Intervertebral disk disease

37 Intervertebral disk disease




Overview/pathophysiology


The intervertebral disk is a semifluid-filled fibrous capsule that facilitates movement of the spine and acts as a shock absorber. The disk’s ability to withstand stressors is not unlimited and diminishes with aging. Pressure on the disk eventually may force elastic material from the center of the disk, called the nucleus pulposus, to break (herniate) through the fibrous rim of the disk, called the annulus. Herniation usually occurs posteriorly because the posterior longitudinal ligament is inherently weaker than the anterior longitudinal ligament. The bulging or rupture (protrusion or extrusion) of an intervertebral disk causes its typical symptoms by pressing on and irritating the spinal nerve roots or spinal cord itself. Herniated nucleus pulposus usually is the result of injury or a series of insults to the vertebral column from lifting or twisting. When the disk ruptures without a known discrete injury, degenerative changes are the likely cause. Deterioration usually occurs suddenly with rupture, but it may happen gradually, with symptoms appearing months or years after the initial injury. Almost all herniated disks occur in the lumbar spine, with 90% of the problems occurring at L4-5 and L5-S1. The spinal cord ends around L1, so lumbar herniated disks impinge on spinal nerves, which are more resilient than actual spinal cord tissue. The spinal nerves usually bounce back and function normally once the problem is relieved. Cervical disk problems most often occur at C5-6 and C6-7, and generally are caused by degenerative changes or trauma, such as whiplash or hyperextension. Cervical herniations may compress spinal nerves or impinge on the spinal cord itself. A genetic mutation (COL 9 AZ gene) also can cause some disk disease. Thoracic disk problems are rare because of the rigid structure of the thoracic spine.


Herniated disks account for about 4% of back pain. Most back pain is related to muscle and ligament strain. Spondylolisthesis (slippage between two vertebrae) and degenerative changes such as stenosis; osteophyte (e.g., bone spur) formation, which can cause spinal nerve root compression; osteoporosis, which can lead to compression fractures; and osteoarthritis of the facet joints are other causes of non-disk back pain. Neoplasm and infection also can be sources of back pain.



Health care setting


Primary care or acute care



Assessment




General indicators:


Onset can be sudden, with intense unilateral pain or with pain that is dull, diffuse, deep, and aching. Symptoms vary according to level of injury and nerves involved. Usually, pain is increased with movement or activities that increase intraabdominal or intrathoracic pressure, such as sneezing, coughing, and straining. Often pain is improved by lying down. Note: Immediate medical attention is essential if there is any weakness or paralysis, extreme sensory loss, or altered bowel or bladder function, which indicate spinal cord compression in the lumbar back (e.g., cauda equina syndrome) and need for emergency decompression surgery. Indicators of cervical spinal cord compression (and need for early surgical treatment) include balance problems, unsteadiness when standing with eyes closed (Romberg’s sign), hyperreflexes, and generalized numbness in feet and legs.



Cervical disk disease:


Pain or numbness in upper extremities, shoulders, thorax, occipital area, or back of the head or neck. Pain can radiate down the forearms and into hands and fingers. Interscapular aching or suboccipital headaches are commonly associated with cervical disk disease. Usually the neck has restricted mobility, and there can be cervical muscle spasm and loss of normal cervical lordosis. Patients may have upper extremity muscle weakness with diminished biceps or triceps reflexes.



Lumbar disk disease:


Pain in the lumbosacral area with possible radiculopathy (sciatica) to the buttock, down the posterior surface of the thigh and calf, and to the lateral border of the foot and toes. Sensory distribution for the L5 nerve root is the medial portion of the foot and the great toe, whereas sensory distribution for S1 is the lateral aspect of the foot, fifth toe, and sole of the foot. Often mobility is altered, as evidenced by decreased ability to stand upright, listing to one side, asymmetric gait, limited ability to flex forward, and restricted side movement caused by pain and muscle spasms. The individual walks cautiously, bearing little weight on the affected side, and often finds sitting or climbing stairs particularly painful. Reflex muscle spasms can cause bulging of the back with concomitant flattening of the lumbar curve and possible scoliosis at the level of the affected disk. Usually patellar and Achilles tendon reflexes are depressed due to nerve impingement. Sciatica usually is associated with intervertebral disk herniation.



