An often life-altering problem, a herniated intervertebral disk (HIVD) can limit a patient's ability to move, interfering with activities of daily living (ADLs). The pain associated with an HIVD may also cause economic, emotional, and social problems. A patient with back pain may miss time from work because of mobility limitations, and alterations in ADLs and pain may cause him to become depressed and withdrawn.
In this article, I'll review the anatomy of the vertebral column, describe how to assess for an HIVD, discuss diagnostic tests, explain nonsurgical and surgical treatments, and outline nursing care.
First, let's have a brief anatomy lesson.
At the center of it all
Comprised of 33 vertebrae from the base of the neck to the coccyx, the vertebral column (spine) forms the longitudinal axis of the skeleton, allowing for free movement and providing points of attachment for ligaments and muscles. It's divided into five regions:
* cervical region (the most mobile)—in which seven vertebrae allow for flexion, extension, lateral bending, and rotation
* thoracic region—in which 12 vertebrae allow for lateral bending, flexion, and extension
* lumbar region—in which five vertebrae allow for flexion and extension
* sacral region—in which five vertebrae fuse to form the sacrum
* coccygeal region—in which four vertebrae fuse to form the coccyx (see The spinal column).
Vertebrae are comprised of a vertebral body, spinous process, pedicles, laminae, and transverse processes (see A closer look at a vertebra). Superior and inferior articular processes called facets are located between the transverse processes and the laminae. Most of the muscles that support the vertebral column attach to the spi-nous and transverse processes. Ligaments attach at the facet joints, where vertebrae meet. The most significant ligament is the ligamentum flavum. Located within the spinal canal and connecting the laminae of adjacent vertebrae, it holds the body erect.
Comprised of an inner and outer layer of cartilage, intervertebral disks separate the vertebrae and provide a cushion. The inner cartilage layer (nucleus pulposus) is composed of collagen and reticular fibers that are 75% water. The outer layer (anulus fibrosus) is composed of circular concentric layers of fibrocartilage.
Problems up ahead
An HIVD occurs when the nucleus pulposus protrudes against or extrudes through the anulus fibrosus, causing pain from direct pressure on the spinal nerve root and the breakdown products from the degenerated nucleus pulposus (see Picturing an HIVD). This can occur posteriorly, anteriorly, or laterally, affecting the more mobile segments of the spine, such as L4 to L5 and L5 to S1. An HIVD in the thoracic region is rare.
More men experience HIVDs than women. Other risk factors include:
* repetitive stress
* advancing age (with age, the intervertebral disk becomes denser because the nucleus pulposus loses water, resulting in disk degeneration)
* sedentary lifestyle
* dietary deficiencies
* inflammatory disease
* neuromuscular disorders
Herniation = pain
Signs and symptoms can occur immediately or may take years to develop. The location and extent of the HIVD determine which signs and symptoms the patient will experience.
A patient with an HIVD in the cervical region of the spine may complain of pain when he flexes or extends his neck or with lateral bending. He may describe a tingling sensation (paresthesia) in his arms, weakness or atrophy of arm muscles, and pain in the shoulders, neck, arms, and hands that's relieved with rest. If the HIVD is located between C5 and C6, the patient may experience altered sensation in the lateral forearm, thumb, index finger, and half of the middle finger; wrist weakness with extension; and weak brachial reflexes. If the HIVD is located between C6 and C7, he may experience altered sensation in the ring and little fingers and medial forearm; weakness with wrist and triceps flexion; weak finger extension; and decreased triceps reflexes.
A patient with an HIVD in the lumbar region may complain of decreased range of motion (ROM) and pain when standing, walking, bending, coughing, or sneezing that's relieved when lying down. He may also experience:
* sciatica (pain along the peripheral distribution of the sciatic nerve)
* pain or tenderness of the disk spaces and sciatic notch upon palpation
* pain and numbness along a sensory region (dermatome)
* decreased or absent reflexes
* weakness or atrophy of leg muscles
* limited forward flexion
* bowel and bladder dysfunction.
