Herniated intervertebral disc2


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Herniated Intervertebral disc ppt. Concept mapping, medical mgt, diagnoses, pharmacologic approach and nursing responsibilities.

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Herniated intervertebral disc2

  1. 1. Herniated Intervertebral Disc
  2. 2. CONCEPT MAP Age Occupational stress Surgical Management: Diagnostic Tests: Discectomy, Herniated MRI, CT Scan and X Ray Laminectomy, Intervertebral Disk Foramenotomy, Medical Management: Pharmacologic Therapy: Bed rest, immobilization Analgesics, muscle relaxant, corticosteroid, sedatives Clinical Manifestations: Muscle weakness, Back pain , also in knees, alteration in thighs or feet. reflexes Postural deformity Sensory loss Acute Pain Disturbed Body Image Disturbed sensory Impaired physical perception mobility Current Evidenced- Bioethical/ Nursing HealthTrends/Updates Based Practice Ethico-Legal Theories Teachings
  3. 3. Herniated Intervertebral DiskIn herniation of the intervertebral disk (ruptured disk), the nucleus of the disk protrudes into the annulus (the fibrous ring around the disk), with subsequent nerve compression. Protrusion or rupture of the nucleus pulposus usually is preceded by degenerative changes that occur with aging. CM
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  6. 6. Normal Herniated Intervertebral Disk CM
  7. 7. Predisposing Factor: Precipitating Factor:•Age-Degenerative changesthat occur with aging. •Occupational stress:Usually at 4th decade of - Causes chronic disclife. degeneration CM
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  9. 9. Clinical Manifestations Back pain, knifelike, aggravated by coughing, sneezing, bending, lifting, defecation, straight legraising. Postural deformity/altered posture and gait Sensory Loss Altered reflexes and Muscle weakness CM
  10. 10. DIAGNOSTIC STUDIES Spinal x-rays: may show degenerative changes in spine/intervertebral space or rule out other suspected pathology, e.g., tumors, osteomyelitis. Ct scan with/without enhancement: may reveal spinal canal narrowing, disc protrusion. CM
  11. 11. MRI: can reveal changes in bone, discs, and softtissues and can validate disc herniation/surgicaldecisions. CM
  12. 12. Nursing Considerations:1. Explain procedure.2. Remove all metals from the client such as jewelry, braces, dentures3. Not indicated for patients with artificial pacemakers, skeletal tractions and prosthesis.3. Assess for claustrophobia ; give psychosocial support. Sedate patient if necessary.
  13. 13. Electrophysiological studies—electromyoneurography (emg) andnerve conduction studies (ncs): can localize lesionto level of particular spinal nerve root involved; nerve conduction andvelocity study usually done in conjunction with study of muscleresponse to assist in diagnosis of peripheral nerve impairment andeffect on skeletal muscle.Myelogram: rarely performed, but when done, may be normal or show“narrowing” of disc space, specific location andsize of herniation.Provocative tests (discography, nerve root blocks): determine siteof origin of pain by replicating and then relievingsymptoms. can also be used to rule out sacroiliac joint involvement. CM
  14. 14. Medical ManagementThe goals of treatment are (1) to rest and immobilize the cervical spine togive the soft tissues time to heal and (2) to reduce inflammation in thesupporting tissues and the affected nerve roots in the cervical spine.This could be achieved by:•Bed rest•Proper positioning on a firm mattress may bring dramaticrelief from pain.•Immobilization by traction or brace (e.g., neck collar) CM
  15. 15. Non-surgical care alternatives to treat the pain, including:1. Chiropractic2. Bed rest and lumbo-sacral support belt.3. Physical therapy4. Massage therapy5. Weight control6. Spinal decompression CM
  16. 16. Pharmacologic therapy Analgesics •NSAIDs •Propoxyphene [Darvon] •Oxycodone [Tylox] Muscle relaxants •Cyclobenzaprine [Flexeril] •Methocarbamol •[Robaxin] •Metaxalone [Skelaxin]) Sedatives Corticosteroids CM
  17. 17. Surgical Management Discectomy: removal of herniated or extruded fragments of intervertebral disk Laminectomy: removal of the bone between the spinal process and facet pedicle junction to expose the neural elements in the spinal canal ; allows the surgeon to inspect the spinal canal, identify and remove pathology, and relieve compression of the cord and roots Hemilaminectomy: removal of part of the lamina and part of the posterior arch of the vertebra. Partial laminectomy or laminotomy: creation of a hole in the lamina of a vertebra. CM
  18. 18. • Discectomy with fusion: a bone graft (from iliac crest orbone bank) is used to fuse the vertebral spinous process; theobject of spinal fusion is to bridge over the defective disk tostabilize the spine and reduce the rate of recurrence• Foraminotomy: removal of the intervertebral foramen to increasethe space for exit of a spinal nerve, resulting in reducedpain, compression, and edema CM
  19. 19. Nursing Process NURSING PRIORITIES 1. reduce back stress, muscle spasm, and pain. 2. promote optimal functioning.3. support patient/so in rehabilitation process.4. provide information concerningcondition/prognosis and treatment needs.
