ERA UNIVERSITY
ERA COLLEGE OF NURSING
ASSIGNMENT
ON
Subject :
Submitted To,
Submitted By
Submitted On:
PIVD(PROLAPESED INTERVERTEBRAL DISC DISEASE)
Introduction:
Intervertebral disc separate the vertebrate and help absorb shock for the spine. Intervertebral disc disease
involves the intervertebral discs. Disc disorders can affect the cervical, thoracic, and lumbar spine.
A prolapsed (herniated) disc occurs when the outer fibres of the intervertebral disc are injured, and the soft
material known as the nucleus pulposus, ruptures out of its enclosed space.
The prolapsed disc or ruptured disc material can enter the spinal canal, squashing the spinal cord, but more
frequently the spinal nerves.
Herniated discs rarely occur in children, and are most common in young and middle-aged adults. A
herniation may develop suddenly, or gradually over weeks or months.
Definition:
“It is 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.”
Epidemiology: AGE: 30 – 40 years. • SEX: Male affected more than female. • MOST COMMON
LEVEL: L4-L5 (next common level is L5-S1). • MOST COMMON TYPE: Postero-lateral type.
Etiology:
Repetitive mechanical activities:frequent bending, twisting, lifting, and other similar activities without
breaks and improper stretching.
Living a sedentary lifestyle: more prone to herniated discs because the muscles thatsupport the back and
neck weaken, which increases strain on the spine.
Traumatic injury to lumbar discs: commonly occurs when lifting while bent at the waist, rather than
lifting with the legs while the back is straight.
Obesity : overload the motion segment.
Tobacco abuse: toxins reduces the disc`s ability to absorb nutrients, which results in the weakening of the
disc.
Mutation : in genes coding for proteins involved in the regulation of the extracellular matrix, such as
MMP2 and THBS2.
Degenerative disc disease(DDD): It is results from loss of fluid in the intervertebral disc with aging . the
discs lose their elasticity, flexibility, and shock absorbing abilities. This condition is normal until
accompanied by pain.
Types Of Disc Prolapsed:
Based on the intactness of annulus fibrosus-
Contained (intact annular fibres)
i. Protrusion
ii. Subannular extrusion
Non contained (disruption of annular fibres)
i. Transannular extrusion
ii. Sequestered
Disc Protrusion:
In this type of herniation, the spinal disc and the associated ligaments remain intact but form an
outpouching that can press against nerves. Technically speaking, the farthest edge of the herniation
measures smaller than the herniation's origin at the base of the disc.
A disc protrusion can remain as is, but it can also progress into one or both of the following two herniation
types.
Disc Extrusion:
This kind of herniation occurs when the nucleus squeezes through a weakness or tear in the annulus, but
the soft material is still connected to the disc.
Your body considers the nucleus material to be a foreign invader, which triggers an immune response and
inflammation. This can bring about additional pain and swelling.
As with protrusion, an extrusion can remain as it is, but can also progress to the next type of herniation.
Disc Sequestration:
Disc sequestration is a subtype of extrusion occurring when the nucleus not only squeezes out but separates
from the main part of the disc. This is also known as a free fragment.
The free fragment can migrate and aggravate spinal nerves, but there is no way to predict where or how
severely. Any symptoms, if they occur, depend on where the fragment settles. Symptoms generally appear
in one extremity (one arm for a neck herniation, or one leg for a lower back herniation).
As with extrusion, sequestration can also trigger an immune response to the nucleus material, bringing
inflammation to the area.
Pathophysiology:
Degenerative disc disease(with aging, vascular channels start to fail and vascular
diffusion of nutrients decrease thus number of viable chondrocytes in the nucleus pulpous
diminishes.
Synthesis rate and concentration of proteoglycans decreases and proportion of collagen
increase in nucleus pulpous.
Water binding capacity of the nucleus decreases.
Nucleus become more fibrous and stiffer.
