PPT ON INTERVERTEBRAL DISC PROLAPSE CLASS

INTERVERTEBRAL DISC PROLAPSE Class

1. INTERVERTEBRAL DISC PROLAPSE (IVDP)

2. Vertebra Cervical Thoracic Lumbar Sacral coccyx

3. Intervertebral disc

4. THE VERTEBRAL DISC The intervertebral disc is a cartilaginous plate, tough and fibrous material is incorporated in a capsule A ball like cushion in the centre of the disc is called nucleus pulposus The fibrous ring around the disc is called annulus .

5. INTERVERTEBRAL DISC DISEASE Intervertebral disc diseases is a condition that involves the deterioration ,herniation or other dysfunction of the intervertebral disc It involves, Cervical Thoracic Lumbar

6. TYPES OF DISC DEGENERATION BULGING DISC HERNIATED DISC DEGENERATED DISC THINNING DISC

7. DEFINITION IVDP is a condition in which a tear in the outer, fibrous ring (annulus fibrosus) of the intervertebral disc allows the soft central portion(nucleus pulposus) to bulge out. Common sites :L4-L5, C6-C7, L5-S1, C5-C6

8. ETIOLOGY Structural degeneration of the disc by degenerative disease Ageing Occupational

9. Repeated stress and trauma to spine Repetitive mechanical activities (frequent bending, twisting, lifting) Traumatic injury Spinal stenosis(narrowing of the spinal canal forces the disc to prolapse) Obesity

10. Practicing poor posture(improper spinal alignment strains the back and neck) Tobacco use weakens the disc Spondylosis- wear and tear of spinal disc

11. STAGES OF DISC HERNIATION Degeneration : there is no bulge Prolapse: just a bulge, contained herniation- nucleus is with in annulus Extrusion: non contained herniation Sequestration: it act as a free fragment - no continuity with the parent disc

12. PATHOPHYSIOLOGY In the herniation of intervertebral disc the nucleus of the disc protrudes into the annulus with subsequent nerve compression

13. IN NUCLEUS Degenerative changes Loss of protein polysaccharides in the disc decreases the water content of the nucleus and it starts to dry out and shrink Loss of elasticity, flexibility and shock absorbing capabilities

14. IN ANNULUS Development of radiating cracks weakens the resistance to nucleus herniation

15. These changes limit the ability of the disc to distribute pressure between vertebra The loads are transferred to annulus fibrosus With the structural damage nucleus pulposus may sweeps through a torn or stretched annulus

16. Produces radiculopathy Continued pressure causes changes in sensation and deep tendon reflexes

17. CLINICAL MANIFESTATION It depends on the location, the rate of development(acute or chronic) and the effect on the surrounding structures

18. Cervical spine Radiculopathy: radiating pain, numbness, tingling and diminished strength or range of motion Pain and stiffness in the neck, in the top of the shoulders, region of scapulae

19. Pain the upper extremities and head Paraesthesia (tingling or pin and needle sensation) Numbness of the extremities Weak handgrip

20. Lumbar spine Lower back ache with muscle spasm followed by, Radicular pain that radiates down the buttocks and below the knee along sciatic nerve Straight leg raising test (SLR) positive due to nerve root irritation.

21. Straight leg raising test (SLR)

22. Reflexes depressed or absent Paraesthesia or muscle weakness in legs ,feet and toes Pain aggravates on bending ,lifting or straining, sneezing or coughing due to increased intra spinal fluid pressure Sensory loss

23. ASSESSMENT AND DIAGNOSIS History and physical examination MRI scan (protrusion and compression) CT scan X ray –to detect structural defects

24. MANAGEMENT Medical /conservative management Goals To provide rest and immobilise the cervical spine To give soft tissue time to heal To reduce inflammation

25. Bed rest (usually 1-2 days)-eliminates stress and gravity. Proper positioning on a firm mattress. Cervical collar, cervical traction or a brace Collar-holds the head in a neutral or slightly flexed position Cervical isometric exercises (strengthen neck muscles)

26. General management Restricted activity for several days Local ice or heat for 10-20 min (increase blood flow)

27. Weight reduction and physical therapy Biofeedback Exercises to strengthen muscles and decrease pain

28. Limit extreme spinal movements Traction Tens(trans cutaneous electrical nerve stimulation) Good body mechanics Discourage extremes of flexion and torsion

29. Pharmacological management Analgesic Opioids ( eg:tramadol ) NSAIDS ( eg:aspirin , ibuprofen) Sedatives (to control anxiety) Muscle relaxants(reduce muscle spasm eg : cyclobenzaprine,metaxalone ) Corticosteroids (to reduce inflammation)

30. Surgical management Indication No improvement by medical management Constant pain and persistent neurologic deficits

31. Intra discal electro thermoplasty (IDET) Minimally invasive – OP procedure Inserting needle to the affected disc with the help of X ray The wire is threaded down through the needle in to the disc

32. The wire is heated and it denervates the small nerve fibres The heat melts the annulus fibrosus which trigger the body to generate new reinforcing proteins in the fibres of annulus

33. Radio frequency discal nucleoplasty Probe ge Same as IDET, instead of heat, radio frequency fibre is used nerate energy which breaks the molecular bonds of the gel in the nucleus pulposus .

