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Spinal C ord Injury Herniated Disc Spinal Cord Tumors PowerPoint PPT Presentation


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Spinal C ord Injury Herniated Disc Spinal Cord Tumors. Pathophysiology Normal Spinal Cord. Spinal cord begins at the foramen magnum in the cranium Cord ends at the L1-L2 vertebra level Spinal nerves continue to the last sacral vertebra The Human Spine. Spinal Cord.

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Spinal C ord Injury Herniated Disc Spinal Cord Tumors

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Spinal c ord injury herniated disc spinal cord tumors l.jpg

Spinal Cord InjuryHerniated DiscSpinal Cord Tumors


Pathophysiology normal spinal cord l.jpg

PathophysiologyNormal Spinal Cord

  • Spinal cord begins at the foramen magnum in the cranium

  • Cord ends at the L1-L2 vertebra level

  • Spinal nerves continue to the last sacral vertebra

  • The Human Spine


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Spinal Cord

Gray matter- cell bodies of voluntary and autonomic motor neurons

White matter axons of ascending and descending motor fibers


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Normal Spinal Cord

  • White tracts send messages to and from the brain

  • Ascending Tracts-

    • carry into higher levels of CNS

    • touch, deep pressure,vibration, position, temperature

  • Descending Tracts

    • impulses for voluntary muscle movement


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Pyramidal-

Voluntary movements

Posterior column (Dorsal)- touch, proprioception, and vibration sense

Lateral spinothalamic tract- pain and temperature sensation (only tract that crosses within the cord)

  • voluntary movement


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Upper Motor Neurons

UMN

Originate in cerebral cortex

Project downward

Result in skeletal muscle movement

Injury = SPASTIC paralysis

Lower Motor Neurons

LMN

Originate at each vertebral level

Project to specific parts of the body

Result in movement /sensation

Injury = FLACCID paralysis


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Normal Spinal Cord

Reflex Arc

  • Involuntary response to a stimulus

  • Where sensory and motor nerves arise from cord

  • Sensory fibers enter posterior

  • Synapse in the grey matter

  • Motor fibers leave anterior

  • Once outside cord join form spinal nerve

  • reflex movement


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Normal Spinal Cord

Dermatones

  • Skin innervated by sensory spinal nerves

  • Myotome- muscle group innervated by motor neurons


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Nervous System and the Spinal Cord

  • ANS can be affected by SCI

  • Sympathetic chains on both sides of the spinal column (T1-L2)

  • Parasympathetic nervous system is the cranial-sacral branch (brainstem, S2-4)


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Spinal Cord Protection

Bones- vertebral column

7 Cervical

12 Thoracic

5- Lumbar

5- Sacral

Discs-

between

vertebra


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Spinal Cord Protection

  • Internal and external ligaments

  • Dura

  • Meninges

  • CSF in subarachnoid space allow for movement within spinal canal


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Etiology of Traumatic SCI

  • MVA- most common cause

  • Other: falls, violence, sport injuries

  • SCI typically occurs from indirect injury from vertebral bones compressing cord

  • SCI frequently occur with head injuries

  • Cord injury may be caused by direct trauma from knives, bullets, etc


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Etiology of Traumatic SCI

  • 78% people with SCI are male

  • Typically young men – 16-30

  • Number of older adults rising (>61 yr)

  • Greater complications

  • Life Expectancy 5 years less than same age without injury

  • 90% go home


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Spinal Cord Injury- SCI

  • Compression

  • Interruption of blood supply

  • Traction

  • Penetrating Trauma


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Spinal Cord Injury

  • Primary

    • Initial mechanism of injury

  • Secondary

    • Ongoing progressive damage

      • Ischemia

      • Hypoxia

      • Microhemorrhage

      • Edema


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Spinal Cord Injury

  • Hemorrhage and edema occur in the cord post injury, causing more damage to cord

  • Extension of the cord injury from cord edema can occur over the first few days

    • watch the phrenic nerve!

