Objectives

Discuss the anatomy of the spine in relation to fractures or degenerative disease.

Identify common nursing goals in care of the adult spine patient.

Describe typical nursing concerns for a post-op spine patient.

Anatomy

Bony = Vertebrae Soft tissue = Discs,

ligament Cord & Nerve Roots

Definitions

Cervical (7)

Thoracic (12)

Lumbar (5)

Sacral (5)-fused

Definitions con’t

Normal Curve-”S shaped” looking from lateral view

Scoliosis – abnormal lateral curve with rotation of vertebrae as well

Kyphosis- anterior curvature of thoracic spine

Radicular- referred pain from pressure on spinal nerve root

Spine Fracture

Etiology: Trauma vs non traumatic

•Elderly – Tumors, metabolic, renal, thyroid

Stable vs unstable Neurologic status

3 Column Theory

Anterior

Posterior third

Middle ThirdAnterior Third

Any 2 = unstable

Fractured C-Spine Examples

OdontoidHangman’s Tear drop Jefferson’s

Odontoid

Type I Type II

Most difficult to heal-shown

Type III

Hangman’s

Hyperextension and distraction

Injury occurs in anterior portion of C2 vertebrae

Piths spinal cord

Tear Drop

HyperflexionAnterior Ligament pulls off corner of anterior vertebraeUNSTABLE

Jefferson’s Fracture

Burst fracture of C1, disrupting the ring of the atlas

Spinal canal is widened

50% - NO neuro deficits

Occasionally requires fusion of occiput to C1

Complications

Atlanto-occipital dislocation Neurologic damage

Permanent or temporary below level of bony injury

Death

Diagnostic Studies Needed

X-ray 2 planes AP & x table lateral May need swimmer’s

view for ? Otontoid fx Flexion Extension C-spine Ligamentous

injury Spasm 10-14 days

Diagnostic Studies Needed con’t

CT scan MRI if nerve

injury suspected

Therapeutic Modalities

Log roll Specialty beds Braces Surgery

Surgical Spinal Fixation

Halo Posterior Spinal fusion

Rods, Hooks, Screws Anterior Spinal fusion

Plates, Cage

Nursing Interventions

Neurologic Status Documentation Sensation level Motor function Spasm Nursing / Body Mechanics Communication of findings key!!

Neurologic Status Documentation

Sensation levels Shoulder = C-5 Nipple T-4 Umbilicus T-10 Great toe L-4

Sensation Levels

Neurologic Status Documentation Motor Function EHL toe extension L4-5 Tighten Anus S 3-5 Thumb pointing up,

index finger straight ahead C-6-8

Motor Function

Nursing Considerations

Cast Syndrome Potentially life threatening syndrome caused by

hyperextension of lumbar spine that results in compression of the superior mesenteric artery-bowel ischemia

Brace use / skin care / pin care Activity / Bowels / Nutrition

Nursing Considerations

Home Care Instructions Neurovascular symptoms to report Brace use Surgical care

Question #1

Joshua, 19, was involved in a motor vehicle crash, unbelted. He reportedly has an L-2 burst fracture. As his nurse, you would:

A. Have him use the trapeze to lift himself in bed.

B. Log roll him side to side as a unit.C. Have him sit first then dangle his legs to

prevent dizziness.D. Boost him with help lifting under his armpits.

Answer #1

Joshua, 19, was involved in a motor vehicle crash, unbelted. He reportedly has an L-2 burst fracture. You will :

b. Log roll him side to side as a unit.Rationale: Log rolling a spine patient is

essential to prevent further neurological impairment

Question #2

Joshua is taken emergently to the OR for decompression and posterior spinal fusion. His post-op orders call for a TLSO. Which of the following instructions about TLSO care is correct?

a. Red and purple marks on skin under brace are normal.

b. It is acceptable to wear it loose.c. Take it off when ever you are standing upright.d. Report any vomiting or abdominal pain

immediately.

Answer #2

Joshua is taken emergently to the OR for decompression and Posterior spinal fusion. His post-op orders call for a TLSO. Which of the following statements are true?

D. Report any vomiting or abdominal pain immediately.

Rationale: Vomiting or abdominal pain might indicate compression against the abdominal cavity, causing vomiting and abdominal pain.

