Intervertebral disk prolapse

1. HERNIATION OF THE
INTERVERTEBRAL
DISK AND ITS
MANAGEMENT
PRESENTED BY:
MISS.SHWETA
SHARMA
M.SC. NURSING
1ST YEAR
AIIMS, JODHPUR

3. INTRODUCTION
 The cervical spine is subjected to stresses that result from
disk degeneration (due to aging, occupational stresses) and
spondylosis (degenerative changes occurring in a disk and
adjacent vertebral bodies). Cervical disk degeneration may
lead to lesions that can cause damage to the spinal cord and
its roots.
 Lumbar disc prolapse is a condition in which there is
outpouching of the disc Nucleus pulposus along with few
annular fibres and end plate cartilage through the tears in
annulus fibrosus into the extradural space.

8.  The highest prevalence is among people aged 30-50 years, with
a male to female ratio of 2:1.
 The prevalence of symptomatic herniated lumbar disc is about
1-3% depending on age and gender.
 In people aged 25-55 years, about 95% of herniated discs occur
at the lower lumbar spine (L4/5 and L5/S1 level); disc
herniation above this level is more common in people aged over
55 years. The second most common site is the cervical region
(C5-C6, C6-C7). The thoracic region accounts for only 0.15% to
4.0% of cases.

9. RISK FACTORS
 Age- 35 to 50 years old.
 Gender- Men have roughly twice the risk for lumbar
herniated discs compared with women.
 Physically demanding work-Heavy lifting and other
physical labour. Pulling, pushing, and twisting
actions can add to risk if they’re done repeatedly.
 Obesity
 Smoking
 Family history

10. PATHOPHYSIOLOGY

12. CLINICAL MANIFESTATIONS
 Pain and stiffness may occur in the neck, the top of the
shoulders, and the region of the scapulae. Patient’s
sometimes interpret these signs as symptoms of heart trouble
or bursitis.
 Pain may also occur in the arm and hand, accompanied by
paresthesia (numbness, tingling or a “pins and needles”
sensation) of the upper extremity.
 Lhermitte’s syndrome- herniation of the disk centrally onto
the spinal cord; an electric like shock sensation in the
extremities or spine with neck flexion or straining and
bilateral arm and leg weakness (myelopathy).

14. DIAGNOSTIC EVALUATION
 History collection
 Physical examination
o Neurological check- loss of sensation, such as numbness, and weakness in
the leg and foot. The patient may be asked to walk normally and on
tiptoes to check for a condition called foot drop, in which the muscles
used to flex the ankles and toes are weakened. Reflexes may be slower
than normal.
o Range of motion
o Vital signs check
o Gait monitoring
o Lumbar spine area exam. If there is inflammation in the lumbar spine, the
skin may appear abnormal or sensitive to touch.

15. Leg raise test/LaSegue test

16. X-Ray
CT SCAN
MRI
Myelogram
EMG-to rule out
peripheral neuropathy
Diskogram

17. USES OF DISCOGRAPHY
• To evaluate equivocal abnormality seen on
myelography, CT or MRI
• To isolate a symptomatic disc among
multiple level abnormality
• To diagnose a lateral disc herniation
• To establish contained discogenic pain
• To select fusion levels
• To evaluate the previously operated spine

18. MEDICAL MANAGEMENT
 Rest and immobilize the cervical spine to give soft tissues time to heal and
to reduce inflammation in the supporting tissues and the affected nerve
roots in the cervical spine.
 Proper positioning on a firm mattress may bring dramatic relief from pain.
 The cervical spine may be rested and immobilized by a cervical collar,
cervical traction or a brace. A collar allows maximal opening of the
intervertebral foramina and holds the head in a neutral or slightly flexed
position.
 The patient may have to wear the collar 24 hours a day during the acute
phase.
 The skin under the collar is inspected for irritation.
 After the patient is free of pain, cervical isometric exercises are started to
strengthen the neck muscles.

19. CERVICAL COLLAR

21. PHARMACOLOGIC THERAPY
Analgesic agents (NSAIDs, acetaminophen/oxycodone, or
acetaminophen/hydrocodone)
Sedative agents- to control the anxiety that is often associated with cervical disk
disease.
Muscle relaxants- cyclobenzaprine, methocarbamol, metaxalone- to interrupt muscle
spasm and to promote comfort.
NSAIDs (aspirin, ibuprofen, naproxen) or corticosteroids- to treat the
inflammation and swelling that usually occurs in the affected nerve roots and supporting
tissues.
Occasionally, a corticosteroid is injected into the epidural space for relief of radicular pain
(spinal nerve root).
NSAIDs are administered with food and antacids to prevent gastrointestinal irritation.
Hot, moist compress (for 10 to 20 minutes) applied to the back of the neck several
times daily to increase blood flow to the muscles and help relax the patient and reduce
muscle spasm.

22. SURGICAL MANAGEMENT
 Cervical discectomy

23. Chemonucleolysis
Chemonucleolysis is the term used
to denote chemical destruction of
nucleus pulposus
[Chemo+nucleo+lysis].
This involves intradiscal injection
of chymopapain which causes
hydrolysis of he cementing protein
of the nucleus pulposus.
This causes decrease in water
binding capacity leading to
reduction in size and drying the
disc.