  • Initially SCI experience spinal shock

    • depression of all cord & ANS function below injury. Lasts from few min to wks


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Spinal and Neurogenic Shock

  • Spinal Shock

    • Decreased reflexes and loss of sensation below the level of injury

    • Motor loss- flaccid paralysis below level injury

    • Sensory loss- loss touch, pressure, temperature pain and proprioception perception below injury

    • Lasts days to months


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Spinal and Neurogenic Shock

Neurogenic shock

  • Due to loss of vasomotor tone

    • SNS loss results in parasympathetic dominance with vasomotor failure

    • Loss of SNS innervation causes peripheral pooling and decreased cardiac output

  • Hypotension and Bradycardia

    • Orthostatic hypotension and poor temperature control (poikilothermic)


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How do you know spinal shock is over?

  • Clonus is one of the first signs

  • Hyperreflexia of foot

  • Test by flexing leg at knee & quickly dorsiflex the foot

  • Rhythmic oscillations of foot against hand

  • clonus


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Classifications of SCI

  • Mechanism of Injury

  • Skeletal and Neurologic Level

  • Completeness (degree) of Injury

    Mechanism of Injury

    Flexion

    Hyperextension

    Compression

    Flexion /Rotation


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Classifications of SCIMechanism of Injury

Flexion (hyperflexion)

  • Most common because of natural protection position.

  • Generally cause neck to be unstable because stretching of ligaments


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Classifications of SCIMechanism of Injury

Hyperextention

  • Caused by chin hitting a surface area, such as dashboard or bathtub

  • Usually causes central cord syndrome symptoms


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Classifications of SCIMechanism of Injury

Compression

  • Caused by force from above, as hit on head

  • Or from below as landing on butt

  • Usually affects the lumbar region


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Classifications of SCIMechanism of Injury

Flexion/Roatation

  • Most unstable

  • Results in tearing of ligamentous structures that normally stabilize the spine

  • Usually results in serious neurologic deficits


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  • Skeletal level

    • Vertebral level where the most damage to the bones

  • Neurologic level

    • The lowest segment of the spinal cord with normal sensory and motor function on both sides of the body

  • Levels of Function in Spinal Cord Injury


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Classification of SCI- Level of Injury

Spinal cord level

  • When referring to spinal cord injury, it is the reflex arc level (neurologic)not the vertebral or bone level.

  • the thoracic, lumbar & sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of vertebral bone


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Classifications of SCICompleteness (Degree) of Injury

  • Complete

  • Incomplete

    • Central cord syndrome

    • Anterior Cord syndrome

    • Brown-Sequard Syndrome

    • Posterior Cord Syndrome

    • Cauda Equina and Conus Medullaris


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Classification of SCI Completeness (degree) of Injury

Complete (transection)

  • After spinal shock:

  • Motor deficits-

    • spastic paralysis below level of injury

  • Sensory-

    • loss of all sensation perception

  • Autonomic deficits- vasomotor failure and spastic bladder


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Classification of SCI Completeness (degree) of Injury

Incomplete

Central Cord Syndrome

  • Injury to the center of the cord by edema and hemorrhage

  • Motor weakness and sensory loss in all extremities

  • Upper extremities affected more


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Classification of SCI Completeness (degree) of Injury

Incomplete

Brown-Séquard Syndrome

  • Hemisection of cord

  • Ipsilateral paralysis

  • Ipsilateral superficial sensation, vibration and proprioception loss

  • Contralateral loss of pain and temperature perception


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Classification of SCI Completeness (degree) of Injury

incomplete

  • Anterior Cord Syndrome

  • Injury to anterior cord

  • Loss of voluntary motor, pain and temperature perception below injury

  • Retains posterior column function (sensations of touch, position, vibration, motion)


