intervertebral disc prolapse

1. PROLAPSED
INTERVERTERBRAL
DISC
PRESENTED BY:
SONAM

4. Typical lumbar vertebrae have several features
distinct from that of cervical or thoracic vertebrae
• Presence of a large vertebral body
• Spinus process is short and thick
• Articular facets, are markedly vertical
• Facets also have the unique feature of a curved articular surface.
This is one feature that differentiates lumbar vertebrae to from
thoracic

5. • L5 has the largest body and transverse process of all
vertebrae. The anterior aspect of the body has a greater
height compared to the posterior. This creates the lumbo
sacral angle between the lumbar region of the vertebrae and
the sacrum
• Due to the size of the intervertebral discs relative to the size
of the vertebral body and the size and horizontal direction of
the spinous process, the lumbar spine has the greatest
degree of extension of the vertebral column

6. INTRODUCTION
• The spine is subjected to stresses that
result from disc degeneration (due to
aging, occupational stresses) and
spondylosis ( degenerative changes
occurring in a disk and adjacent
vertebral bodies). disc degeneration
may lead to lesions that can cause
damage to the spinal cord and its
roots.

7. .
• Lumbar disc herniation is a
common low back disorder.
• A herniated disc is a displacement
of disc material beyond the
intervertebral disc space.
• This herniation process begins
from failure in the innermost
annulus rings and progresses
radially outward.
• Also known as prolapsed disc.

8. EPIDEMIOLOGY
• The highest prevalence is among people aged 30- 50 years, with a male
to female ratio of 2:1.
• The prevalence of symptomatic herniated lumbar disc is about 1-3%
depending on age and gender.
• In people aged 25-55 years, about 95% of herniated discs occur at the
lower lumbar spine (L4/ L5 and L5/S1 level) .
• Herniation above this level is more common in people aged over 55
years.
• The second most common site is the cervical region (C5 -C6, C6 –C7)
• The thoracic region accounts for only 0.15% to 4.0% of cases

9. TYPES OF
HERNIATION
•Posterolateral disc herniation
•Central (posterior) herniation
•Lateral disc herniation

10. RISK FACTORS
• Age: 35 to 50 years
• Gender

11. .
• Physically demanding work
• Pulling, pushing and twisting actions
• Family history
• Trauma

12. STAGES OF HERNIATION
•Bulging
•Protrusion
•Extrusion
•Sequestration

13. PATHOPHYSIOLOGY

14. With aging, vascular channels start to fail and vascular diffusion of nutrients
decrease thus number of viable chondrocytes in the nucleus pulposus diminishes
Synthesis rate and concentration of proteoglycans decreases and proportion of
collagen increase in nucleus pulposus
Water binding capacity of the nucleus decreases
Nucleus becomes more fibrous and stiffer
Nucleus is less able to bear and disburse load, transforming load to the posterior
annulus

15. CLINICAL MANIFESTATION
•Pain
•Radiating pain
•Pain, accompanied by
paresthesia (numbness,
tingling, or a pins and
needles sensation)

16. • Slow, debilitating tip toe walking
• Atrophy and weakness
• Loss of bladder and bowel control
• Muscle spasm

17. .
• Lhermitte’s syndrome- herniation of the disk centrally onto the spinal cord,
an electric like shock sensation in the extremities or spine with neck flexion
or straining and bilateral arm and leg weakness (myelopathy)

18. DIAGNOSTIC FINDINGS
• History collection
• Physical examination
• Neurological check: loss of sensation, such as numbness, and
weakness in the leg and foot. The patient may be asked to walk
normally and on tiptoes to check for a condition called foot
drop, in which the muscles used to flex the ankles and toes are
weakened. Reflexes may be slower than normal

19. .
Vitals signs check
• Gait monitoring
• Lumbar spine area exam.
• If there is inflammation in the lumbar spine , the skin may
appear abnormal or sensitive to touch

23. .
• X ray
• CT scan
• MRI
• Myelogram
• EMG

24. .

25. USES OF DISCOGRAPHY
• To evaluate equivocal abnormality seen on myelography, CT
or MRI
• To isolate a symptomatic disc among multiple level
abnormality
• To diagnose a lateral disc herniation
• To establish contained discogenic pain
• To select fusion levels
• To evaluate the previously operated spine

26. MEDICAL MANAGEMENT
• Rest and immobilize
• Proper positioning on a firm mattress
• The cervical pain may be rested and immobilized by a cervical collar, cervical
traction or a brace.
• A collar allows maximal opening of the intervertebral foramina and holds the head
in a neutral or slightly flexed position
• The patient may have to wear the collar 24 hours a day during the acute phase
• The skin under the collar is inspected for irritation
• After the patient is free of pain, cervical isometric exercises are started to
strengthen the neck muscles