  20. 20. Nursing AssessmentACTIVITY/RESTmay report: history of occupation requiring heavy lifting, sitting, drivingfor long periodsmay exhibit: atrophy of muscles on the affected sidegait disturbancesEGO INTEGRITYmay report: fear of paralysisfinancial, employment concernsmay exhibit: anxiety, depression, withdrawal from family/so CM
  21. 21. NEUROSENSORYmay report: tingling, numbness, weakness of affectedextremity/extremitiesmay exhibit: decreased deep tendon reflexes; muscle weakness,hypotoniatenderness/spasm of paravertebral musclesdecreased pain perception (sensory)PAIN/DISCOMFORTmay report: pain knifelike, aggravated bycoughing, sneezing, bending, lifting, defecation, straight legraising; unremitting pain or intermittent episodes of more severe pain; radiationto leg/feet, buttocks area (lumbar), or shoulder or head/face, neck (cervical)heard “snapping” sound at time of initial pain/trauma or felt “back giving way”limited mobility/forward bendingmay exhibit: stance: leans away from affected areaaltered gait, walking with a limp, elevated hip on affected sidepain on palpation CM
  22. 22. Nursing Diagnoses cute related to physical injury agents: nerve compression, muscle spasm mpaired physical mobility related to pain and discomfort, muscle spasms restrictive therapies, e.g., bedrest, traction neuromuscular impairment nxiety related to situational crisis isturbed body image related to postural deformity CM
  23. 23. PlanningThe goals for the patient may include relief of pain,improved mobility, increased knowledge and self careability, and prevention of complications. CM
  24. 24. Nursing Interventions/ ManagementPOSITIONING THE PATIENT To position the patient, a pillow is placed under the head and the knee rest is elevated slightly to relax the back muscles. The patient is encouraged to move from side to side to relieve pressure and is reassured that no injury will result from moving. The patient turns as a unit (logrolls), without twisting the back. CM
  25. 25. LOGROLLINGThe patient’s arms will becrossed and the spine aligned.To avoid twisting the spine, thehead, shoulders, knees, andhips are turned atthe same time so that thepatient rolls over like a log.When in a side-lying position,the patient’s back, buttocks,and legs are supported withpillows. CM
  26. 26. Bed rest for 1 to 2 days on a firm mattress (to limit spinal flexion)is encouraged to reduce the weight load and gravitational forces,thereby freeing the disk from stressThe patient is allowed to assume a comfortable position; usually, a semi-Fowler’s position with moderate hip and knee flexion relaxes theback muscles.When the patient is in a side-lying position, a pillow is placed betweenthe legs.To get out of bed, the patient lies on one side while pushing up to asitting position.NSAIDs and systemic corticosteroids may be administered to counter theinflammation that usually occurs in the supporting tissues and theaffected nerve roots.Moist heat and massage help to relax spastic muscles and have asedative effect. CM
  27. 27. EvaluationExpected patient outcomes may include:1. Reports decreasing frequency and severity of pain2. Demonstrates improved mobility:a. Demonstrates progressive participation in self-care activitiesb. Identifies prescribed activity limitations and restrictionsc. Demonstrates proper body mechanic CM
  28. 28. Current Trends/Updates/Researches Genes Linked To Spinal Disc Degeneration Identified ScienceDaily (Mar. 17, 2009) — Lumbar disc degeneration is an uncomfortable condition that affects millions of people, but two University of Alberta researchers have identified some of the genes that are causing problems. and Tapio Videman, in the Faculty of Rehabilitation Michele Crites-Battie Medicine, have discovered eight genes that are directly related to disc degeneration. "We found more genes associated with disc degeneration than was discovered in 30 prior studies," said Videman. "This is very exciting.“ The pair started by studying 25 specific genes they thought could be linked to the disease. They picked these "candidate" genes based on the views of two leading experts and Videman have collaborated with through the in the field who Crites-Battie years. They narrowed their search down using state-of-the-art DNA analyzers, then applying statistical methods and analyzing MRIs of twins spines. CM
  29. 29. "Identifying genes involved can provide important insights into the biologicalmechanisms behind disc degeneration and a better understanding of . "This caneventually what is going wrong in the system," said Crites-Battie lead to effectiveinterventions for the problem.“The pair will now look at the interaction between these eight genes and theirenvironment. This will help them identify what gene forms indicate susceptibility."This will tell us who should avoid physical loading, and in which people obesitycould be a risk factor for spine problems," said Videman.But this could be a long process as disc degeneration is whats called polygenic,meaning it involves more than one gene."There are likely to be quite a number of genes involved and a system of complexgene-gene and gene-environment interactions," said Crites-Battie. "Obtaining a fullappreciation of the genetic architecture of disc degeneration is likely to be a verylengthy, involved process." CM