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Classification of SCI Completeness (degree) of Injury

incomplete

  • Posterior Cord Syndrome

  • Least frequent syndrome

  • Injury to the posterior (dorsal) columns

  • Loss of proprioception

  • Pain, temperature, sensation and motor function below the level of the lesion remain intact


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Classification of SCI Completeness (degree) of Injury

incomplete

  • ConusMedullaris

    • Injury to the sacral cord (conus) and lumbar nerve roots

  • CaudaEquina

    • Injury to the lumbosacral nerve roots

  • Result- areflexic (flaccid)bladder and bowel, flaccid lower limbs


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Clinical Manifestations of SCI

  • Skin:

    • pressure ulcers

  • Neuro:

    • pain

    • sensory loss

    • upper/lower motor deficits

    • autonomic dysreflexia

  • Cardio:

    • dysrhythmias

    • spinal shock

    • loss of SNS control over blood vessels

    • orthostatic hypotension,

    • poikilothermic


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  • Respiratory-

    • decrease chest expansion, cough reflex & vital capacity

    • diaphragm function-phrenic nerve

  • GI

    • stress ulcers

    • paralytic ileus

    • bowel- impaction & incontinence

  • GU

    • upper/lower motor bladder

    • Impotence

    • sexual dysfunction

  • Musculoskeletal

    • joint contractures

    • bone demineralization

    • osteoporosis

    • muscle spasms

    • muscle atrophy

    • pathologic fractures

    • para/tetraplegia


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Common Manifestation/Complications

Upper and Lower Motor Deficits

  • Upper motor deficits result in spastic paralysis

  • Lower motor deficits result in flaccid paralysis and muscle atrophy


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Common Manifestations/Complications

  • Spinal cord injuries are described by the level of the injury– the cord segment or dermatome level

  • Such as C6; L4 spinal cord injury

  • Terms used to describe motor deficits

    • Prefix:

      • para- meaning two extremities

      • tetra- or quadra- all four extremities

    • Suffix :

      • -paresis meaning weakness

    • -plegia meaning paralysis

      Quadraparesis means what?


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Common Manifestations/Complications

  • C1-3 usually fatal-

  • Loss of phrenic innervation ventilator dependent

  • No B/B control

  • Spastic paralysis

  • Electric w/c with chin/mouth control


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Common Manifestations/Complications

  • C6- weak grasp

  • Has shoulder/biceps to transfer & push w/c

  • No bowel/bladder control.

  • Considered level of independence


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Common Manifestations/Complications

  • T1-6- full use of upper extremity

  • Transfer

  • Drive car with hand controls and do ADL’s

  • No bowel/bladder control


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Immediate Care

Emergency Care at Scene, ER & ICU

  • Transport with cervical collar

  • Assess ABC’s; O2; tracheotomy/vent

  • IV for life line

  • NG to suction

  • Foley


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Diagnostic Studies for SCI

  • X-ray of spinal column

  • CT/MRI

  • Blood gases


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Therapeutic Interventions

  • Medications

  • IV methylprednisolone (Solu-Medrol) within 8 hrs to decrease cord edema


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Therapeutic Interventions

  • Medications

  • To control or to prevent complications of SCI and immobility:

    • Vasopressors to maintain perfusion

    • Histamine H2 blockers to prevent stress ulcers

    • Anticoagulants

    • Stool softeners

    • Antispasmodics


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Therapeutic Interventions

Stabilization/

Immobilization

Traction-

Gardner-wells tongs

Halo

Casts

Splints

Collars

Braces


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Therapeutic Interventions

Surgery for SCI

  • Manipulation to correct dislocation or to unlock vertebrae

  • Decompression laminectomy

  • Spinal fusion

  • Wiring or rods to hold vertebrae together


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Nursing Management Assessment

  • HEALTH HISTOY

  • Description of how and when injury occurred

  • Other illnesses or disease processes

  • Ability to move, breathe, and associated injury such as a head injury, fractures


