Neurosensory: Herniated Disk and Spinal Cord tumors

1. Neurosensory: Herniated Disk and Spinal Cord tumors Marnie Quick RN, MSN, CNRN

2. A. Pathophysiology/etiologyNormal spine as related to herniated disk • Herniated nucleus pulposus, slipped disk, ruptured disk • Function of disk is to allow for mobility of the spine and act as shock absorber • Located between vertebral bodies • Composed of nucleus pulposus a gelatinous material surrounded • By annulus fibrosis- a fibrous coil

3. Spinal nerves come out between vertebra from the reflex ark in the spinal cord

4. Causes of degenerative disease: Video of diff causes:http://www.spineandscoliosis.com/subject.php?pn=spinal-conditions

5. HNP- Herniated Nucleus Pulpsus • HNP- annulus becomes weakened/torn and the nucleus pulpsus herniates through it. • HNP compresses • Spinal nerve (sensory or motor component) as it leaves the spinal cord • Or the cord itself- the white tracks within the cord- rare

6. Risk factors developing herniated disk • Standing erect- cumulative effect and daily stress • Aging changes in disc and ligaments, osteoarthritis • Poor body mechanics • Overweight, sedentary life style • Smoking • Trauma

7. Sensory root or nerve of the spinal nerve is usually affected resulting in sensory symptoms- pain, parenthesis, or loss of sensation • Motor root or nerve may be affected which results in motor symptoms- paresis or paralysis • Manifestations depend on what nerve root, spinal nerve is being compressed– which dermatomes • Radiculopathy- pathology of the nerve root • Video: http://www.spineandscoliosis.com/subject.php?pn=animate-lumradsciatica

8. Common manifestations/complications Lumbar HNP • A common site is L4-5 disc- the 4th lumbar nerve root • Most common is posterior sensory nerve or root compressed • Classic symptoms- low back sciatica pain. The pain increases with increase in intrathorasic pressure- sneezing, straining, coughing • Other symptoms- postural changes, urinary, male sexual function, paresis/paralysis, foot drop, paresthesias, numbness, muscle spasms, B&B incontinence, cord reflexes decreased>absent

9. Common manifestations/complications Cervical HNP • C5-C6 disk- affects the 6th cervical nerve root • Pain- neck, shoulder, anterior upper arm to thumb • Absent/diminished reflexes to the arm • Motor changes- paresis or paralysis • Sensory- paresthesias or pain • Muscle spasms- may cause pain and set up a pain-spasm-pain cycle.

10. Collaborative Care: Diagnostic tests • X-ray identify deformities and narrowing of disk space • CT/MRI • Mylogram- picture > • Diskogram • Nerve conduction studies (EMG) to detect electrical activity of skeletal muscles

11. Collaborative Care: Treatment- Conservative • Bed rest with firm mattress; log roll; side lying position with knees bent and pillow between legs to support legs • Avoid flexion of the spine- brace/corset, cervical collar to provide support • Medications- nonnarcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodics and tranquilizers. Avoid smoking • Heat/cold therapy to decrease muscle spasms • Break the pain-spasm-pain cycle with meds (antispasmodics/pain meds)

12. Treatment- Conservative • Intermittent skin traction (cervical/pelvic) • Ultrasound, massage, relaxation techniques • TENS unit (Transcutaneous electrical nerve stimulation) • Progressive mobilization with approved exercise program –includes abdominal/thigh strengthening • Teaching good body mechanics • Weight loss

13. Treatment- Surgery • Laminectomy- removal of a portion of the lamina to relieve pressure and to get to the herniated nucleus pulposus that is protruding out • IDET or Percutanecus Disc Nucluoplasty View video below: http://www.spineandscoliosis.com/subject.php?pn=animate-nucleoplasty

14. Treatment- Surgery • Spinal fusion removes most of the disk and replaces it with bone usually from the patient iliac crest. View video: http://www.spineandscoliosis.com/subject.php?pn=animate-spinalfusion Videos of Lumbar inter-Body Fusion with cage: http://www.spineandscoliosis.com/subject.php?pn=animate-alifmesh http://www.spineandscoliosis.com/subject.php?pn=animate-ibf • Flexibility is lost at the site- requires longer hosp stay

15. Treatment- Surgery • Foraminotomy is enlargement of the bony overgrowth at the opening which is compressing the nerve. View video on Foraminotomy:http://www.spineandscoliosis.com/subject.php?pn=animate-cervpostfor • Microdiskectomy is use of electron microscope through a small incision to remove a portion of the HNP that is displaced. If cervical HNP, usually use the anterior approach in the neck

16. Charite disk: View Video on artificial disks: http://www.spineandscoliosis.com/subject.php?pn=animate-cervartificialdisc

17. Prevention of HNP • Back school approach- • Causes of HNP • Learn how to prevent • Good body mechanics • Exercises to strengthen leg and abdominal muscles • Change in life-style or occupation

18. Nursing Assessment Specific to HNP Health History • Assess for risk factors- the cumulative effect of standing erect and daily stress; aging changes in disc/ligaments; poor body mechanics; overweight; trauma • Employment, history of pain, and other neuro changes

19. Nursing Assessment specific to HNP Physical exam • Use similar methods to assess as utilized SCI • Muscle strength and coordination • Sensation- sharp/dull of paperclip using dermatome as reference • Pain evaluation- pain scale • Pre/Post-op assessment

