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

A. Pathophysiology/etiology Normal 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

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

Causes of degenerative disease: Video of diff causes: http://www

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

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

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

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

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.

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

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)

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

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

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

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

Charite disk: View Video on artificial disks: http://www

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

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

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

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

If post-op lumbar- assess bowels sounds, voiding 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

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

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

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

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

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

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

Classification of spinal cord tumors by 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

Intermedullary spinal cord tumor

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

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

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)

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

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

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

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

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

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

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