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Nursing Management Assessment

PHYSICAL EXAM

  • LOC and pupils- may have indirect SCI from head injury

  • Respiratory status- phrenic nerve (diaphragm) and intercostals; lung sounds

  • Vital signs

  • Motor

  • Sensory

  • Bowel and bladder function


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Nursing ManagementAssessment

Motor Assessment Upper Extremity

  • Movement, strength and symmetry

  • Hand grips

  • Flex and extend arm at elbow- with and without resistance


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Nursing Management Assessment

Motor Assessment Lower Extremity

  • Flex and extend leg at knee with and without resistance

  • Planter and dorsi flexion of foot

  • Assess for Clonus


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Nursing Management Assessment

Sensory assessment

  • With the sharp and dull ends of a paperclip have the individual, with their eyes closed identify

  • Use the dermatome as reference to identify level

  • C6 thumb; T4 nipple; T10 naval


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Nursing Problems/Interventions

  • 1.Impaired mobility

  • 2.Impaired gas exchange

  • 3. Impaired skin integrity

  • 4. Constipation

  • 5. Impaired urinary elimination

  • 6. Risk for autonomic dysreflexia

  • 7. Ineffective coping


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1. Impaired Physical Mobility

  • Log roll as a single unit; provide assistance as needed to keep alignment; teach patient

  • Care traction, collars, splints, braces, assistive devices for ADL’s

  • Flaccid paralysis- use high top tennis shoes or splints to prevent contractures. Remove at least every 2 hrs for ROM (active ROM best)


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1. Impaired Physical Mobility

  • Spastic Paralysis

    • Prevent spasms by avoiding; sudden movements or jarring of the bed; internal stimulus (full bladder/skin breakdown; use of footboard; staying in one position too long; fatigue

    • Treat spasms by decreasing causes; hot or cold packs; passive stretching; antispasmodic medications

  • Assess skin break down thrombophlebitis; remove TED hose at least every shift


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1. Impaired Physical Mobility

  • Prevent/treat orthostatic hypotension

    • Abdominal binder, calf compressors, TED hose when individual gets up

    • Assess BP, especially when rising

    • Teach use of transfer board

    • Assist Physical Therapy with tilt table as individual gradually gets use to being in an upright position


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2. Impaired Gas Exchange

  • Phrenic nerve (C3-5) controls the diaphragm bilaterally. If nerve is nonfunctioning then individual is ventilator dependent.

  • Thoracic nerves control the intercostals muscles for breathing and abdominal muscles aide in breathing and coughing


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2. Impaired Gas Exchange

  • Respiratory rate, rhythm, depth, breath sounds, respiratory effort, ABG’s, O2 saturation

  • Signs of impending extension of SCI up cord to phrenic nerve level (C3-5)

  • Need for ventilatory assistance tracheotomy, ventilator

  • Quad cough (assistive cough) as needed


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3. Impaired Skin Integrity

  • Change position frequently

  • Protection from extremes in temperature

  • Inspect skin at least 2x/day especially over boney prominences

  • Avoid shearing and friction to soft tissue with transfers

  • Removal of TED hose every 8 hours

  • Nutritional status


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4. Constipation

  • Bowels rely more on bulk than on nerves

  • Stimulate bowels at the same time each day. Best after a meal when normal peristalsis occurs

  • Individual may progress from Dulcolax suppository to glycerin then to gloved finger for digital stimulation

  • Assess bowel sounds prior to giving food for the first time– paralytic ileus!