If the HIVD is located between L3 and L4, the patient may experience decreased sensation in the anterior thigh and lateral aspect of the ankle and a diminished or absent knee reflex. If the HIVD is located between L4 and L5, he may experience decreased sensation in the lateral aspect of the thigh, anterior aspect of the lower leg, and the space between the great toe and second toe; and decreased dorsiflexion of the ankle and extension of the great toe. If the HIVD is located between L5 and S1, he may experience decreased sensation to the lateral and posterior aspect of the lower leg, foot, and last three toes; or an absent or weak Achilles reflex (plantar flexion of the foot when the Achilles tendon is struck).
Although rare in the United States, the most significant potential complication of an HIVD is cauda equina syndrome (CES), in which blood flow to the cauda equina nerve plexus (the extension of the dorsal and ventral spinal nerves beyond the spinal cord) is occluded. The cauda equina nerve plexus is located in the lumbar region and receives its arterial blood supply from T7 to L4. If blood flow is interrupted, a hematoma may form, causing pressure on the nerve plexus. The hallmark signs and symptoms of CES are loss of bowel and bladder function secondary to loss of sphincter control, impotence in men, lumbar nerve root pain (radiculopathy), and increased back pain with an increase in paralysis or weakness of the legs. If CES is suspected, the healthcare provider will order magnetic resonance imaging (MRI), a computed tomography (CT) scan, or a myelogram to locate the compressed nerve root. CES is a medical emergency that requires immediate surgery to relieve the pressure on the nerves and reestablish arterial blood flow; irreversible damage to the involved nerve root can occur if CES is left untreated.
So what do you need to do if you suspect your patient has an HIVD? Let's take a look at assessment next.
Thorough assessment is a must
First, obtain a complete medical history and perform a physical assessment. Note a family history of back pain or a history of alcohol use, recreational drug use, or smoking. Review your patient's occupational history to help determine whether the back pain is job-related.
Assess the location of the pain and note its frequency, duration, and factors that aggravate or relieve the discomfort. Ask your patient about the onset of pain: Does it occur when bending, lifting, twisting, sneezing, or coughing or did it occur after an accident or injury? If the pain is related to an accident or injury, assess when, where, and how the incident occurred. If it resulted from a motor vehicle collision, note where your patient was seated in the vehicle, whether he was wearing a seat belt, and how badly the vehicle was damaged.
If your patient has a lumbar HIVD, his ability to lean forward will be reduced. Your patient will also not put as much weight or pressure on the affected side when standing or walking. The straight leg-raising or cross straight leg-raising test can help you determine whether your patient's pain is the result of an HIVD. To perform the straight leg-raising test, ask the patient to lie flat on his back (supine) and raise his symptomatic leg, then dorsiflex his foot. Document the degree of elevation where the pain occurs and the effects of dorsiflexion. Nerve roots are affected, and patients with an HIVD will experience pain when the leg is lifted 30 to 70 degrees. If pain is increased with dorsiflexion of the foot, suspect an HIVD. Perform a cross straight leg-raising test by having him lie supine and raise his unaffected leg. If he reports pain in his back or affected leg during this test, strongly suspect an HIVD.
All eyes on the MRI
If the healthcare provider suspects your patient has an HIVD, she'll order one or more of these diagnostic tests:
* MRI to view the soft tissues (spinal cord, nerves, and intervertebral disks) of the spine, if not contraindicated. MRI is the diagnostic tool of choice to view spinal soft tissue; however, it may be contraindicated for patients who have a history of metal, such as shrapnel, bullets, stents, or prostheses, in their body.
* CT scan to provide a three-dimensional view of the spine; a contrast medium or a radionucleotide may be injected to enhance the image, if not contraindicated. Although the CT scan depicts spinal body structures well, such as vertebral fractures, it doesn't adequately depict the soft tissue of the lumbar spine by itself. When the CT scan is combined with a myleogram, it's able to depict soft spinal tissue.
* myelogram, in which a radiopaque water-soluble contrast medium is injected into the spinal canal to show the structures causing compression. A myelogram is an invasive procedure and may be contraindicated in patients who are allergic to iodine or contrast media.
* spinal X-rays (anterior, posterior, lateral, and oblique views) to show structural problems and rule out disease or other conditions that could be causing the back pain. Fecal matter and overlying gas in the bowels can decrease the clarity of the X-ray films. A full bladder also decreases the clarity of the films by casting a shadow over the sacrum and distal end of the vertebral column. For this reason, it's important for patients to empty their bowels and bladder before having the X-rays taken.