Nucleus is less able to bear and disburse load, transferring load to the posterior annulus
annulus in tact annulus fail
facet joints share even more of the axial load
facet joints undergo degenerative changes and develop osteophytes FACET JOINT SYNDROME
ANNULUS FAIL
Fissures develop across annular lamellae may extend upto disc periphery
Internal disc disruption cause axial pain
Expression of this degraded nuclear material through these radial fissures DISC
HARNIATION
Clinical Manifestation:
The hallmark of disc herniation is pain. Any of the three herniation types have the potential to cause it and
other symptoms.
For example, depending on its location, a protrusion can come in contact with spinal nerves just as easily as
an extrusion or sequestration can. The amount of pain and other symptoms will depend on how the nerves
have been compromised.
Along with pain, herniations can press against the spinal cord or nerves and cause radiculopathy, the
neuromuscular symptoms typical of a disc herniation.
For a lumbar herniation, these include back spasms, sciatica, tingling, numbness, pain down the back of
the legs, and possible muscle weakness and loss of lower-body motor function.
For a cervical herniation, these include neck spasms, pain/tingling/numbness down one arm, shoulder
pain and/or weakness, and weakened reflex response in these areas.
LEVEL OF T12-L1 L1-L2 L2-L3 L3-L4 L4-L5 L5-S1
PROLAPSED
NERVE ROOT L1 L2 L3 L4 L5 S1
COMPRESSE
D
PAIN Thoracolumba Thoracolumb Upper Lower back , Sacroiliac Sacroiliac
r ar lumber hip, joint, hip, joint, hip,
junction,groin junction,groin spine, posteriorlater lateral posterioleter
, proximal , proximal anterior al thigh, thigh and al thigh, and
part of thigh part of thigh aspects of anterior leg lateral leg posterioleter
proximal al leg to heel
thigh
PARESTHESI Oblique band Oblique band Oblique Mesial to shin Lateral Posterior
A/ SENSORY proximal 3rd mid 3rd thigh band of tibia, leg, aspect of
LOSS of thigh anteriorly lower part medial dorsum of thigh, back
anteriorly just of thigh aspects of the foot , 1st of calf ,
below anteriorly foot web space lateral side
inguinal leg just above and sole of
the knee foot
REFLEXES Knee jerk Knee jerk Knee jerk Changes Ankle jerk
slightly slightly diminished or uncommo absent or
diminished diminishe absent n diminished
d (posterior
tibial
reflex
diminishe
d or
absent
STAGE OF STAGE OF STAGE OF STAGE OF
DEGENERATIVE DISFUNCTION INSTABILITY STABILIZATION
DISEASE OF DISC
SYMPTOMS Low back pain often Catch in back on Low back pain
localized or referred to movement decrease in severity
groin / greater Pain on coming to
trochanter/ posterior standing position after
thigh flexion
Aggravated on
movement
Relieved on rest
SIGNS Local tenderness on Abnormal movement of Muscle tenderness –
one side & at one level, spine, Observation of Stiffness, Reduced
Hypo mobility, catch Sway or shift when movements , Scoliosis
Extension painful, coming erect after flexion.
Neurological
examination normal
DIAGNOSTIC EVALUATION:
History collection physical examination: ATTITUDE: The lumbar spine is flattened and slightly flexed,
hip and knee slightly flexed on the affected side and hip rotates forward to relax Piriformis
GAIT Slow and deliberate walk holding their loins with the hands.
TIP-TOE WALK due to not able to put the heel to the floor.
SIATIC SCOLIOSIS -Deviation of spine to one side to take the nerve away from the prolapsed disc is
called SCIATIC SCOLIOSIS which becomes more obvious on bending forwards. ,Trunk deviated to
opposite side – SHOULDER TYPE (lateral) , Trunk deviated to same side – AXILLARY TYPE (medial)
CLINICAL EXAMINATION • SLRT– positive < 40 degree. • Cross SLRT – May or may not +ve.