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5. Impaired Urinary Elimination

  • Flaccid bladder (lower motor neuron lesion)

    No reflex from S2,3,4

    Automatic empting of bladder

    Urine fills the bladder and dribbles out

    Need Foley or freq intermittent self catheterization

  • Spastic bladder (upper motor neuron lesion)

    Reflex arc but no connection to or from brain

    Reflex fires at will

    Bladder training- trigger points to stimulate empting; self catheterization


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5. Impaired Urinary Elimination

  • Use bladder scan to see amount of urine in bladder

  • Goal- residual <100ml/20% bladder capacity

  • Some individuals may need suprapubic catheter

  • Assess effectiveness of medication

    • Urecholine to stimulate bladder contraction

    • Urinary antiseptic


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6. Risk for Autonomic Dysreflexia

  • SCI above T6

  • Results in loss of normal compensatory mechanisms when sympathetic nervous system is stimulated

  • Life threatening- if goes unchecked BP can result in cerebral hemorrhage

  • Vasodilatation symptoms above SCI

  • Vasoconstriction symptoms below SCI

  • The cause of SNS stimulation


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6. Risk for Autonomic Dysreflexia

  • Elevate head of bed- causes orthostatic hypotension

  • Identify cause/alleviate- if full bladder- cath; if skin- remove pressure, if full bowel- empty, etc

  • Remove support hose/abdominal binder

  • Monitor blood pressure- can get > 300 S

  • Give PRN medication to lower BP

  • If above not effective– call physician


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7. Ineffective Coping/Grief and Depression

  • Assess thoughts on ‘quality of life’; body image; role changes

  • Physical and psychological support

  • Most common SCI is 15-30 yeas old and generally a risk taker– this greatly affects their perception of life and rehabilitation


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7. Ineffective Coping/sexuality

Male

Female

  • UMN lesion

    • reflexogenic (S2,3,4) erections

  • LMN lesion

    • psychogenic erections (psychological stimulation)

  • Ejaculation/fertility may be affected

  • hormones more than nerves regarding fertility.

  • C-section because of chance for autonomic dysreflexia during labor.

  • Lack of sensation/movement affects sexual performance


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7. Ineffective Coping/sexuality

  • Assess readiness/knowledge/your ability

  • Use proper terminology

  • Suggestions:

    • empty bladder before sex

    • withhold fluids and antispasmodics

    • certain positions may increase spasms

    • explore new erogenous zones

    • penile implants

  • Refer to specially trained counselor


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Home Care

  • Assess psychological, physiological resources

  • need for rehabilitation (in-house or out patient)

  • need for community resources

  • Home assessment


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What’s new in SCI treatment?

  • Superman breather

  • YouTube - Superman breather – USA

    Kevin Everett

  • hypothermia treatment for SCI

  • Standing Tall

  • Travis Roy- 11 Seconds

  • Stem Cell treatment for SCI

  • Lipitor for SCI


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  • Case study- Jim Valdez

  • 1. Why does Jim have flaccid paralysis on admission to ICU?

  • 2. What symptoms indicate that he is in spinal shock? What was done about these symptoms?

  • 3. How will we know when he is out of spinal shock?

  • 4. How does progressive mobilization assist with orthostatic hypotension? What else can be done?

  • 5. What are realistic functional goals for Jim?


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Herniated Disc and Spinal Cord tumors


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Spinal Cord Anatomy

  • Function of disc is to allow for mobility of the spine and act as shock absorber

  • spinal cord anatomy


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Pathophysiology/Etiology

  • Located between vertebral bodies

  • Composed of nucleus pulposus a gelatinous material surrounded by annulus fibrosis- a fibrous coil

  • Spinal nerves come out between vertebra


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Herniated Disc

  • Herniated nucleus pulposus, (HNP) slipped disc, ruptured disc

  • HNP- annulus becomes weakened/torn and the nucleus pulposusherniates through it.

