics/antispasmotics
    anti-inflam) good body mechanics back support
    (brace, etc)
  • Teach need to adhere to activity restrictions,
    grad inc, Physician approved exercise program.
    Lumbar better to stand than sit. Life style
    changes Avoid sit-ups
  • Post surgery the individual may have similar pain
    as pre-op due to lack of resiliency of the spinal
    nerves to bounce back quickly
  • If use bone for fusion, 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

23
Chronic pain
  • Surgery may not relieve pain
  • Nonpharmalogical methods to control pain
  • Pain clinic

24
Post-op care after spinal surgery
  • Maintain proper body alignment
  • Pain control
  • Check dressinggt blood/CSF donor site
  • Monitor extremities CMS (Circulation Motor and
    Sensory)
  • Assess paralytic ileus, bladder empting (bladder
    scan/intermittent cath
  • Activity order
  • Teach use of brace/orthotic
  • Lumbar- avoid sitting prolonged periods
  • Firm mattress

25
Constipation
  • As a result of bed rest and decreased mobility
    and fear of pain with straining of stool
  • Constipation prevention methods fluids, diet, etc

26
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

27
Spinal Cord Tumors Patho- normal
spine as relates to 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
  • Spinal tumors are classified by anatomical area
    and as primary (origin in spinal cord) or
    secondary (metastatic from other parts of the
    body)
  • Most spinal cord tumors found thoracic region
  • Compress, invade neural tissue, cause ischemia

28
Classification of spinal cord tumors by
anatomical area
  • Extradural-
  • Outside the dura (outer layer of the meninges)
  • from bones of spine, in extradural space, or in
    paraspinal tissue
  • 90 of all spinal cord tumors
  • Usually malignant metastatic lesions
  • Intradural Inside the dura
  • Intramedullary within the spinal cord itself
    (40 of intradural tumors) Benign good prognosis
  • Extramedullary within dura mater outside of the
    spinal cord

29
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30
Intermedullary spinal cord tumor
31
  • 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 manifestation/complications
  • Symptoms depend on the anatomical level of the
    spinal column, the anatomical location, the type
    of tumor and the spinal nerves affected
  • Pain is the most common presenting symptom that
    is not relieved by bed rest
  • Other symptoms are similar to those found with
    HNP or spinal cord injury- sensory or motor

33
  • Manifestations 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
Collaborative Care for spinal cord tumor
  • Diagnostic tests include
  • X-ray of the spinal column
  • Myelogram
  • Lumbar puncture with CSF analysis
  • Medications spinal tumors
  • Control pain- narcotic analgesics, may be given
    epidural catheter, PCA, NSAIDs
  • Reduce cord edema and tumor size- steroids
    dexamethasome (Decadron) high dose for a few
    days, then taper off with a Medrol dose pack

35
Collaborative Care for spinal cord tumor
  • 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
  • HNP module for post-op care

36
Collaborative Care for spinal cord tumor
  • Radiation Therapy spinal tumors
  • Usually used for metastatic spinal cord tumors to
    reduce size of the tumor to control pain

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

38
Pertinent 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
  • 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
  • 6. Urinary retention
  • Reflex ark (S2,3,4) interference can cause
    neurogenic bladder as discussed with SCI
  • 7. Home care
  • Rhabilitation
  • Home evaluation
  • Support groups

41
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