Herniated Nucleus Pulposus

HERNIATED NUCLEUS PULPOSUS DEFINITION 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. ALTERNATIVE NAMES Lumbar radiculopathy; Cervical radiculopathy; Herniated intervertebral disk; Prolapsed intervertebral disk; Slipped disk; Ruptured disk INCIDENT 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. RISK/PREDISPOSING FACTORS • •

Strenuous physical activity Congenital conditions that affect the size of the lumbar spinal canal.

MANIFESTATION 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

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

TYPE/STAGE/CLASSIFICATION Person who has sustained one disc herniation is statistically at increased risk for experiencing another. There is an approximate 5% rate of recurrent disc herniation at the same level, and a lesser incidence of new disc herniation at another level. Factors involved may be weight related level of physical conditioning, work or behavioral habits. Since these factors are typically the same after surgery, there is an increased risk of herniated disc in this group, over the general population. However, the good news is that the majority of disc herniations (90%) do not require surgery, and will resolve with conservative, nonoperative treatment, without significant long-term sequelae. Unfortunately, approximately 5% of patients with herniated, degenerated discs will go on to experience symptomatic or severe and incapacitating low back pain which significantly affects their life activities and work. This unfortunate result is not always specifically the result of surgery. The causes of this unremitting pain are not always clear or agreed on, and my be from several sources. When this occurs, the prognosis is poor for returning to normal life activities regardless of age. After a successful laminotomy and discectomy, 80-85% of patients do extremely well and are able to return to their normal job in approximately six weeks time. There may be small permanent patches of numbness in the involved leg which, fortunately, are not disabling. Flare-ups or exacerbations of less severe and less significant sciatic type pain may develop in the future (usually on an infrequent basis).

Impaired mobility

DIAGNOSTIC STUDIES •

EMG may be done to determine the exact nerve root that is involved.

Electromyography is a test that measures muscle response to nervous stimulation. A needle electrode is inserted through the skin into the muscle. Each muscle fiber that contracts will produce an action potential. The presence, size, and shape of the wave form of the action potential produced on the oscilloscope, provides information about the ability of the muscle to respond to nervous stimulation. •

Nerve conduction velocity test may also be done.

The nerve conduction velocity test is performed to evaluate nerve function. It tests the speed impulses travel through a nerve.

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Myelogram may be done to determine the size and location of disk herniation.

The contrast dye makes the spinal canal clearly visible in this X-ray image. A herniated disc can be seen compressing the spinal nerves.

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Spine MRI or spine CT will show spinal canal compression by the herniated disk.

CT stands for computerized tomography. In this procedure, a thin X-ray beam is rotated around the area of the body to be visualized. Using very complicated mathematical processes called algorithms, the computer is able to generate a 3-D image of a section through the body. CT scans are very detailed and provide excellent information for the physician.

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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 •

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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. NSAIDs are used for long-term pain control, but narcotics may be given if the pain does not respond to anti-inflammatory drugs. 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. 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. Microdiskectomy - a procedure removing fragments of nucleated disk through a very small opening. 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 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. 4. Provide information concerning condition/prognosis and treatment needs. 5. Discharge plan DRG projected mean length of inpatient stay: 4.9–6.5 days considerations: May require assistance with transportation, self-care, and homemaker/maintenance tasks Refer to section at end of plan for postdischarge considerations. ILLUSTRATIONS

Skeletal Spine

The spine is divided into several sections. The cervical vertebrae make up the neck. The thoracic vertebrae comprise the chest section and have ribs attached. The lumbar vertebrae are the remaining vertebrae below the last thoracic bone and the top of the sacrum. The sacral vertebrae are caged within the bones of the pelvis, and the coccyx represents the terminal vertebrae or vestigial tail.

Herniated Nucleus Pulposus

Herniated nucleus pulposus is a condition in which part or all of the soft, gelatinous central portion of an intervertebral disk is forced through a weakened part of the disk, resulting in back pain and nerve root irritation.

Sciatic Nerve

The main nerve traveling down the leg is the sciatic nerve. Pain associated with the sciatic nerve usually originates higher along the spinal cord when nerve roots become compressed or damaged from narrowing of the vertebral column or from a slipped disk. Symptoms can include tingling, numbness, or pain, which radiates to the buttocks legs and feet. Herniated disk repair

When the soft, gelatinous central portion of an intervertebral disk is forced through a weakened part of a disk, it is a condition known as a slipped disk. Most herniation takes place in the lumbar area of the spine, and it is one of the most common causes of lower back pain. The mainstay of treatment for herniated disks is an initial period of rest with pain and anti-inflammatory medications followed by physical therapy. If pain and symptoms persist, surgery to remove the herniated portion of the intervertebral disk is recommended. Lumbar spinal surgery - series: Normal anatomy

The spine is made of bones (vertebrae) separated by soft cushions (intervertebral discs). Lumbar spinal surgery - series: Indications

Lumbar (lower back) spine disease is usually caused by herniated intervertebral discs, abnormal growth of bony processes on the vertebral bodies (osteophytes), which compress spinal nerves, trauma, and narrowing (stenosis) of the spinal column around the spinal cord.

Lumbar spinal surgery - series: Incision

The surgery is done while the patient is deep asleep and pain-free (general anesthesia). An incision is made over the lower back, in the midline.

Lumbar spinal surgery - series: Procedure

The bone that curves around and covers the spinal cord (lamina) is removed (laminectomy) and the tissue that is causing pressure on the nerve or spinal cord is removed. The hole through which the nerve passes can be enlarged to prevent further pressure on the nerve. Sometimes, a piece of bone (bone graft), interbody cages, or pedicle screws may be used to strengthen the area of surgery.

Lumbar spinal surgery - series: Aftercare

Patients usually require physical therapy to optimize spinal mobility after lumbar spine surgery. Results are variable depending on the disease treated. Reference: http://www.nlm.nih.gov/medlineplus/ http://adam.about.com/ http://google.com/

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