    Risk Factors-

  • Standing erect

  • Aging changes

  • Poor body mechanics

  • Overweight

  • Trauma


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Common Manifestations/Complications

  • HNP compresses

    • Spinal nerve (sensory or motor component) as it leaves the spinal cord

    • Or the cord itself- the white tracts within the cord- rare


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Common Manifestations/Complications

  • Sensory root or nerve usually affected

    • pain, parenthesis, or loss of sensation

  • Motor root or nerve may be affected

    • paresis or paralysis

  • Manifestations

    • depend on what nerve root, spinal nerve is being compressed– which dermatomes

  • Radiculopathy-

    • pathology of the nerve root


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Common Manifestations/Complications Lumbar HNP

  • Most common site for HNP

    • L4-5 disc- the 5th lumbar nerve root

    • posterior sensory nerve or root compressed

  • Classic symptoms-

    • low back sciatica pain

    • pain increases with increase in intrathoracic pressure

  • herniated disc L4-L5


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Other Symptoms Lumbar HNP:

  • Postural changes

  • Urinary/male sexual function changes

  • Paresis or paralysis

  • Foot drop

  • Paresthesias

  • Numbness

  • Muscle spasms

  • Absent cord reflexes


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Common Manifestations/Complications Cervical HNP

C5-C6 disc- 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


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Therapeutic Interventions- Diagnostic Tests

  • X-ray

    • identify deformities and narrowing of disk space

  • CT/MRI

  • Mylogram p1336

  • Nerve conduction studies (EMG)

    • detect electrical activity of skeletal muscles


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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

    • non-narcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodics and tranquilizers


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Treatment- Conservative

  • Heat/cold therapy to decrease muscle spasms

  • Break the pain-spasm-pain cycle

  • Ultrasound, massage, relaxation techniques

  • Progressive mobilization with approved exercise program –includes abdominal/thigh strengthening

  • Teaching good body mechanics

  • Weight loss

  • TENS unit


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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

  • herniated disc repair

  • Foraminotomy

    • Enlargement of the bony overgrowth at the opening which is compressing the nerve


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Treatment- Surgery

  • Microdiskectomy

    • 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

    • anterior cervical fusion


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Treatment- Surgery

  • Spinal fusion

    • removes most of the disc and replaces it with bone usually from the patient iliac crest

    • Fusion also with rods, pins, synthetic protein

    • Flexibility is lost at the site- requires longer hospital stay

  • spinal fusion

  • Artificial Disc

    • Combination of metal and plastic

    • Attached to vertebrae above and below


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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


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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


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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


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Post-Op Assessment for HNP

  • Sensory/motor assessment- care not to injure op site

  • Assess for CSF drainage or bleeding from op site

  • Encourage turn (log roll, cough, deep breath)

  • Assess for postural hypotension

    • especially if client was on bed rest for several days/weeks prior to surgery


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Post-op Assessment for HNP

  • If Anterior Cervical-

    • Assess injury to the carotid, esophagus, trachea, laryngeal nerve (speech- hoarseness)

    • Assess respiration, neck size, swallowing and speech

  • If Post-Op Lumbar-

    • Assess bowels sounds, voiding.

    • Minimize stress of post-op site- flat with pillow between knees, log roll, etc


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Nursing Problems/Interventions 1. Acute Pain

  • Post surgery the individual may have similar pain as pre-op due to lack of resiliency of the spinal nerves to ‘bounce’ back quickly

  • 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


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2. Chronic Pain

  • Surgery may not relieve pain

  • Nonpharmalogical methods to control pain

  • Pain clinic


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3. Constipation

  • As a result of bed rest and decreased mobility and fear of pain with straining of stool

  • Constipation prevention methods– fluids, diet, etc


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4. 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


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Spinal Cord Tumors

  • CNS is made up of neural tissue and support tissue

  • These tissues undergo changes and result in spinal cord tumors

  • Blood vessels and bone also can be part of the tumor


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Intramedullary- arise from neural tissues of the spinal cord

Extramedullary- arise from tissues outside the spinal cord may be benign or malignant

Intradural-from the nerve roots or meninges in subarachnoid space

Extradural- from the epidural tissue or vertebra


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Classification by origin

  • Primary- originating in the spinal cord or meninges

  • Secondary- metastases from other parts of the body

  • 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


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Common Manifestations/Complications