* discogram, in which a contrast medium is injected directly into the intervertebral disk to show herniation and to reproduce the patient's pain; this test is used only when an MRI shows an HIVD.
The mainstay of treatment for an HIVD is an initial period of rest with medications to relieve pain and inflammation, followed by physical therapy. Unless the patient experiences CES or has a profound and progressive increase in muscle weakness, surgical options aren't considered until after at least 3 months of conservative management of the back pain. A back brace or corset may be ordered, but if over used it can prevent the back and abdominal muscles from becoming stronger and more supportive.
Conservative treatments include:
* bed rest. Usually lasting 1 to 2 days, bed rest helps reduce inflammation and edema in the soft tissues around the disk, relieve pressure on the nerve roots, and encourage healing.
* nonsteroidal anti-inflammatory drugs (NSAIDs). An NSAID, such as aspirin, ibuprofen, or naproxen, is usually ordered to reduce inflammation and pain. If the patient's pain is severe, he may take an opioid analgesic for short-term use during the acute phase until the pain is under control and NSAIDs will be more effective.
* oral or injected corticosteroids. An oral corticosteroid, such as prednisone, may be ordered for short-term use to help reduce inflammation. Occasionally, a corticosteroid may be injected into the epidural space to relieve radiculopathy, especially in the lumbar region. These injections are usually given as a series of three, spaced out over several weeks. Trigger point injections may be another option. When a muscle doesn't relax, a knot can form, putting pressure on the surrounding nerves and causing referred pain. A small needle is inserted into the trigger point (painful area of the muscle), and a local anesthetic or corticosteroid is injected. This inactivates the trigger point, alleviating the pain. As with any injectable medications, hypersensitivity needs to be assessed.
* muscle relaxants. To reduce spasms and promote comfort, the healthcare provider may prescribe muscle relaxants, such as cyclobenzaprine and metaxalone.
* cold, heat, and massage therapies. These therapies are often used in conjunction with medications. Cold therapy may be effective in reducing inflammation and pain. After the inflammation is reduced, heat therapy helps relax muscles and improve circulation. Massage therapy may facilitate relaxation, reduce stress, and relieve pain from muscle spasms without manipulating the spine.
* physical therapy. Typically, a patient participates in sessions two or three times a week for at least 6 weeks. First, he learns extension and isometric exercises to regain ROM and strengthen abdominal and surrounding muscles to compensate for the damaged spinal tissue. When his pain is under control and he regains enough strength, he'll learn flexion exercises. To maintain progress, he needs to perform the exercises at home between therapy sessions. He'll also learn proper body mechanics and body alignment to prevent other injuries. Weight loss may also be recommended to reduce the amount of stress placed on the spine; however, the patient may need other nonsurgical treatments to reduce pain before physical activity such as exercise can take place.
* ultrasound and phonophoresis. In ultrasound, high frequency sound waves are transferred to tissue via a round-headed probe. A gentle heat is produced as the sound waves travel into the tissue, aiding relaxation and distraction from pain as well as warming the muscles for exercise. In phonophoresis, a topical medication, such as lidocaine, aspirin, or hydrocortisone, is applied and ultrasound is used to force the medication into the subcutaneous tissues. The patient's sensitivity to the medication must be assessed before using phonophoresis.
* iontophoresis. In this method, topical pain medication is delivered into the skin using low-level electric impulses. Again, hypersensitivity to the medication needs to be assessed before this treatment.
What if that's not enough?
Most patients achieve pain relief with conservative treatment; however, surgery is an option if nonsurgical methods don't work or if the patient experiences neurologic deficits, loss of motor function, severe intractable pain, boney instability, or progressive deformity with loss of function. Diskectomy and laminectomy are the surgical procedures for an HIVD. A spinal fusion may be performed if the patient has spinal deformity or instability or if he experiences recurrent herniations or significant chronic low back pain with radiculopathy.
Let's take a closer look.
Diskectomy is the removal of the protruding or extruding nucleus pulposus. Per formed anteriorly or posteriorly, it's often done in conjunction with laminectomy to provide room for removal of the herniation. The minimally invasive microdiskectomy is also an option (see Picturing microdiskectomy).
