2. Spinal Cord Anatomy spinal cord anatomy

3. Spinal Cord Anatomy

4. Pathophysiology/Etiology Function of disc is to allow for mobility of the spine and act as shock absorber

5. Pathophysiology/Etiology Located between vertebral bodies Composed of nucleus pulposus a gelatinous material surrounded by annulus fibrosis- a fibrous coil

6. Pathophysiology/Etiology Spinal nerves come out between vertebra

7. Herniated Disc Herniated nucleus pulposus, slipped disc, ruptured disc HNP- annulus becomes weakened/torn and the nucleus pulpsus herniates through it. Risk Factors- Standing erect- cumulative effect and daily stress Aging changes in disc and ligaments, osteoarthritis Poor body mechanics Overweight Trauma

8. Common Manifestations/Complications HNP compresses Spinal nerve (sensory or motor component) as it leaves the spinal cord Or the cord itself- the white tracts within the cord- rare

9. Common Manifestations/Complications 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. Common Manifestations/Complications Lumbar HNP Most common site for HNP is L4-5 disc- the 5 th 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 herniated disc L4-L5

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 disc- affects the 6 th 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. 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 herniated disc repair

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

18. Treatment- Surgery Foraminotomy Enlargement of the bony overgrowth at the opening which is compressing the nerve Microdiskectomy 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. 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 for HNP Sensory/motor assessment- care not to injure op site Assess for CSF drainage or bleeding from op site Encourage turn (log roll, cough, deep breath) Assess for postural hypotension, especially if client was on bed rest for several days/weeks prior to surgery

23. Post-op Assessment for HNP 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. Minimize stress of post-op site- flat with pillow between knees, log roll, etc

24. 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 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

29. Classification of 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

30. Classification of Spinal Cord Tumors by Origin Primary- originating in the spinal cord or meninges that is not relieved by bed rest Secondary- metastases from other parts of the body

31. Spinal Cord Tumors 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 Manifestations/Complications Symptoms depend on the anatomical level of the spinal column, the anatomical location, the type of tumor and the spinal nerves affected Pain that is not relieved by bed rest is the most common presenting symptom Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor

33. Common Manifestations/Complications Manifestations of 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. Therapeutic Interventions Diagnostic tests include: X-ray of the spinal column Myelogram Lumbar puncture with CSF analysis

35. Therapeutic Interventions 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

36. Therapeutic Interventions 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. Nursing Assessment Health history Pain, motor and sensory changes, bowel and bladder changes, Babinski reflex. Physical exam Similar to physical assessment for HNP

39. 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. Nursing Problems/Interventions 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. Nursing Problems/Interventions 6. Urinary retention 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 Disc http://wps.prenhall.com/wps/media/objects/737/755395/intervertebral_disk.pdf

43. Added Critical thinking questions Nursing Care Plan: A Client with Ruptured Intervertebral Disc 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? 9. Would the Dr use the anterior or posterior surgical route to get to her disc?

47. LeMone Blackboard: Media Links http://wps.prenhall.com/chet_lemone_medicalsurg_3 /0,7859,757263-,00.html http://wps.prenhall.com/chet_lemone_medicalsurg_3 /0,7859,757263-,00.html http://www.spine-health.com/