HERNIATED NUCLEUS PULPOSUS

BY: INDIRA GAYLE G RIOROSOBSN 4-2 BATCH 2013

Cavite State University

Disc Hernation - Physiology

Herniated nucleus pulposus, HNP- annulus becomes

weakened/torn and the nucleus pulposus herniates through it.

Tears in the annulus

Disc Hernation - Physiology

Compression of the nerve root in the foramen leads to pain

slipped disc, ruptured disc

Sagittal Section through the Spinal Cord

Intervertebral disc

2. Vertebral body

3. Dura mater

4. Extradural or epidural space

5. Spinal cord

6. Subarachnoid space

Common Manifestations 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

Common Manifestations

Most common site for HNP is L4-5 disc- the 5th lumbar nerve root

Most common is the posterior sensory nerve root compressed

Classic symptoms- low back sciatica pain

Other symptoms

Postural changes Urinary/male sexual function

changes Paresis or paralysis Foot drop Numbness Muscle spasms Absent cord reflexes

SYMPTOMS OF HERNIATEDLUMBAR DISK

• Muscle spasm• Muscle weakness or atrophy in later

stages• Pain radiating to the buttocks, legs,

and feet• Pain made worse with coughing, straining, or laughing• Severe low back pain• Tingling or numbness in legs or feet

SYMPTOMS OF HERNIATED CERVICAL DISK

• Arm muscle weakness• Deep pain near or over the shoulder blades

on the affected side• Neck pain, especially in the back and sides• Increased pain when bending the neck or

turning head to the side• Pain radiating to the shoulder, upper arm,

forearm, and rarely the hand, fingers or chest• Pain made worse with coughing, straining, or

laughing• Spasm of the neck muscles

Diagnostic Exams

X-ray identify deformities and narrowing of disk space

CT/MRI Spine MRI or spine CT will show spinal canal compression by the herniated disk.

Electromyography is a test that measures muscle response to nervous stimulation. Each muscle fiber that contracts will produce an action potential.

The nerve conduction velocity test is performed to evaluate nerve function. It tests the speed impulses travel through a nerve.

Myelogram may be done to determine the size and location of disk herniation.

The contrast dye makes the spinal canal clearly visible in this X-ray image. A herniated disc can be seen compressing the spinal nerves.

Physical Examination

Fever – possible infectionVertebral tenderness - not specific and not

reproducible between examinersLimited spinal mobility – not specific (may

help in planning P.T. If sciatica is present – do straight leg raisePositive test reproduces the symptoms of

sciatica – pain that radiates below the knee (not just back or hamstring)

straight leg raise test

The straight leg raise test is positive if pain in the sciatic distribution is reproduced between 30° and 70° passive flexion of the straight leg. Dorsiflexion of the foot exacerbates the pain

Treatment

Conservative Tx.Moderate bed restSpinal manipulation Physical therapyMedication

NSAIDsMuscle relaxantsRarely narcotics

• 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

• 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

Management

SURGERY • Diskectomy - removes a protruding disk.

This procedure requires general anesthesia (asleep and no pain) and 2 - 3 day hospital stay.

• Microdiskectomy - a procedure removing fragments of nucleated disk through a very small opening.

• Chemonucleolysis - involves the injection of an enzyme (called chymopapain) into the herniated disk to dissolve the protruding gelatinous substance. This procedure may be an alternative to diskectomy in certain situations.

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

MEDICATIONS

NsaidSteroid injectionMuscle relaxantNarcotics

Prevention of HNPBack 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 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

2. Chronic PainSurgery may not relieve pain

Nonpharmalogical methods to control pain

Pain clinic

3. ConstipationAs a result of bed rest and

decreased mobility and fear of pain with straining of stool

Constipation prevention methods– fluids, diet, etc

4. Home CareWhen riding in a car, take frequent

stops to move and stretchPrevention– Back school approachMay have to deal with pain as a

chronic conditionMay need to make life/job changes