Physical assessment:


Possible findings include depressed reflexes, muscle atrophy, paresthesias (described as “pins and needles”), or anesthesia (numbness) in the dermatome of the involved nerves. The straight leg raise test and sciatic nerve test are two of several that are performed to confirm presence of lumbar disk disease.



Risk factors:


Repetitive bending or lifting involving a twisting motion, continuous vibration, smoking, poor physical condition (especially weak abdominal muscles), poor posture, obesity, above-average height, osteoporosis, prolonged sitting, depression, severe scoliosis, spondylolisthesis, or genetic predisposition.



Diagnostic tests


In the absence of serious symptoms, diagnostic testing may not be done until 3 mo have passed and symptoms persist (90% of back pain resolves in less than 1 mo). Diagnostic testing should be done for pain that is constant, severe, unrelieved by rest or position, and is not calmed by antiinflammatory medication inasmuch as these symptoms may indicate presence of neoplasm or infection. Thoracic back pain also should be investigated because it may be caused by medical problems (e.g., aortic aneurysm).




Magnetic resonance imaging (MRI) scan:


May reveal a disk impinging on the spinal cord or nerve root, or may show a related pathologic condition, such as a tumor or spondylosis. A magnetic resonance (MR) neurogram helps image nerves after they leave the spinal column and can show compressions as they travel through the spinal foramina. MR myelogram helps view the cerebral spinal fluid sac without having to use a needle puncture. MRI has replaced computed tomography (CT) scan and myelogram as the test of choice in diagnosing herniated nucleus pulposus and is considered the “gold standard.”



CT scan of the spine:


May reveal disk protrusion/prolapse or a related pathologic condition, such as a bone spur, tumor, spondylosis, or spinal stenosis.



X-ray examination of the spine:


May show narrowing of the vertebral interspaces in affected areas, loss of spine curvature, bone spur formation, and spondylosis.



Diskography:


Identifies degenerated or extruded disks or annulus tear by means of contrast medium injected into the disk space using fluoroscopy. Often it is done in combination with CT and may differentiate between disk infection and rupture.



Myelogram:


May show characteristic deformity and filling defect or a related pathologic condition; it is usually done in conjunction with a CT scan.



Electromyography:


May show denervation patterns of specific nerve roots to indicate level and site of injury.



Evoked potential studies:


For example, somatosensory studies may show slowed conduction due to nerve root compromise and can localize specific nerve root.



Laboratory tests


Serum alkaline and acid phosphatase, glucose, calcium, erythrocyte sedimentation rate (ESR), and white blood cell count may rule out metabolic bone disease, metastatic tumors, diabetic mononeuritis, and disk space infection.





Nursing diagnosis:



Deficient knowledge


related to unfamiliarity with pain control measures


Desired Outcome: Following instruction during outpatient treatment session or within the 24-hr period before hospital discharge, patient verbalizes knowledge about pain control measures and demonstrates ability to initiate these measures when appropriate.





































































ASSESSMENT/INTERVENTIONS RATIONALES
Teach methods of controlling pain and their individual applications.
Methods include distraction, use of counterirritants, massage, hydrotherapy, aquatherapy, acupressure, dorsal column stimulation, use of transcutaneous electrical nerve stimulation, behavior modification, relaxation techniques, hypnosis, music therapy, imagery, biofeedback, and diathermy. Whole body vibration exercise and spinal manipulation may be considered for uncomplicated back problems with no radiculopathy.

