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

2. 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

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

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:

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:

14. Treatment- Surgery
Spinal fusion removes most of the disk and replaces it with bone usually from the patient iliac crest. View video:
Videos of Lumbar inter-Body Fusion with cage:
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:
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

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
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 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

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 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