1. Module 8 Neurosensory: Herniated Disk and Spinal Cord tumors
Marnie Quick RN, MSN, CNRN

3. A. Pathophysiology/etiology Normal spine as related to herniated disk
Herniated nucleus pulposus, slipped disk, ruptured disk
Function of disc is to allow for mobility of the spine and act as shock absorber

4. Located between vertebral bodies
Composed of nucleus pulposus a gelatinous material surrounded
By annulus fibrosis- a fibrous coil

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

6. Risk factors developing herniated disk
Standing erect- cumulative effect and daily stress
Aging changes in disc and ligaments, osteoarthritis
Poor body mechanics
Overweight
Trauma

8. 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

9. 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

10. B. Common manifestations/complications Lumbar HNP
Most common site for HNP is L4-5 disc- the 5th lumbar nerve root
Most common is the posterior sensory nerve or root compressed
Classic symptoms- low back sciatica pain. The pain increases with increase in intrathorasic pressure

11. Other symptoms lumbar HNP:
Postural changes
Urinary/male sexual function changes
Paresis or paralysis
Foot drop
Paresthesias
Numbness
Muscle spasms
Absent cord reflexes

12. 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

13. C. Therapeutic Interventions- diagnostic tests
X-ray identify deformities and narrowing of disk space
CT/MRI
Mylogram p1336
Nerve conduction studies (EMG) to detect electrical activity of skeletal muscles

14. 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

15. 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

16. 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

17. Treatment- Surgery
Spinal fusion removes most of the disk and replaces it with bone usually from the patient iliac crest
Flexibility is lost at the site- requires longer hosp stay

18. Treatment- Surgery
Foraminotomy is enlargement of the bony overgrowth at the opening which is compressing the nerve
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

19. 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

20. D. 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

21. 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

22. 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

23. 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

24. E. Pertinent 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

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

26. 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

27. 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

28. Spinal Cord Tumors A. Patho- normal cord & 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 or secondary

29. Spinal cord tumors by anatomical area
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

31. Spinal cord tumors primary or secondary
Primary- originating in the spinal cord or meninges
Secondary- metastases from other parts of the body

32. 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

33. B. 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

34. 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)

35. C. Therapeutic interventions spinal tumors
Diagnostic tests include:
X-ray of the spinal column
Myelogram
Lumbar puncture with CSF analysis

36. 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

37. 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

38. D. 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

39. E. 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

40. 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

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

42. Nursing Care Plan: A Client with a Ruptured Intravertebral Disk LeMone p. 1340

43. Added Critical thinking questions LeMone p
Added Critical thinking questions LeMone p Nursing Care Plan: A Client with Ruptured Intervertebral Disk
1. If Marees’ C6-C7 disk is herniated, where does the dermatome for C7 spinal nerve supply?
2. Is Marees’ anterior or posterior nerve root being compressed by the herniation?
3. Why is Maree Ivans prescribed both analgesics and muscle relaxants around the clock when awake?
4. How does a cervical collar help? What else may help relieve the pain?
5. If the conservative methods did not work, what else might the physician have done?
6. Why are conservative methods tried for a period of time rather than immediate surgery?

46. 7. Where is the posterior/anterior nerve root. 8. Where is the lamina
7. Where is the posterior/anterior nerve root? 8. Where is the lamina? 9. Would the Dr use the anterior or posterior surgical route to get to her disk?

47. LeMone Blackboard: Media Links