In addition, applying intermittent heat may reduce muscle spasm, whereas icing may prevent further inflammatory swelling and provide some topical anesthesia. Icing should be done frequently, especially for the first 24-48 hr after surgery, and is often recommended after exercise. Continuous low-level heat wrap therapy reduces pain and improves function. Heat may be applied via warm/hot showers or heating pads. Cold can be achieved by freezing water in a paper cup, tearing off top of cup to expose the ice, and massaging in a circular motion, using remaining portion of cup as a handle. A bag of frozen peas or corn may be used to apply continuous cold to lower back. With any of these methods, a layer of cloth should be used so that ice does not touch the skin. A 20-min application of cold 4-6 times per day is recommended.
Suggest patient use a stool to rest affected leg when standing. This measure will help relieve sciatica.
Advise patient to sit in a straight-back chair that is high enough to get out of easily, including toilet seats that are raised. Higher seats facilitate ease of movement in and out of chairs and provide comfort. Straddling a straight-back chair and resting arms on the chair back is comfortable for many individuals.
Encourage use of a moderately-firm to firm mattress and extra pillows as needed for positioning. These measures support normal lumbar curvature. Some patients find the normal bed height too low and use blocks to raise it to a more comfortable height.
Instruct patient on bedrest to roll rather than lift off bedpan. This action prevents straining of the back. The patient may find a fracture bedpan more comfortable than a regular bedpan.
Caution patient to avoid sudden twisting or turning movements. Explain importance of logrolling when moving from side to side. These measures prevent movements that could induce further back injury. Orthotics (e.g., splints, braces, girdles, cervical collars) also may be used to limit motion of the vertebral column. Temporary use of a back brace or corset may enable earlier return to activity with lumbar disk disease. Generally, long-term use of braces is discouraged because it prohibits development of necessary supporting musculature.
Advise patient to avoid staying in one position too long, fatigue, chilling, and anxiety. These factors can cause back spasms.
Suggest lying on side with knees bent or lying supine with knees supported on pillows. Advise patient that a small pillow supporting the nape of the neck may be helpful with cervical pain. Teach patient to avoid prolonged periods of sitting, which stress the back. These measures promote spinal comfort.
If appropriate, teach patient to apply a heating pad to the back for 15-30 min before getting out of bed in the morning. Heat will help allay stiffness and discomfort after a night in bed. Heating pads should be used only for short intervals and only if patient’s temperature sensations are intact.
Remind patient to place a towel or cloth between heating pad and skin. This measure will help prevent burns.
Encourage patient to rest when tired or stressed and not to exercise when in pain. Tired muscles are more susceptible to injury. Usually patient resumes normal activity as soon as possible, but pain is an indicator to limit the offending activity.
Instruct in use of cervical traction if prescribed. Although infrequently prescribed, it may be used to help a cervical disk that has been bulging to slip back into place and unload the neck muscles and ligaments. Traditional method is a neck/head harness attached to a pulley and weight. A device for home use may include an inflatable collar that expands to push the head away from the shoulders.
Encourage a high-bulk diet, adequate or increased fluids, and stool softeners. These measures prevent constipation, which would cause straining and pain.
Teach purpose and potential side effects of the following medications for acute pain:  

– Analgesics (e.g., acetaminophen and tramadol, and opiate combinations such as hydrocodone and acetaminophen or oxycodone and acetaminophen)
 Sufficient medication is given to achieve pain relief or adequate pain reduction.

– Nonsteroidal antiinflammatory drugs (NSAIDs) and salicylates
 These medications reduce inflammation and relieve pain. Dosing usually is scheduled initially to obtain a sustained antiinflammatory effect. Side effects include blood thinning and gastric irritation, and kidneys may be affected if these drugs are taken for a long time.

– Misoprostol or stomach protectants such as sucralfate or ranitidine
 These agents may be considered to reduce gastric irritation caused by stress, medications, and steroids (if used).

– Muscle relaxants (e.g., cyclobenzaprine, carisoprodol, methocarbamol, diazepam)
 These medications decrease muscle spasms, thereby reducing pain. Common side effects are drowsiness, fatigue, dizziness, dry mouth, and gastrointestinal (GI) upset.

– Corticosteroids (e.g., dexamethasone)
 Steroids may be given for a short period to reduce cord edema, if present, but use is controversial.
Teach patient about the following medications used for chronic pain:  

– Analgesics (e.g., NSAIDs, tramadol, gabapentin, amitriptyline)
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Intervertebral disk disease

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