Intervertebral disk prolapse

Intervertebral disk prolapse

1. HERNIATION OF THE INTERVERTEBRAL DISK AND ITS MANAGEMENT PRESENTED BY: MISS.SHWETA SHARMA M.SC. NURSING 1ST YEAR AIIMS, JODHPUR

2. INTRODUCTION The cervical spine is subjected to stresses that result from disk degeneration (due to aging, occupational stresses) and spondylosis (degenerative changes occurring in a disk and adjacent vertebral bodies). Cervical disk degeneration may lead to lesions that can cause damage to the spinal cord and its roots. Lumbar disc prolapse is a condition in which there is outpouching of the disc Nucleus pulposus along with few annular fibres and end plate cartilage through the tears in annulus fibrosus into the extradural space.

3. 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 (L4/5 and L5/S1 level); disc 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.

4. RISK FACTORS Age- 35 to 50 years old. Gender- Men have roughly twice the risk for lumbar herniated discs compared with women. Physically demanding work-Heavy lifting and other physical labour . Pulling, pushing, and twisting actions can add to risk if they’re done repeatedly. Obesity Smoking Family history

5. PATHOPHYSIOLOGY

6. CLINICAL MANIFESTATIONS Pain and stiffness may occur in the neck, the top of the shoulders, and the region of the scapulae. Patient’s sometimes interpret these signs as symptoms of heart trouble or bursitis. Pain may also occur in the arm and hand, accompanied by paresthesia (numbness, tingling or a “pins and needles ” sensation) of the upper extremity. 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).

7. DIAGNOSTIC EVALUATION 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. Range of motion Vital 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.

8. Leg raise test/ LaSegue test

9. X-Ray CT SCAN MRI Myelogram EMG-to rule out peripheral neuropathy Diskogram

10. 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

11. MEDICAL MANAGEMENT Rest and immobilize the cervical spine to give soft tissues time to heal and to reduce inflammation in the supporting tissues and the affected nerve roots in the cervical spine. Proper positioning on a firm mattress may bring dramatic relief from pain. The cervical spine 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.

12. CERVICAL COLLAR

13. PHARMACOLOGIC THERAPY  Analgesic agents (NSAIDs, acetaminophen/oxycodone, or acetaminophen/hydrocodone)  Sedative agents- to control the anxiety that is often associated with cervical disk disease.  Muscle relaxants- cyclobenzaprine, methocarbamol, metaxalone- to interrupt muscle spasm and to promote comfort.  NSAIDs (aspirin, ibuprofen, naproxen) or corticosteroids- to treat the inflammation and swelling that usually occurs in the affected nerve roots and supporting tissues. Occasionally, a corticosteroid is injected into the epidural space for relief of radicular pain (spinal nerve root). NSAIDs are administered with food and antacids to prevent gastrointestinal irritation.  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.

14. SURGICAL MANAGEMENT Cervical discectomy

15. Chemonucleolysis 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 he cementing protein of the nucleus pulposus. This causes decrease in water binding capacity leading to reduction in size and drying the disc.

16. Intradiscal electrothermic therapy (IDET)

17. COMPLICATIONS OF CERVICAL DISK PROLAPSE Anterior approach- Carotid or vertebral artery injury Recurrent laryngeal nerve dysfunction Esophageal perforation Airway obstruction Posterior approach- Damage to the nerve root or the spinal cord due to retraction or contusion of either of these structures, resulting in weakness of muscles supplied by the nerve root or cord. Other- Hematoma at the surgical site, resulting in cord compression and neurologic deficit. Recurrent or persistent pain after surgery.

18. OF LUMBAR DISK PROLAPSE Cauda equina syndrome- Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. Chronic pain Permanent nerve injury Paralysis

19. NURSING MANAGEMENT NURSING ASSESSMENT • 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 compression. • Assess muscle tone, tenderness and range of motion in neck and shoulders. • Assess mood and stress levels.

20. NURSING DIAGNOSIS Pre-operative • Acute pain related to compression of injured area as evidenced by numeric pain scale score. • Impaired physical mobility related to pain and disease physiology as evidenced by inability to move independently. • Deficient knowledge related to impeding surgery as evidenced by frequent questioning by patient and family members.

21. Post-operative • Acute pain related to the surgical procedure as evidenced by numeric pain scale score. • Impaired physical mobility related to the postoperative surgical regimen as evidenced by inability to move out of bed. • Deficient knowledge related to postoperative course and home care management as evidenced by frequent questioning by patient and family members.

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

23. RESEARCH ARTICLES 1.Occupational factors and low back pain: a cross-sectional study of Bangladeshi female nurses. A cross-sectional study was performed with 229 female nurses from two selected tertiary hospitals in Bangladesh. Data was collected through face-to-face interview using a standard structured questionnaire. The multiple logistic regression analyses indicate that insufficient supporting staffs, overtime working hours and manual lifting in a working environment are associated with lower back pain. Besides , age and parity are found positively associated with chronic lower back pain. Conclusion of the study was that the prevalence of lower back pain among nurses in Bangladesh is high and should be actively addressed. Nurses to patient’s ratio should be taken into consideration to reduce the occurrence of lower back pain among nurses employed in hospitals.

24. 2.Back disorders and lumbar load in nursing staff in geriatric care: a comparison of home-based care and nursing homes. A cross-sectional study was performed on 1390 health care workers in nursing homes and home care. Occupational exposure to daily care activities with patient transfers was measured by a standardised questionnaire. Staff in nursing homes had more often positive orthopaedic findings than staff in home care. At the same time the values calculated for lumbar load were found to be significant higher in staff in nursing homes than in home-based care: 45% vs. 6% were above the reference value. Nursing homes were well equipped with technical lifting aids, though their provision with assistive advices is unsatisfactory. Situation in home care seems worse, especially as the staff often has to get by without assistance. The study concluded that future interventions should focus on counteracting work-related lumbar load among staff in nursing homes. Equipment and training in handling of assistive devices should be improved especially for staff working in home care.

25. SUMMARY AND CONCLUSION •As discussed throughout the presentation, learning about herniation of intervertebral disk and its management will help nurses to care for patients of herniation of intervertebral disk. •Nurses can do assessment of patients with herniation of intervertebral disk, observe the sign and symptoms, provide the necessary nursing care, prevent complications and support the patient psychologically. •Nurses can also counsel the patients and their family for various options available in treatment for herniation of intervertebral disk.

26. REFERENCES 1.Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of Medical Surgical Nursing. 2015. New Delhi. Wolters Kluwer.13th Edition. Volume 2. Pg. no.2074-2076. 2. Lewis. Medical Surgical Nursing Assessment and Management of clinical problems.2015. New Delhi. Elsevier. 2nd Edition. Volume II. Pg. no.1609-1613. 3. PubMed. Herniated lumbar disc. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907819/ [cited 11 nov 2019] 4. ResearchGate. Occupational factors and low back pain: a cross-sectional study of Bangladeshi female nurses. Available from https://www.researchgate.net/publication/316562159_Occupational_factors_and_low_back_pain_a_cross-sectional_study_of_Bangladeshi_female_nurses [cited 11 nov 2019] 5. PubMed. Back disorders and lumbar load in nursing staff in geriatric care: a comparison of home-based care and nursing homes. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2801493/ [cited 11 nov 2019] 6.UPMC. Dynamic Lumbar Spine Stabilization Surgery. Available from https://www.upmc.com/services/neurosurgery/spine/treatment/surgery/lumbar-stabilization [cited 11 nov 2019]