Laminectomy is the removal of part of the laminae, facet joints, and, possibly, the ligamentum flavum to gain access to the disk and spinal canal (See Picturing lumbar lam inectomy). It's usually sufficient to decompress the nerve and alleviate symptoms after inflammation to the nerve root subsides.
Spinal fusion may be performed to stabilize the disk by anatomically realigning the vertebrae and fusing two or more of the involved vertebrae together. A posterior-lateral or anterior approach or both may be used over the course of one or two surgeries. A bone graft, often obtained from the laminae that are removed during laminectomy, may be used to provide mechanical support and a foundation for bone cells (osteogenic cells) to grow. A bone graft may also be harvested from the patient's iliac crest, tibia, or resected rib. Metal implants or instruments (pedicle screws, plates, wires, rods, or intervertebral fusion cages) are used to stabilize the vertebrae, prevent neurologic damage, help the bone graft solidify and completely fuse, and facilitate rehabilitation. Most patients return to preoperative activities 2 to 3 months after spinal fusion; however, in some patients, complete solidification and fusion may take 6 to 12 months.
Making a difference
Nursing care for nonsurgical treatments primarily involves evaluating the effectiveness of the treatment regimen. Assess whether the prescribed pain medications and treatments are providing enough pain relief to allow your patient to perform ADLs and resume other daily routines.
If oral medications are prescribed, make sure your patient is taking them as directed and assess for hypersensitivity and adverse reactions. Because he'll take these medications at home, educate him about possible adverse reactions and to notify his healthcare provider immediately if he experiences any.
If topical medications are applied, assess for skin irritation or hypersensitivity to the medication. If injections are ordered, document the injection site and the type and amount of medication injected. Also perform neurologic checks after an injection to ensure that nerves weren't adversely affected.
If physical therapy is ordered for your patient, review the progress reports, which document the treatment plan, his progress, and therapy recommendations. Ask your patient about his progress and reassess him for pain control, improvements in strength and mobility, improvements in his ability to perform ADLs and daily routines, and changes in neurologic function.
If your patient has undergone surgery, here's what you need to do:
* Monitor vital signs frequently.
* Perform neurologic checks systematically, distal to proximal, below the level of the spinal surgery.
* Assess his pain level. He may use patient-controlled analgesia for the first 24 to 48 hours; then switch to oral opioids and muscle relaxants. (If he has undergone spinal fusion, teach him to avoid NSAIDs during the healing phase because they increase the risk of hematoma formation and may impede fusion.)
* Assess his distal pulses, proximal pulses, and capillary refill time in the involved extremities.
* Assess his ability to distinguish different sensations (for example, sharp versus dull) and to determine the location of the external stimulation.
* Assess his mobility and the strength of his extremities.
To assess for mobility of the arms, ask your patient to move his fingers and hands, rotate his wrists, and raise and lower his arms. To assess for strength and compare strength bilaterally for the arms, ask him to grasp your hands and squeeze. To assess for strength and resistance, place your hands on your patient's arms, placing some pressure, and ask him to raise his arms.
To assess the legs for mobility, ask your patient to wiggle his toes, rotate his ankles, move his feet out to the side, and raise and lower his legs. To assess for strength, place your hands on the bottoms of his feet and have him push down on your hands as though he's driving a car (plantar flexion). Then place your hands on top of his feet, applying some pressure, and ask him to pull his feet toward his nose (dorsiflexion). Ask him to raise his legs. Again, this will test strength and resistance.
In order to make comparisons of the right and left, be sure to assess both arms at the same time and then assess both legs at the same time. If there's weakness, ask your patient or refer to pre-op notes to determine if the weakness is the same, better, or worse than before surgery. Immediately following surgery, your patient may still have some of the same sensations as he had before surgery because of edema and inflammation that may place pressure on the nerves.
* Assess the incision for signs and symptoms of infection, such as edema, redness, or drainage. Drainage that's clear or has a pale yellow ring around it (halo sign) may indicate a cerebrospinal fluid leak. Excessive bloody drainage may indicate a hemorrhage. Notify the surgeon immediately. (If your patient has a drain in place, drainage shouldn't exceed more than 250 mL in an 8-hour period during the first 24 hours.)
* Change the dressing as ordered.