  30. 30. This discovery comes about a year after the pairs award winning 10-yearinternational twin-spine study proved that disc degeneration is affected largelyby genetics."For years it has been thought that wear and tear was the main cause," said.Crites-BattieThe U of A researchers have made huge strides in the field and aredetermined to put an end to lower-back pain."This study could lead to interventions and actions individuals could take tominimize disc degeneration to which [patients] might be particularly prone," ."We are very excited about continuing down this trail and said Crites-Battiebelieve there is still much more to be learned." CM
  31. 31. Evidence-Based PracticeNarrowing of Lumbar Spinal Canal Predicts Chronic Low Back Pain MoreAccurately than Intervertebral Disc Degeneration: A Magnetic ResonanceImaging Study in Young Finnish Male ConscriptsThe objective of this magnetic resonance imaging study was to evaluate the roleof degenerative changes, developmental spinal stenosis, and compression ofspinal nerve roots in chronic low back (CLBP) and radicular pain in Finnishconscripts. The degree of degeneration, protrusion, and herniation of theintervertebral discs and stenosis of the nerve root canals was evaluated, andthe midsagittal diameter and cross-sectional area of the lumbar vertebrae canalwere measured in 108 conscripts with CLBP and 90 asymptomatic controls.The midsagittal diameters at L1-L4 levels were significantly smaller in thepatients with CLBP than in the controls. Moreover, degeneration of the L4/5 discand protrusion or herniation of the L5/S1 disc and stenosis of the nerve rootcanals at level L5/S1 were more frequent among the CLBP patients.Multifactorial analysis of the magnetic resonance imaging findings provided atotal explanatory rate of only 33%. Narrowing of the vertebral canal in theanteroposterior direction was more likely to produce CLBP and radiating painthan intervertebral disc degeneration or narrowing of the intervertebral nerveroot canals. CM
  32. 32. Bioethical Principles/Ethico-Legal Principle of Beneficence Principle of Respect for Autonomy Principle of Human Dignity Principle of Informed Consent Principle of Double Effect CM
  33. 33. Nursing TheoriesSister Callista Roy Adaptation ModelJean Watson Human Caring Other theory Wear and Tear Theory of Aging CM
  34. 34. Health TeachingsPain Management• Limit bed rest; keep knees flexed to decrease strain on back• Nonpharmacologic approaches: distraction, relaxation, imagery,thermal interventions (eg, ice or heat), stress reduction• Pharmacologic approaches: nonsteroidal anti-inflammatorydrugs,analgesics, muscle relaxantsExercise• Stretch to enhance flexibility, do strengthening exercises• Perform prescribed back exercises to increase function,emphasizing gradual increases in time and repetitionsBody Mechanics• Practice good posture• Avoid twisting body• Push objects rather than pull them• Keep load close to body when lifting• Bend knees and tighten abdominal muscles when lifting CM
  35. 35. •Avoid overreaching• Use wide base of support• Use back brace to protect backWork Modifications• Adjust work area to avoid stress on back• Adjust height of chair or work table• Use lumbar support in chair• Avoid prolonged standing and repetitive tasks• Avoid bending, twisting, and lifting heavy objects• Avoid work involving continuous vibrationsStress Reduction• Discuss with patient the interdependence of stress and anxiety onmuscle tension and pain• Explore effective coping mechanisms• Teach stress reduction techniques• Refer patient to back clinic CM
  36. 36. Health PromotionStanding• Avoid prolonged standing and walking.• When standing for any length of time, rest one foot on a smallstool or box to relieve lumbar lordosis.• Avoid forward flexion work positions.• Avoid high heels.Sitting• Avoid sitting for prolonged periods.• Sit in a straight-back chair with back well supported and arm rests to support someof the body weight; use a footstool to position knees higher than hips if necessary.• Eradicate the hollow of the back by sitting with the buttocks “tucked under.”• Maintain back support; use a soft support at the small of the back.• Avoid knee and hip extension. When driving a car, have the seat pushed forward asfar as possible for comfort.• Guard against extension strains—reaching, pushing, sitting with legs straight out.• Alternate periods of sitting with walking. CM
  37. 37. •Place a firm bed board under the mattress.• Avoid sleeping in a prone position.• When lying on the side, place a pillow under the head and onebetween the legs, with the legs flexed at the hips and knees.• When supine, use a pillow under the knees to decrease lordosis.Lifting• When lifting, keep the back straight and hold the load as close to the bodyas possible.• Lift with the large leg muscles, not the back muscles.• Use trunk muscles to stabilize the spine.• Squat while keeping the back straight when it is necessary to pick somethingoff the floor.• Avoid twisting the trunk of the body, lifting above waist level, and reaching upfor any length of time.Exercising• Daily exercise is important in the prevention of back problems.• Walking and gradually increasing the distance and pace of walking isrecommended.• Perform prescribed back exercises twice daily, increasing exercise gradually.• Avoid jumping and jarring activities. CM