INTERVERTEBRAL DISC PROLAPSE Class

1. INTERVERTEBRAL
DISC PROLAPSE (IVDP)

2. Vertebra
Cervical
Thoracic
Lumbar
Sacral
coccyx

3. Intervertebral disc

5. THE VERTEBRAL DISC
The intervertebral disc is a cartilaginous plate,
tough and fibrous material is incorporated in a
capsule
A ball like cushion in the centre of the disc is
called nucleus pulposus
The fibrous ring around the disc is called
annulus.

8. INTERVERTEBRAL DISC
DISEASE
Intervertebral disc diseases is a condition that
involves the deterioration ,herniation or other
dysfunction of the intervertebral disc
It involves,
Cervical
Thoracic
Lumbar

9. TYPES OF DISC
DEGENERATION
 BULGING DISC
 HERNIATED DISC
 DEGENERATED DISC
 THINNING DISC

11. DEFINITION
IVDP is a condition in which a tear in the outer,
fibrous ring (annulus fibrosus) of the intervertebral
disc allows the soft central portion(nucleus pulposus)
to bulge out.
Common sites :L4-L5, C6-C7, L5-S1, C5-C6

12. ETIOLOGY
Structural degeneration
of the disc by
degenerative disease
Ageing
Occupational

13. Repeated stress and trauma to spine
Repetitive mechanical activities (frequent
bending, twisting, lifting)
Traumatic injury
Spinal stenosis(narrowing of the spinal canal
forces the disc to prolapse)
Obesity

14. Practicing poor posture(improper spinal alignment
strains the back and neck)
Tobacco use weakens the disc
Spondylosis- wear and tear of spinal disc

15. STAGES OF DISC HERNIATION
Degeneration : there is no bulge
Prolapse: just a bulge, contained herniation-
nucleus is with in annulus
Extrusion: non contained herniation
Sequestration: it act as a free fragment - no
continuity with the parent disc

17. PATHOPHYSIOLOGY
In the herniation of intervertebral disc the
nucleus of the disc protrudes into the annulus
with subsequent nerve compression

18. IN NUCLEUS
Degenerative changes
Loss of protein polysaccharides in the disc
decreases the water content of the nucleus
and it starts to dry out and shrink
Loss of elasticity, flexibility and shock
absorbing capabilities

19. IN ANNULUS
Development of radiating cracks
weakens the resistance to nucleus
herniation

20. These changes limit the ability of the disc to
distribute pressure between vertebra
 The loads are transferred to annulus fibrosus
With the structural damage nucleus pulposus
may sweeps through a torn or stretched annulus

21. Produces radiculopathy
Continued pressure causes changes in
sensation and deep tendon reflexes

22. CLINICAL MANIFESTATION
It depends on the location, the rate of
development(acute or chronic) and the effect
on the surrounding structures

23. Cervical spine
 Radiculopathy: radiating pain, numbness, tingling and
diminished strength or range of motion
 Pain and stiffness in the neck, in the top of the shoulders,
region of scapulae

24. Pain the upper extremities and head
Paraesthesia (tingling or pin and needle sensation)
Numbness of the extremities
Weak handgrip

25. Lumbar spine
 Lower back ache with muscle spasm followed by,
 Radicular pain that radiates down the buttocks and below the
knee along sciatic nerve
 Straight leg raising test (SLR) positive due to nerve root irritation.

26. Straight leg raising test (SLR)

27. Reflexes depressed or absent
Paraesthesia or muscle weakness in legs ,feet and
toes
Pain aggravates on bending ,lifting or straining,
sneezing or coughing due to increased intra spinal
fluid pressure
Sensory loss

28. ASSESSMENT AND DIAGNOSIS
History and physical examination
MRI scan (protrusion and
compression)
CT scan
X ray –to detect structural defects

30. MANAGEMENT
Medical /conservative management
Goals
To provide rest and immobilise the cervical
spine
To give soft tissue time to heal
To reduce inflammation

31. Bed rest (usually 1-2 days)-eliminates stress and
gravity.
Proper positioning on a firm mattress.
Cervical collar, cervical traction or a brace
Collar-holds the head in a neutral or slightly
flexed position
Cervical isometric exercises (strengthen neck
muscles)

32. General management
Restricted activity for several days
Local ice or heat for 10-20 min (increase blood
flow)

33. Weight reduction and physical therapy
Biofeedback
Exercises to strengthen muscles and
decrease pain

34. Limit extreme spinal movements
Traction
Tens(trans cutaneous electrical nerve
stimulation)
Good body mechanics
Discourage extremes of flexion and torsion

35. Pharmacological management
Analgesic
Opioids ( eg:tramadol)
NSAIDS (eg:aspirin, ibuprofen)
Sedatives (to control anxiety)
Muscle relaxants(reduce muscle spasm eg:
cyclobenzaprine,metaxalone)
Corticosteroids (to reduce inflammation)

36. Surgical management
Indication
No improvement by medical management
Constant pain and persistent neurologic
deficits

37. Intra discal electro thermoplasty (IDET)
Minimally invasive – OP procedure
Inserting needle to the affected disc
with the help of X ray
The wire is threaded down through
the needle in to the disc

40. The wire is heated and it denervates the small
nerve fibres
The heat melts the annulus fibrosus which
trigger the body to generate new reinforcing
proteins in the fibres of annulus

41. Radio frequency discal nucleoplasty
Probe geSame as IDET, instead of heat,
radio frequency fibre is used
nerate energy which breaks the molecular
bonds of the gel in the nucleus pulposus.