20. Post-op assessment from HNP • NVS sensory/motor- care not to injure op site • Assess for CSF drainage or bleeding from op site • Encourage turn (log roll, cough, deep breath) • If anterior cervical- assess injury to the carotid, esophagus, trachea, laryngeal nerve (speech- hoarseness)- assess respiration, neck size, swallowing and speech

21. If post-op lumbar- assess bowels sounds, voiding. Minimize stress of post-op site- flat with pillow between knees, log roll, etc • Assess for postural hypotension, especially if ind was on bed rest for several days/weeks prior to surgery

22. Pertinent nursing problems/interventions 1. Acute pain • Bedrest; medication (analgesics/antispasmotics; anti-inflam); good body mechanics; back support (brace, etc) • Teach need to adhere to activity restrictions, grad inc, Physician approved exercise program. Lumbar better to stand than sit. Life style changes Avoid sit-ups • Post surgery the individual may have similar pain as pre-op due to lack of resiliency of the spinal nerves to ‘bounce’ back quickly • If use bone for fusion, donor site (illiac crest) may cause more pain than laminectomy • Individual may be in a pain-spasm-pain cycle, therefore may need both antispasmodic as well as analgesic

23. Chronic pain • Surgery may not relieve pain • Nonpharmalogical methods to control pain • Pain clinic

24. Post-op care after spinal surgery • Maintain proper body alignment • Pain control • Check dressing> blood/CSF; donor site • Monitor extremities: CMS (Circulation; Motor and Sensory) • Assess paralytic ileus, bladder empting (bladder scan/intermittent cath • Activity order • Teach use of brace/orthotic • Lumbar- avoid sitting prolonged periods • Firm mattress

25. Constipation • As a result of bed rest and decreased mobility and fear of pain with straining of stool • Constipation prevention methods– fluids, diet, etc

26. Home care • When riding in a car, take frequent stops to move and stretch • Prevention– Back school approach • May have to deal with pain as a chronic condition • May need to make life/job changes

27. Spinal Cord Tumors Patho- normal spine as relates to cord tumors • CNS is made up of neural tissue (neurons) and support tissue (glial) • These tissues undergo changes and result in spinal cord tumors • Blood vessels and bone (vertebra) also can be part of the tumor • Spinal tumors are classified by anatomical area and as primary (origin in spinal cord) or secondary (metastatic from other parts of the body) • Most spinal cord tumors found thoracic region • Compress, invade neural tissue, cause ischemia

28. Classification of spinal cord tumorsby anatomical area • Extradural- • Outside the dura (outer layer of the meninges) • from bones of spine, in extradural space, or in paraspinal tissue • 90% of all spinal cord tumors • Usually malignant metastatic lesions • Intradural: Inside the dura • Intramedullary: within the spinal cord itself (40% of intradural tumors) Benign; good prognosis • Extramedullary: within dura mater outside of the spinal cord

30. Intermedullary spinal cord tumor

31. Most spinal cord tumors are found in the thoracic region • Spinal cord tumors can compress (benign), invade the neural tissue, or cause ischemia to the area because of vascular obstruction

32. Common manifestation/complications • Symptoms depend on the anatomical level of the spinal column, the anatomical location, the type of tumor and the spinal nerves affected • Pain is the most common presenting symptom that is not relieved by bed rest • Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor

33. Manifestations thoracic cord tumor • Paresis & spasticity of one leg then the other • Pain back & chest, not relieved by bedrest; sensory changes • Babinski reflex • Bowel (ileus); bladder dysfunction (UMN in type)

34. Collaborative Care for spinal cord tumor • Diagnostic tests include: • X-ray of the spinal column • Myelogram • Lumbar puncture with CSF analysis • Medications spinal tumors • Control pain- narcotic analgesics, may be given epidural catheter, PCA, NSAID’s • Reduce cord edema and tumor size- steroids dexamethasome (Decadron) high dose for a few days, then taper off with a Medrol dose pack

35. Collaborative Care for spinal cord tumor • Surgery for spinal cord tumors • Laminectomy to remove or to decrease the size (decompression laminectomy) of the spinal cord tumor • Spinal fusion or the insertion of rods if several vertebra involved and the column is unstable • HNP module for post-op care

36. Collaborative Care for spinal cord tumor • Radiation Therapy spinal tumors • Usually used for metastatic spinal cord tumors to reduce size of the tumor to control pain

37. Nursing assessment specific to cord tumors • Health history • Pain, motor and sensory changes, bowel and bladder changes, Babinski reflex. • Physical exam • Similar to physical assessment for HNP

38. Pertinent nursing problems/interventions • 1. Anxiety • Metatastic tumor vs benign spinal cord tumor • Education and support system • 2. Risk for constipation • From spinal cord compression, narcotics, bed rest • Adjust fluid and diet

39. 3. Impaired physical mobility • From bed rest and motor involvement • Basic nursing- ROM, etc • 4. Acute pain • From compression or invasion of tumor • Assess and treat • 5. Sexual dysfunction • Male sacral reflex ark (S 2,3,4) interference • Similar care as discussed with SCI

40. 6. Urinary retention • Reflex ark (S2,3,4) interference can cause neurogenic bladder as discussed with SCI • 7. Home care • Rhabilitation • Home evaluation • Support groups