* Assist your patient with turning and repositioning to prevent skin breakdown and pressure ulcers. (If surgery was performed to the lumbar region, he may need to remain supine for the first 24 to 48 hours.) Anti-embolism stockings and sequential compression devices will be applied to prevent thromboembolism. If your patient is unable to move and reposition his legs, heel boots may be applied to prevent heel skin breakdown.
* Encourage coughing and deep breathing to reduce the risk of atelectasis and pneumonia secondary to decreased mobility.
* Encourage early ambulation and teach him exercises, such as ankle exercises, to promote venous return and increase circulation.
* Assess your patient's abdomen and bowel sounds during each head-to-toe assessment. Bowel sounds may not be heard initially, but you can determine when the bowel sounds start to become present and in which quadrants. After auscultation, assess the abdomen for distension and firmness. Ask your patient if he's passing flatus. If an anterior approach was used during surgery, he may be NPO for the first 24 to 48 hours. Initially, he'll receive a liquid diet. If this diet is tolerated with no nausea or vomiting, he'll be advanced to his previous diet as ordered. Assess his ability to swallow before advancing his diet.
Teach your patient about post-op limitations to his ADLs after discharge. He won't be allowed to bend, twist, or lift anything that weighs more than 5 to 10 pounds for at least 6 weeks after surgery. An initial post-op X-ray will be taken to compare with X-rays taken during post-surgical visits. Based on the X-rays and the extensiveness of the surgery, restrictions may need to be extended for up to 1 year.
Teach him how to properly use assistive devices to dress, undress, and bathe. He should use straight-back chairs and a firm mattress to help limit the amount of pressure on his back and prevent twisting his spine. Driving is often prohibited during the healing phase, usually for the first 6 weeks; however, driving may be restricted for up to 1 year based on X-rays and follow-up visits.
Your patient will be at risk for blood clots for up to 6 weeks, so instruct him to continue to wear antiembolism stockings and exercise to promote circulation. Depending on his preexisting medical conditions and the length of surgery, the healthcare provider may order low-dose, low-molecular-weight heparin for 2 to 6 weeks after surgery to prevent blood clots. Anti-coagulants increase the risk of hematoma formation and impede the healing process with spinal surgery.
Stress to your patient the importance of maintaining spinal alignment after discharge. A brace or corset may be ordered for your patient to wear after surgery. Depending on the type of surgery, the brace may need to be worn at all times or only worn when out of bed. A cervical brace is ordered for all cervical surgeries. A brace or corset may be ordered for thoracic or lumbar surgery depending on the surgeon's preference, the extent of the surgery, and the stability of the spine before surgery.
Footloose and pain free
An HIVD can cause economic, emotional, and social turmoil in your patient's life, not to mention serious pain. But with proper detection and an effective treatment plan, he'll be footloose and pain free. n
Signs and symptoms of HIVD by region Cervical region (general)
* Pain upon neck flexion, extension, or lateral bending
* Paresthesia in the arms
* Weakness or atrophy of arm muscles
* Pain in the shoulders, neck, arms, and hands that's relieved with rest
C5 to C6
* Altered sensation in the lateral forearm, thumb, index finger, and half of the middle finger
* Wrist weakness with extension
* Weak brachial reflexes
C6 to C7
* Altered sensation in the ring and little fingers and medial forearm
* Weakness with wrist and triceps flexion
* Weak finger extension
* Decreased triceps reflexes
* Lumbar region (general)
* Decreased range of motion
* Pain when standing, walking, bending, coughing, or sneezing that's relieved when lying down
* Pain or tenderness of the disk spaces and sciatic notch upon palpation
* Pain and numbness along a sensory region
* Decreased or absent reflexes
* Weakness or atrophy of leg muscles
* Limited forward flexion
* Bowel and bladder dysfunction
L3 to L4
* Decreased sensation in the anterior thigh and lateral aspect of the ankle
* Diminished or absent knee reflex
L4 to L5
* Decreased sensation in the lateral aspect of the thigh, anterior aspect of the lower leg, and the space between the great toe and second toe
* Decreased dorsiflexion of the ankle and extension of the great toe
L5 to S1
* Decreased sensation in the lateral and posterior aspect of the lower leg, foot, and last three toes
* Absent or weak Achilles reflex
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