29. Log roll method

30. PHARMACOLOGICAL THERAPY
• Analgesic agent
• Sedative agent
• Muscle relaxants: cyclobenzaprine, methocarbamol, metaxalone to interrupt
muscle spasm and to promote comfort
• Occasionally, a corticosteroid is injected into the epidural space for relief of
radicular pain (spinal nerve root)
• Hot, moist compress (for 10 to 20 minutes) applied to the back of the neck
several times daily to increase blood flow to the muscles and help relax the
patient and reduce muscle spasm

31. DISCECTOMY
• This procedure is used to
remove part of an
intervertebral disc that is
compressing the spinal
cord or a nerve root
(1557) Lumbar Discectomy Surgery - YouTu

32. LAMINECTOMY
• Removes the lamina
part to relieve spinal
stenosis or nerve
compression

33. INTRADISCAL
ELECTROTHERMIC THERAPY
(1557) LUMBAR IDET (INTRADISCAL ELECTROTHERMAL THERAPY) PROCEDURE -
YOUTUBE

34. NUCLEOPLASTY
• Nucleoplasty is the most advanced form of percutaneous
discectomy developed to date
• Tissue removal from the nucleus acts to “decompress” the disc and
relieve the pressure exerted by the disc on the nearby nerve root
• (1557) NUCLEOPLASTY ANIMATION – YOUTUBE

35. LUMBAR FUSION
• Fusion surgery helps two or more bones grow together into
one solid bone. Fusion cages are new devices, essentially
hollow screws filled with bone graft, that help the bones of
the spine heal together firmly
• Lumbar fusion is only indicated for recurrent lumbar disc
herniations, not primary herniation
• (1557) LUMBAR FUSION OF L5 S1 ANIMATION – YOUTUBE

36. CHEMO NUCLEOLYSIS
Chemo nucleolysis: chemonucleolysis is the term used to denote
chemical destruction of nucleus pulposus (chemo+ nucleo+lysis)
• This involves intradiscal injection of chymopapain which causes
hydrolysis of the cementing protein of the nucleus pulposus
• This causes decrease in water binding capacity leading to
reduction in size and drying of disc

37. DISC ARTHROPLASTY
• Artificial disc replacement (ADR), or
total disc replacement (TDR) is a type of
arthroplasty
• It is a surgical procedure in which
degenerated intervertebral discs in the
spinal column are replaced with artificial
devices in the lumbar (lower) or cervical
(upper) spine
• Used for cases of cervical disc herniation
• (1557) DISC REPLACEMENT SURGERY
FOR THE BACK - YOUTUBE

38. COMPLICATION
• Cauda equina syndrome
• Chronic pain
• Permanent nerve injury
• Paralysis

39. NURSING MANAGEMENT
• Assess the patient for any past injuries to the neck because unresolved trauma
can cause persistent discomfort, pain and tenderness and symptoms of
arthritis in the injured joint of the cervical spine
• Assessment includes determining the onset, location, and radiation of pain
• Assess for paresthesia, limited movement and diminished function of neck,
shoulders, and upper extremities
• It is important to determine whether the symptoms are bilateral, with large
herniations, bilateral symptoms may be caused by cord complication
• Assess muscle tone, tenderness, and range of motion in neck and shoulders
• Assess mood and stress levels

40. NURSING DIAGNOSIS
• Acute pain related to compression of nerve as evidenced by
visual analogue scale
• Risk for trauma related to temporary weakness of vertebral
column, and changes in muscle coordination as evidenced by
balancing difficulty and weakness verbalized by the patient

41. .
• Risk for constipation and urinary retention related to position
postoperatively and pain in lower back operated site as
evidenced by redness, and swelling in the near side of incision
site
• Impaired physical mobility related to pain and radiculopathy as
evidenced by severe pain during standing and walking and
inability to move independently
• Deficient knowledge related to preoperative and postoperative
management as evidenced by frequent questioning by patient and
family members

42. PROGNOSIS
• Extruded disc, large herniations, sequestrations have a greater
tendency to resolution than small herniations and disc bulges
• Recurrence of disc prolapse can be prevented by a proper
exercise programme and avoidance of stress to the lower part
of back

43. BIBLIOGRAPHY
 Brunner and suddharths. Textbook of medical and surgical nursing. 13th
edition vol. I. .New delhi: reed elsevier india pvt. Ltd.; 2014. Pg. No. 580-
596
 Lewis. Medical surgical nursing. Assessment and management of clinical
problems. Vol. I. 2015. New delhi. Elsevier pg. No. 461-493
 Joyce M. Black and jane hokanson; medical surgical nursing; volume 2, 8th
edition, reed elsevier, india pvt.
• https://www.physio-pedia.com/disc-herniation
• https://nurseslabscom/8-laminectomy-disc-surgery-nursing-care-plan/

44. .
THANK
YOU