34. Interspinous process decompression system A device made of titanium is fits on to a mount that is placed on vertebra in the lower back It is used in patients with pain due to lumbar spinal stenosis

35. Discectomy It is a surgical procedure to decompress the nerve root Microsurgical discectomy : using microscope the surgeon visualise the disc and increase safety, make effective and reduce rehabilitation time.

36. Laminectomy Common and traditional surgical procedure for lumbar disc disease It involves the surgical excision of the vertebra(lamina) to gain access to the spinal cord or to relieve pressure on nerves.

37. Hemilaminectomy - Hemilaminectomy is surgery to help alleviate the symptoms of an impinged or irritated nerve root in the spine

38. DISC ARTHROPLASTY The damaged disc is removed and new one is implanted

39. Artificial disc replacement surgery

40. Lumbar fusion Anterior lumbar fusion is an operation done on the front (the anterior region) of the lower spine. Fusion surgery helps two or more bones grow together into one solid bone. • Moss Miami fixation

41. Complications of disc surgery Archnoiditis - inflammation of arachinoid membrane Adhesions and scarring around the spinal nerves chronic neuritis and neurofibrosis . Disc surgery may relieve pressure ,but not reverse the effects of neural injury, scarring and pain.

42. Failed disc syndrome Remaining of the disability Hematoma at surgical site leads to cord compression

43. Nursing management Assessment (pre op) Ask about past injuries Determine onset, location and radiation of pain Assess paraesthesia, limited movement and diminished function of neck ,shoulders and upper extremities

44. Whether the symptoms are bilateral with large herniation's (cord compression) Palpate the area around the cervical spine to assess muscle tone and tenderness Range of motion in neck and shoulders

45. Nursing management Ask about health issues that may affect post op function Assess mood and stress levels Assess bowel and bladder function Teach legrolling ,deep breathing coughing exercise and muscle setting exercise

46. Assessment (post op) After lumbar disc excision Vital signs (BP, pulse for CVS function assessment, respiratory difficulty) Wound (haemorrhage, vascular injury) Post op neurologic deficit Sensation and motor strength of extremities Colour temperature and sensation of toes Urinary retention (sign of neurologic deficit )

47. Nursing diagnosis Acute pain related to surgical procedure Impaired physical mobility related to post op surgical regimen Deficient knowledge about the post op course Anxiety related to surgery

48. Constipation related decreased mobility Self care deficit Urinary retention Disturbed sleep pattern

49. Nursing interventions Relieving pain and medications The patient may be kept flat in the bed for 12 to 24 hrs. Monitor site for hematoma Administer prescribed medications Post op- requires opioids such as IV morphine 24 to 48 hrs Patient controlled analgesics for continued pain Once fluid diet takes then oral medications Muscle relaxant

50. Positioning the patient Maintain proper alignment of spine Ambulation depends on surgery

51. Potential for CSF leakage Inspect dressing for serosanguinous drainage ( dural leak) Report and care for headache Note colour, amount and characteristics

52. Monitor neurologic signs frequently Sensation, numbness, paraesthesia, tingling Temperature, capillary refill and pulses Swallowing deficits ,upper and lower extremity weakness Assess sudden radicular or spinal root pain-spinal instability

53. Paralytic ileus May occur and affect bowel fuction Manifest as –nausea, abdominal distention, constipation Assess passage of flatus, bowel sounds in all quadrants Flat soft abdomen Provide stool softners ( eg : docusate)

54. Bladder emptying Due to activity restriction, opioids and anaesthesia it may affect Use commode Ambulate the patient Ensure privacy Intermittent catheterisation/indwelling catheter Monitor incontinence/distention and report

55. I mproving activities/mobility - Limit activities and use rigid orthosis ( thoraco - lambar -sacral orthosis) -Chair back, brace, cervical collar(neck brace) -Turn body instead of neck to look side to side -Neck: position in neutral position -Assist during position changes -Alert for spinal cord edema : manifest as respiratory distress and worsening neurologic status of upper limb.

56. Spinal fusion Proper body mechanics Avoid sitting or standing for prolonged periods Encourage activities if that include walking ,lying down and shifting weight from one foot to the other when standing Restrict lifting

57. Teach to mentally think before activities Any twisting movement of the spine is contraindicated Use thighs and knees than back to absorb shock of movement A firm mattress or bed board is essential Monitor and manage potential complications