Herniations Nucleus Pulposus

HERNIATIONS NUCLEUS PULPOSUS • •

Intervertebral disk cartilaginous plate forms cushion between vertebral bodies Nucleus Pulposus o Ball Like cushion in center ob disk

HERNIATION (RUPTURED DISK) o Nucleus of disk protrudes into annulus (fibrous ring around the disk) with subsequent nerve compression. C/O Pain PROTRUSION / RUPTURE o Usually proceeded by degeneration change that occurs with aging. Drying of nucleus • • • •

Immediate symptom (most patients) of trauma short lived, those resulting from disk do not appear for months or years With degeneration of disk, capsule pushes back into spinal canal, or it may rupture and allow the nucleus pulposus to be pushed against dural sac or against spinal nerve as it emerges from spinal column Radiculopathy o Sequence produces pain due to pressure in area of distribution of involved nerve ending Continued pressure may produce degenerative changes in involved verve, such changes sensation and reflex action

CLINICAL MANIFESTATIONS •

Depend on: o Location o Rate of development (acute or chronic) o Effect of surrounding structures

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Herniated disk with pain

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Cervical C5 – C6 o Shoulder pain with numbness radiates down arm

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Thoracic (rare)

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Lumbar L4-L5 or L5-S1 o Lower back pain downward o Back pain with numbness, tingling o Muscle spasms o Muscle weakness (one side stronger than other) o Alteration reflexes

o Intensity pain depends upon leg location o Change in gait

ASSESSMENT AND DIAGNOSTIC FINDINGS •

MRI o Most definitive o Soft tissue damage

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CT Myelogram Neuro Checks

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EMG o Determines if nerve root is involved

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Straight leg testing: 20-30o with herniation

MEDICAL MANAGEMENT LUMBAR o Lumbar most common o Bedrest on firm mattress – Semi fowlers, lateral side with leg drawn chest; pillow between legs o Sit on soft chair or cushion under them o Medications  Muscle relaxes – Robaxin, Soma • Drowsiness, sleepiness  Analgesic – Tylox, Darvocet – N  Sedative – Valium  NSAID’s – Anaprox  Corticosteriods o PT – Strengthen muscles o Back brace before surgery o Obese – Loose weight CERVICAL o C-Collar o Bedrest o Medications  Muscle relaxers – Robaxin, Soma • Drowsiness, sleepness  Analgesic – Tylox, Darvocet – N  Sedative – Valium  NSAID’s – Anaprox  Corticosteriods

o Apply moist heat o Cervical traction is neither effective nor recommended

SURGICAL MANAGEMENT •

Surgical excision of herniated disk performed when evidence of progressing neurological deficit o Muscle weakness and atrophy o Loss of sensory and motor function o Loss of sphincter control o Continuing pain and sciatica  Inflammation of sciatic nerve resulting in pain, tenderness along nerve through thigh and leg

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Goal of surgical treatment: reduce pressure on nerve root to relieve pain, reverse neurological deficits

SURGICAL TECHNIQUES •

Depends on type of disk herniation, surgical morbidity, overall results of surgery

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Discectomy o Removal of herniated or extended fragments of intervertrbral disk Laminectomy o Removal of lamina to expose neural elements in spinal canal; allows surgeon to inspect spinal canal, identify and remove pathology, relieve compression of cord and roots Descectomy With Fusion o Bone graft (from iliac or bone bank) used to fuse vertebral spinous process; object spinal fusion to bridge over the defective disk to stabilize spine, reduce rate of recurrence.

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Anterior or Posterior approach depends on MRI results o Anterior  Carotid artery  Laryngeal nerve damage  Esophageal perfusion – NPO  Airway Obstruction Edema o Posterior  Damage to spinal cord / nerve root

NURSING DIAGNOSIS (CERVICAL) Pain related to surgery Knowledge deficit R/T surgical repair CP: Hemorrhage Recurrent Pain Return of pain post op