25. Intradiscal electrothermic therapy (IDET)

30. COMPLICATIONS
OF CERVICAL DISK PROLAPSE
Anterior approach-
 Carotid or vertebral artery injury
 Recurrent laryngeal nerve dysfunction
 Esophageal perforation
 Airway obstruction
Posterior approach-
Damage to the nerve root or the spinal cord due to retraction or contusion of either of
these structures, resulting in weakness of muscles supplied by the nerve root or cord.
Other-
 Hematoma at the surgical site, resulting in cord compression and neurologic deficit.
 Recurrent or persistent pain after surgery.

31. OF LUMBAR DISK PROLAPSE
Cauda equina syndrome- Cauda equina
syndrome (CES) is a condition that occurs when
the bundle of nerves below the end of the
spinal cord known as the cauda equina is
damaged.
Chronic pain
Permanent nerve injury
Paralysis

34. NURSING MANAGEMENT
NURSING ASSESSMENT
• Assess the patient for any past injuries to the neck because unresolved
trauma can cause persistent discomfort, pain and tenderness and symptoms
of arthritis in the injured joint of the cervical spine.
• Assessment includes determining the onset, location, and radiation of
pain.
• Assess for paresthesia, limited movement and diminished function of
neck, shoulders and upper extremities.
• It is important to determine whether the symptoms are bilateral; with
large herniations, bilateral symptoms may be caused by cord compression.
• Assess muscle tone, tenderness and range of motion in neck and
shoulders.
• Assess mood and stress levels.

35. NURSING DIAGNOSIS
Pre-operative
•Acute pain related to compression of injured area as
evidenced by numeric pain scale score.
•Impaired physical mobility related to pain and disease
physiology as evidenced by inability to move
independently.
•Deficient knowledge related to impeding surgery as
evidenced by frequent questioning by patient and family
members.

36. Post-operative
•Acute pain related to the surgical procedure as
evidenced by numeric pain scale score.
•Impaired physical mobility related to the
postoperative surgical regimen as evidenced by
inability to move out of bed.
•Deficient knowledge related to postoperative
course and home care management as evidenced
by frequent questioning by patient and family
members.

37. PROGNOSIS
•Extruded disc, large herniations,
sequestrations have a greater tendency to
resolution than small herniations & disc
bulges.
•Recurrence of disc prolapse can be
prevented by a proper exercise programme
and avoidance of stress to the lower part of
back.

38. RESEARCH ARTICLES
1.Occupational factors and low back pain: a cross-sectional study of
Bangladeshi female nurses.
A cross-sectional study was performed with 229 female nurses from
two selected tertiary hospitals in Bangladesh. Data was collected
through face-to-face interview using a standard structured
questionnaire. The multiple logistic regression analyses indicate that
insufficient supporting staffs, overtime working hours and manual
lifting in a working environment are associated with lower back pain.
Besides, age and parity are found positively associated with chronic
lower back pain. Conclusion of the study was that the prevalence of
lower back pain among nurses in Bangladesh is high and should be
actively addressed. Nurses to patient’s ratio should be taken into
consideration to reduce the occurrence of lower back pain among
nurses employed in hospitals.

39. 2.Back disorders and lumbar load in nursing staff in geriatric care: a
comparison of home-based care and nursing homes.
A cross-sectional study was performed on 1390 health care workers in
nursing homes and home care. Occupational exposure to daily care
activities with patient transfers was measured by a standardised
questionnaire. Staff in nursing homes had more often positive orthopaedic
findings than staff in home care. At the same time the values calculated
for lumbar load were found to be significant higher in staff in nursing
homes than in home-based care: 45% vs. 6% were above the reference
value. Nursing homes were well equipped with technical lifting aids,
though their provision with assistive advices is unsatisfactory. Situation in
home care seems worse, especially as the staff often has to get by
without assistance. The study concluded that future interventions should
focus on counteracting work-related lumbar load among staff in nursing
homes. Equipment and training in handling of assistive devices should be
improved especially for staff working in home care.

40. SUMMARY AND CONCLUSION
•As discussed throughout the presentation, learning about
herniation of intervertebral disk and its management will help
nurses to care for patients of herniation of intervertebral disk.
•Nurses can do assessment of patients with herniation of
intervertebral disk, observe the sign and symptoms, provide the
necessary nursing care, prevent complications and support the
patient psychologically.
•Nurses can also counsel the patients and their family for various
options available in treatment for herniation of intervertebral disk.

41. REFERENCES
1.Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of Medical Surgical
Nursing. 2015. New Delhi. Wolters Kluwer.13th Edition. Volume 2. Pg. no.2074-2076.
2. Lewis. Medical Surgical Nursing Assessment and Management of clinical problems.2015. New
Delhi. Elsevier. 2nd Edition. Volume II. Pg. no.1609-1613.
3. PubMed. Herniated lumbar disc. Available from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907819/ [cited 11 nov 2019]
4. ResearchGate. Occupational factors and low back pain: a cross-sectional study of Bangladeshi
female nurses. Available from
https://www.researchgate.net/publication/316562159_Occupational_factors_and_low_back_pa
in_a_cross-sectional_study_of_Bangladeshi_female_nurses [cited 11 nov 2019]
5. PubMed. Back disorders and lumbar load in nursing staff in geriatric care: a comparison of
home-based care and nursing homes. Available from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2801493/ [cited 11 nov 2019]
6.UPMC. Dynamic Lumbar Spine Stabilization Surgery. Available from
https://www.upmc.com/services/neurosurgery/spine/treatment/surgery/lumbar-stabilization
[cited 11 nov 2019]