42. Interspinous process decompression system
A device made of titanium is fits on to a mount that is
placed on vertebra in the lower back
 It is used in patients with pain due to lumbar spinal
stenosis

44. Discectomy
 It is a surgical procedure to decompress the nerve
root
Microsurgical discectomy: using microscope the
surgeon visualise the disc and increase safety,
make effective and reduce rehabilitation time.

45. Laminectomy
Common and traditional surgical procedure for
lumbar disc disease
It involves the surgical excision of the
vertebra(lamina) to gain access to the spinal
cord or to relieve pressure on nerves.

48. Hemilaminectomy -
Hemilaminectomy is
surgery to help
alleviate the
symptoms of an
impinged or irritated
nerve root in the
spine

50. DISC ARTHROPLASTY
The damaged disc is removed and new one
is implanted

51. Artificial disc replacement surgery

52. Lumbar fusion
• Anterior lumbar fusion is an
operation done on the
front (the anterior region) of
the lower spine.
• Fusion surgery helps two or more
bones grow together into one
solid bone.
•Moss Miami fixation

53. Complications of disc surgery
Archnoiditis- inflammation of arachinoid
membrane
Adhesions and scarring around the spinal nerves
chronic neuritis and neurofibrosis.
Disc surgery may relieve pressure ,but not reverse
the effects of neural injury, scarring and pain.

54.  Failed disc syndrome
Remaining of the disability
Hematoma at surgical site leads to cord
compression

55. Nursing management
 Assessment (pre op)
 Ask about past injuries
 Determine onset, location and radiation of pain
 Assess paraesthesia, limited movement and diminished
function of neck ,shoulders and upper extremities

56.  Whether the symptoms are bilateral with large herniation's
(cord compression)
 Palpate the area around the cervical spine to assess muscle
tone and tenderness
 Range of motion in neck and shoulders

57. Nursing management
 Ask about health issues that may affect post op function
Assess mood and stress levels
Assess bowel and bladder function
Teach legrolling ,deep breathing coughing
exercise and muscle setting exercise

58.  Assessment (post op)
After lumbar disc excision
Vital signs (BP, pulse for CVS function assessment,
respiratory difficulty)
Wound (haemorrhage, vascular injury)
Post op neurologic deficit
Sensation and motor strength of extremities
Colour temperature and sensation of toes
Urinary retention (sign of neurologic deficit)

59. Nursing diagnosis
 Acute pain related to surgical procedure
 Impaired physical mobility related to post op surgical
regimen
 Deficient knowledge about the post op course
 Anxiety related to surgery

60. Constipation related decreased mobility
Self care deficit
Urinary retention
Disturbed sleep pattern

61. Nursing interventions
Relieving pain and medications
 The patient may be kept flat in the bed for 12 to 24 hrs.
 Monitor site for hematoma
 Administer prescribed medications
 Post op- requires opioids such as IV morphine 24 to 48 hrs
 Patient controlled analgesics for continued pain
 Once fluid diet takes then oral medications
 Muscle relaxant

62. Positioning the patient
Maintain proper alignment of
spine
Ambulation depends on surgery

63. Potential for CSF leakage
Inspect dressing for serosanguinous drainage (dural
leak)
Report and care for headache
Note colour, amount and characteristics

64. Monitor neurologic signs frequently
Sensation, numbness, paraesthesia, tingling
Temperature, capillary refill and pulses
Swallowing deficits ,upper and lower extremity
weakness
Assess sudden radicular or spinal root pain-spinal
instability

65. Paralytic ileus
 May occur and affect bowel fuction
 Manifest as –nausea, abdominal distention, constipation
 Assess passage of flatus, bowel sounds in all quadrants
 Flat soft abdomen
 Provide stool softners ( eg: docusate)

66. Bladder emptying
 Due to activity restriction, opioids and anaesthesia it may
affect
 Use commode
 Ambulate the patient
 Ensure privacy
 Intermittent catheterisation/indwelling catheter
 Monitor incontinence/distention and report

67. Improving activities/mobility
-Limit activities and use rigid orthosis (thoraco-lambar-sacral orthosis)
-Chair back, brace, cervical collar(neck brace)
-Turn body instead of neck to look side to side
-Neck: position in neutral position
-Assist during position changes
-Alert for spinal cord edema: manifest as respiratory distress and
worsening neurologic status of upper limb.

68. Spinal fusion
Proper body mechanics
Avoid sitting or standing for prolonged periods
Encourage activities if that include walking ,lying
down and shifting weight from one foot to the other
when standing
Restrict lifting

69. Teach to mentally think before activities
Any twisting movement of the spine is
contraindicated
Use thighs and knees than back to absorb shock of
movement
A firm mattress or bed board is essential
Monitor and manage potential complications