Herniated Nucleus
cervical (neck) disk herniation, and
Pulposus
“ruptured disk”
A condition in which the gelatinous
intervertebral disk protrudes
through the surrounding cartilage,
causing pressure on the spinal
nerve roots, pain, and disability
Other terms:
• Lumbar radiculopathy
• Cervical radiculopathy
• Herniated intervertebral disk
• Prolapsed intervertebral disk
• Slipped disk
Etiology and Risk Factors
Anatomy of the Spine
occurs 15 times more often than
it is one of the most common
causes of lower back pain.
Nerve roots (large nerves that
branch out from the spinal cord)
may become compressed resulting
in neurological symptoms, such as
sensory or motor changes.
Disk herniation occurs more
frequently in middle aged and
older men, especially those
The bones (vertebrae) of the spinal
involved in strenuous physical
column run down the back,
activity.
connecting the skull to the pelvis.
These bones protect nerves that
come out of the brain and travel
down the back and to the entire Normal Invertebral Disk
body. The spinal column is divided
into several segments -- the
cervical spine (the neck), the
thoracic spine (the part of the back
behind the chest), the lumbar spine
(lower back), and sacral spine (the
part connected to the pelvis that
does not move).
The spinal vertebrae are separated
by disks filled with a soft,
gelatinous substance, which
provide cushioning to the spinal
column. These disks may herniate
(move out of place) or rupture from
trauma or strain.
Most herniation takes place in the
lower back (lumbar area) of the
spine. Lumbar disk herniation
Herniated Nucleus Pulposus
Clinical Manifestations
HERNIATED LUMBAR 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
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
Diagnostics
EMG - may be done to determine
the exact nerve root(s) that is
(are) involved.
Nerve conduction velocity test
– determine the adequacy of the
conduction of the nerve impulse
as it courses down a nerve
Myelogram - may be done to
determine the size and location
of disk herniation.
Spine MRI or spine CT - will show
spinal canal compression by the
herniated disk.
Spine x-ray - to rule out other
causes of back or neck pain.
However, it is not possible to
diagnosis herniated disk by
spinal x-ray alone.
Medical – Surgical
Management
MEDICATIONS
Non steroidal anti-
inflammatory medications
(NSAIDs) and narcotic pain
killers will be given to people with
a sudden herniated disk caused by
some sort of injury (such as a car
accident or lifting a very heavy
object) that is immediately
followed by severe pain in the back
and leg.
LIFESTYLE CHANGES
Any extra weight being carried by
an individual, especially up front in
the stomach area, will make back
pain worse. Diet and exercise are
crucial to improving back pain in
overweight patients.
Physical therapy is important for
nearly everyone with disk disease.
Therapists will tell you how to
properly lift, dress, walk, and
perform other activities. They will
also work on strengthening the
muscles of the abdomen and lower
back to help support the spine.
Flexibility of the spine and legs is
taught in many therapy programs.
INJECTIONS
Steroid injections into the back
in the area of the herniated disk
can help control pain for several
months. Such injections reduce
swelling around the disk and
relieve many symptoms. Spinal
injections are usually done on an
outpatient basis using x-ray or
fluoroscopy to identify the area
where the injection is needed.
SURGERY
Diskectomy removes a protruding
disk. This procedure requires
general anesthesia (asleep and no
pain) and 2-3 day hospital stay.
You will be encouraged to walk the
first day after surgery to reduce
the risk of blood clots.
Microdiskectomy is 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.
Prognosis
Most people will improve with
conservative treatment. A small
percentage may continue to have
chronic back pain even after
treatment.
It may take several months to a
year or more to resume all
activities without pain or strain to
the back. People with certain
occupations that involve heavy
lifting or back strain may need to
change job activities to avoid
recurrent back injury.
Complications
• Long-term back pain
• Loss of movement or sensation
in the legs or feet
• Loss of bowel and bladder
function
• Permanent spinal cord injury
(very rare)
Nursing Management
Nursing Diagnoses
> Pain
> Fear
> Activity Intolerance
> Impaired physical Mobility
> Altered home maintenance
management
> Ineffective individual coping
> Body image disturbance
> Constipation
> Knowledge deficit
Planning - Expected Patient
Outcomes
Goals for care include -
> A steady reduction in incidence
and severity of back pain and
spasm
> Able to be more physically
active
> Able to perform self care
activities
> Not develop chronic sick role
behavior
> Have positive self concept and
positive attitude
> Have regular bowel movements
Implementation
> May be treated on an out-pt
basis with analgesics, muscle
relaxants and/or brace - bedrest
with firm mattress or bedboard
> Fitted for brace for use while
OOB - may remove while in bed -
Inspect skin under brace for
redness
> Don’t drive with brace
> Nerve block may be given
> Intermittent traction - Buck’s or
Pelvic Evaluation
Promoting Comfort > Reports of decreased or absent
> Maintain bedrest - head of bed back pain and spasm
elevated slightly to Low Fowler’s > Demonstration of safe
with knees slightly flexed (bed movement, presence of intact
gatched) movement and sensation in the
> Side-lying with bed flat with extremities
pillow between knees > Correct description of activity
> Log roll if need to turn side to restrictions to be observed after
side discharge and symptoms
> May have BRP - or roll onto indicating need for medical
fracture bedpan evaluation
> Use of analgesics, NSAIDS, > Able to perform self care
muscle relaxants activities with less difficulty
> Application of moist heat and > Able to be more physically
back rubs active
Preventing Injury Prepared by: Joel Ian D. Espenilla
> Teach log rolling
> Prevent constipation - Stool
softeners - Increase fluids and
roughage in diet
> PT may teach pt ROM exercises
and back-strengthening exercises
- as symptoms decrease
> Teach principles of good body
mechanics
Home Care
Teach pt and caregiver -
> How to log roll
> Avoid prolonged sitting - do not
cross legs - may use lumbar roll or
pillow for sitting
> Do not lift or carry weight in
excess of 5 lbs.
> Avoid driving car
> Avoid stairs
> No exercise including walking,
running, or exercise program
without consulting MD or PT