  • Symptoms depend on the anatomical level of the spinal column, the anatomical location, the type of tumor and the spinal nerves affected

  • Pain that is not relieved by bed rest is the most common presenting symptom

  • Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor


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Common Manifestations/Complications

  • Manifestations of 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)


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Therapeutic Interventions

  • Diagnostic tests include:

    • X-ray of the spinal column

    • Myelogram

    • Lumbar puncture with CSF analysis


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Therapeutic Interventions

  • Medications spinal tumors

    • Control pain- narcotic analgesics, epidural catheter, PCA, NSAID’s

    • Reduce cord edema and tumor size-

      • Steroids- high dose Dexamethasone


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Therapeutic Interventions

  • 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

  • Radiation to reduce size and control pain


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Nursing Assessment

  • Health history

    • Pain, motor and sensory changes, bowel

      and bladder changes, Babinski reflex.

  • Physical exam

    • Similar to physical assessment for HNP


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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


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Nursing Problems/Interventions

  • 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 arc (S 2,3,4) interference

    • Similar care as discussed with SCI


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Nursing Problems/Interventions

  • 6. Urinary retention

    • Reflex arc (S2,3,4) interference can cause neurogenic bladder as discussed with SCI

  • 7. Home care

    • Rehabilitation

    • Home evaluation

    • Support groups

    • case study


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  • A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?

    • Bladder distension

    • Neurological deficit

    • Pulse ox readings

    • The client’s feelings about the injury


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  • While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions?

    •  Autonomic dysreflexia

    • Hemorrhagic shock

    • Neurogenic shock

    • Pulmonary embolism


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  • A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?

    • Place the client flat in bed

    • Assess patency of the indwelling urinary catheter

    • Give one SL nitroglycerin tablet

    • Raise the head of the bed immediately to 90 degrees


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  • The nurse is caring for an elderly client diagnosed with a herniated nucleus pulposus of L4-L5. Which scientific rationale explains the incidence of a ruptured disc in the elderly?

    • The client did not use good body mechanics when lifting an object.

    • There is an increased blood supply to the back as the body ages.

    • Older clients develop atherosclerotic joint disease as a result of fat deposits.

    • Clients develop intervertebral disc degeneration as they age.


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  • A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord?

    •  Acetazolamide (Diamox)

    • Furosemide (Lasix)

    • Methylprednisolone (Solu-Medrol)

    • Sodium bicarbonate


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  • A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?

    • To hasten wound healing

    • To immobilize the surgical spine

    • To prevent autonomic dysreflexia

    • To hold bony fragments of the skull together


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  • Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury?

    •  Insert an indwelling urinary catheter to straight drainage

    • Schedule intermittent catherization every 2 to 4 hours

    •  Perform a straight catherization every 8 hours while awake

    • Perform Crede’s maneuver to the lower abdomen before the client voids.


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  • A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase?

    • Absent corneal reflex

    • Decerebate posturing

    • Movement of only the right or left half of the body

    • The need for mechanical ventilation


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  • The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?

    • Positive reflexes

    • Hyperreflexia

    •  Inability to elicit a Babinski’s reflex

    • Reflex emptying of the bladder


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  • Your T1 spinal cord injured patient complains of a headache. You should

    • Give him prn Tylenol

    • Disimpact his bowels

    • Call the doctor

    • Take his blood pressure


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  • What can the nurse do to best speed the patients recovery from a laminectomy of L5?

    • Keep patient flat in bed

    • Teach the back school approach

    • Medicate for pain q2 hours

    • Ambulate as soon as orders permit


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  • Your patient has a malignant metastatic lesion at T8 and is in for palliative radiation. What is your main goal with this patient?

    • Teach patient self catheterization

    • Ensure patient receives pain medication as needed

    • Encourage patient to discuss fears

    • Ambulate twice a shift


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