Spondylolysis / Spondylolisthesis

Define: Spondylo =

vertebrae Lysis = broken Listhesis = slipped

forward

Spondylolysis / Spondylolisthesis

M = F Teens or Elderly Genetics, stress, degenerative Gymnasts, football lineman, weight

lifters Elderly OA of facets > loose joints,

repetitive stress on vertebrae

Spondylolysis / Spondylolisthesis

Chronic or acute LBP Often radicular in nature Exam

Spasms + SLR Tight hamstrings

Spondylolysis / Spondylolisthesis

Treatment- Conservative Rest 3 days maximum!! /Back Brace Analgesics / Antispasmodics / ice or heat Physical therapy / Back School

(Education) Avoid painful activities

Spondylolysis / Spondylolisthesis

PSF with or without instrumentation

ASF for severe slips or failed PSF

Question #3

The surgeon has chosen to fix a spine with pedicle screws and posterior spinal fusion. During a post-op nursing assessment, which one of the following would be urgently reported to the surgeon?

a. Absent or sluggish bowel sounds.b. Pain and spasm in lower mid back.c. Inability to feel side of left thigh or move

left leg.d. Burning on urination.

Answer #3

The surgeon has chosen to fix a spine with pedicle screws and posterior spinal fusion. During pre-op nursing assessment you note this (these) urgently reportable changes related to fracture site.

C. Inability to feel side of left thigh or move left legRationale: This would be indicative of neurological

impairment and are essential to be reported immediately. The other problems are expected and/or not emergent.

Herniated Nucleus Pulposa

M > F 20-45yrs Etiology

Degeneration Abnormal body mechanics Deconditioned - Poor muscle tone Trauma

Herniated Nucleus Pulposa

History- Some Event Back and leg pain Numbness and/or dysesthesias Muscle weakness-nerve distribution ^ with sitting / sneezing, coughing Worse with valsalva

Herniated Nucleus Pulposa

Exam “Classic Sign” Painful SLR Won’t lean forward Change in sensation,

strength or reflexes Bowel or Bladder

changes

Herniated Nucleus Pulposa

Radiographs / MRI /EMG

Herniated Nucleus Pulposa

Treatment- Conservative (80%) Rest 3 days max Analgesics / Antispasmodics / ice or heat Physical therapy / Education Avoid painful activities

Epidural Steroids Surgical

Laminectomy no fusion

Question #4

Fred c/o pain, which is horrible if he sneezes. He can’t even sit in his car. He was dx with a herniated disc, hates hospitals & wants to know what else can be done besides surgery. Which of the following is the best response?

a. Rest, analgesics, antispasmodics, and back care education help 80% of the people.

b. He should continue all activity even if it is painful for 3 days.

c. There is no other treatment. He needs a fusion.d. Steroid injection it works 100% of the time.

Answer #4

Fred c/o pain, which is horrible if he sneezes. He can’t even sit in his car. He was dx with a herniated disc, hates hospitals & wants to know what else can be done besides surgery. You explain:

A. Rest, analgesics, antispasmodics, and back school help 80% of the people.

Rationale: For this type of problem, conservative treatment is the most beneficial.

Degenerative Disc Disease

M >F Not Always Elderly water content in disc Annular ligament fiber

failure Hx: back pain w/ activities

for a while May have radicular

symptoms

Spinal Cord Problems

SCI Spinal Stenosis

Spinal Cord Injury

Traumatic M>F Complete vs Incomplete

Meaning some sparing of neurological function, either sensory or motor

Level is everything!

Levels

Spinal Cord – C1-L1 Conus Medularis Dist spinal cord

Bowel Bladder Cauda Equina Lesions = Roots below

Conus L-2

Spinal Stenosis

Etiology: congenital vs acquired (degenerative)

Lumbar region most common Also called neurogenic claudication

Spinal Stenosis

Back pain, leg pain when upright Walking usually makes

symptoms worse-“neurogenic claudication”

Relieved by bending, sitting Nocturnal leg cramps

Spinal Stenosis

Exam normal Can be abnormal if severe hypertrophy of

bone in foramen, causing nerve root compression

Check pulses r/o PVD- may need ABIs Check for hip OA X-ray: normal for age but may demonstrate

hypertrophy of bone in foramen MRI to eval. nerves

Spinal Stenosis Treatment

Activity modification Altered expectations Therapy to improve endurance, strength Epidural steroids Surgery: Decompression

+/- fusion

Degenerative Scoliosis

Lateral curvature of the spine

40-50 ° may require surgery

Etiol: Degenerative disc

Kyphosis (45°)

Posterior “hump” thoracic region Etiology

Congenital Scheuermann’s disease Neuromuscular Ankylosing spondylitis Metabolic (Osteoporosis) Tumor

Ankylosing Spondylitis

M > F Inflammatory disease

Surgical Intervention

ABC’s, normal Post-op Often serious cardio- pulmonary

compromise Neurologic exams

DOCUMENT Pain control, positioning Bowel & bladder

Questions

Thank You!