SPINAL DISC HERNIATION:

SPINAL DISC HERNIATION:

Spinal Disc Herniation

 

What is spinal disc herniation?

        A spinal disc herniation informally and misleadingly called a “slipped disc” is a medical condition affecting the spine, in which a tear in the outer, fibrous of an intervertebral disc allows the soft, central portion to bulge out.

 

Stages of Spinal Disc Herniation:

 

M

       Disc herniation can occur in any disc in the spine, but the two most common form are lumbar disc herniation. The former is the most common, causing lower back pain and often leg pain as well, in which case it is commonly referred to as sciatica.

 

       Cervical disc herniations occurs in the neck, most often between the fifth & sixth (C5/6) and the sixth and seventh (C6/7) cervical vertebral bodies. Symptoms can affect the back of the skull, the neck, shoulder girdle, scapula, shoulder, arm, and hand. The nerves of the cervical plexus and brachial plexus can be affected.

 

Thoracic disc herniation:

 

      Thoracic discs are very stable and herniations is this region are quite rare. Herniation of the uppermost thoracic disc can mimic cervical disc herniations, while herniation of the other discs can mimic lumbar herniations.

 

Lumbar disc herniation:

 

      Lumbar disc herniations occurs in the lower back, often between the fourth and fifth lumber vertebral bodies or between the fifth and the sacrum.

 

MRI scan of large herniation (on the right) of the disc between the L4-L5 vertebrae.

 

Cervical Disc Herniation:

·         Pain & Muscle Spasm in neck.

·         Decreased range of motion secondary to pain.

·         Unilateral hand and arm pain.

·         Numbness & tingling (paresthesia) in upper extremities.

·         Weakness of upper extremity.

 

Lumbar Disc Herniation:

·         Low back pain with sensory and motor dysfunction.

·         Pain radiating from lower back into the buttocks and down the leg.

·         Paresthesia, weakness and reflex impairment.

·         Muscle spasm.

·         Decreased range of motion.

 

 

 

DIAGNOSIS:

 

1)      Neurological Examination:

 

Straight leg raise:

 

           The straight leg raise may be positive, this finding has low specificity; however it has high sensitivity.

 

Imaging

·         X-ray studies

·         Computed tomography scan (CT or CAT scan)

·         Magnetic resonance Imaging (MRI)

 

2)      Myelogram: An x-ray of the spinal canal following injection of a contrast material into the surrounding cerebrospinal fluid spaces. By revealing displacement of the contrast material, it can show the presence of structures that can cause pressure on the spinal cord or nerves, such as herniated discs, tumors, or bone spurs.

3)      Electromyogram and Nerve conduction studies (EMG/NCS):  These tests measure the electrical impulse along nerve roots, peripheral nerves, and muscle tissue. This will indicate whether where is ongoing nerve damage, if the nerves are in a state of healing from a past injury, or whether there is another site of nerve compression.

 

MANAGEMENT:

 

           The majority of herniated discs will heal themselves in about six weeks and do not require surgery. One study found that ``After 12 weeks, 73% of patient showed reasonable to major improvement without surgery.``

           Pain medication are often prescribed to alleviate the acute pain and allow the patient to begin exercising and stretching.

           There are a variety on non-surgical alternatives used in treatment of the condition, which may or may not help:

1)      Rest and activity modification- Complete rest and avoidance of activities that aggravate symptom are recommended.

2)      Physical therapy

3)      Massage therapy

4)      Ice & heat applications

5)      Non-steroidal anti-inflammatory drugs (NSAIDs) e.g, Zerodol.

6)      Oral steroids (e.g. prednisone or methylprednisolone)

7)      Epidural (cortisone) injection

8)      Intravenous sedation, analgesia-assisted traction therapy (IVSAAT)

9)      Weight control

 

 

 

 

SURGERY:

 

           Surgery should only be considered as a last resort after all conservative treatments (non-surgical therapy) have been tried, that did not alleviate the pain and heal the disc herniation.

 

           Surgery is indicated if a patient has a significant neurological deficit. The presence of cauda equina syndrome (in which there is incontinence, weakness and genital numbness) is considered a medical emergency requiring immediate attention and possibly surgical decompression.

 

          Surgical options include:

Surgical goals include relief or nerve compression, allowing the nerve to recover, as well as the relief of associated back pain and restoration of normal function.

 

·         Chemonucleolysis – dissolves the protruding disc

·         IDET (a minimally invasive surgery for disc pain)

·         Discectomy/Microdiscectomy – to relieve nerve compression

·         Laminectomy – to relieve spinal stenosis or nerve compression

·         Hemilaminectomy – to relieve spinal stenosis or nerve compression

·         Lumbar fusion (lumbar fusion is only indicated for recurrent lumbar disc herniations, not primary herniations)

·         Anterior cervical discectomy and fusion (for cervical disc herniation)

·         Disc arthroplasty (experimental for cases of cervical disc herniation)

·         Dynamic stabilization

·         Artificial disc replacement, a relatively new form of surgery in the U.S. but has been in use  in Europe for decades, primarily used to treat low back pain from a degenerated disc.

·         Nucleoplasty

 

NURSING MANAGEMENT OF PATIENT WITH A CERVICAL DISCECTOMY:

 

Nursing diagnosis:

1.      Pain related to the surgical procedure.

2.      Impaired physical mobility related postoperative surgical regimen.

3.      Knowledge deficit about the postoperative course and home care management.

 

Nursing Interventions:

 

1)      Relieving Pain:

·         The patient may be kept flat in bed for 12 to 24

·         Monitoring the donor site for hematoma formation

·         Administering the prescribed postoperative analgesic,positioning for comfort

·         Reassuring the patient that the pain can be relieved

·         A pure diet may be given if the patient has dysphagia

·          

 

2)      Improving Mobility:

·         Assess the mobility of patient

·         A cervical collar is usually worn, which contributes to limited neck motion and altered mobility

·         Patients are instructed to turn the body instead of the neck when looking from side to side

·         Patient are assisted during position changes, making sure that head, shoulder and thorax are kept aligned.

 

3)      Teaching patients self care:

·         A cervical collar is usually worn for about 6 weeks

·         The patients are instructed in care and use of the cervical collar

·         Patients are instructed to alternate tasks in which the body does not move

·         The patient is instructed about strategies for pain management.