LASEGUE SIGN
BOWSTRING TEST
FEMORAL NERVE STRETCH TEST
FLIP TEST NEGATIVE POSITIVE
DIFFERENTIAL DIAGNOSIS INTRASPINAL CAUSES Proximal to disc: Conus and Cauda equine
lesions (eg. Neurofibroma, ependymoma) Disc level • Herniated nucleus pulposus • Stenosis (Canal or
recess) • Infection: Osteomyelitis or discitis ( with nerve root pressure) • Inflammation: Arachnoiditis •
Neoplasm: Benign or malignant with nerve root pressure
EXTRASPINAL CAUSES Pelvis • Gynaecological conditions • Orthopaedic conditions ( osteoarthritis of
hip, Muscle related disease, Facet joint arthropathy) • Sacroiliac joint disease • Neoplasm Peripheral nerve
lesions • Neuropathy (Diabetic, tumour, alcohol) • Local sciatic nerve conditions (Trauma, tumour) •
Inflammation (herpes zoster)
Contralateral pain with side bending Pain reproduced with sustained muscle contraction against resistance
Pain increases on prolonged muscle use Pain localised to affected muscle Flexion relieves symptoms
myogenic or muscle related Back and/or leg pain develops after walks a limited distance. Spinal stenosis
X-ray : • Narrowing of disc space • Osteophytes formation along the peripheries of the adjacent vertebral
bodies • Sclerosis or condensation of subchondral bone of the adjacent vertebral bodies above and below
the affected disc • Loss of lumbar lordosis • Translation of vertebral bodies.
CT scan: • ADVANTAGES • highly accurate & noninvasive tool. • superior imaging of cortical and
trabecular bone. • identify root compressive lesions such as disc herniation. • differentiate between bony
osteophyte from soft disc. • to diagnose foraminal encroachment of disc material
LIMITATION OF CT SCAN • It cannot differentiate between scar tissue and new disc herniation • It does
not have sufficient soft tissue resolution to allow differentiation between annulus and nucleus.
MRI: It allows direct visualization of herniated disc material and its relationship to neural tissue including
intrathecal contents
Myelogram:
Diskogram
Electromyogram (EMG): an electrogram test looks at the function of the nerve roots leaving the spine. It
is done by inserting tiny electrodes into the muscle of lower extremity. on the basis of the electrical signals
in the muscles, it show if the muscle is being pinched or irritated as it leaves the spine.
MANAGEMENT:
Conservative : majority of disc prolapse respond well to conservative therapy. Resolution of first disc
prolapse takes place approximately 95% of patients over a period of 3 months.
Restricted activity for several days, limited total bed rest.
Local ice or heat
Physical therapy
Analgesics (eg. Tramadol)
Nonsteroidal anti-inflammatory drugs
Muscle relaxants(eg.cyclobenzaprine)
Antiseizure drugs(eg. Gabapentin)
Antidepressants ( eg.pregabalin)
Epidural corticosteroid injections
Surgical therapy: if conservative treatment is unsuccessful, radiculopathy becomes worse, or loss of
bowel or bladder control(cauda equine syndrome) occurs, surgery may be considered. Surgery for a
damaged disc is generally performed if the patient is in constant pain and /or has a persistent neurological
deficit.
Intradiscal electrothermoplasty( IDET): it is a minimally invasive outpatient procedure for treatment of
back and sciatic pain . a needle is inserted into the affected disc with X- RAY guidance.
A wire is then threaded through the needle and into the disc, as the wire is heated, small nerve fibers that
have invaded the degenerating disc are destroyed. The heat also partially melts the annulus fibroses. This
causes the body to generate new reinforcing proteins in the fibers of the annulus.
Radiofrequency discal nucleoplasty (coblation nucleoplasty): a needle is inserted into the disc similar to
IDET. Instead of a heated wire, a special radiofrequency probe is used. The probe generates energy that
breaks the molecular bonds of the gel in the nucleus pulposus. Up to 20% of the nucleus is removed
Surgical therapy Radiofrequency nucleoplasty. A needle is inserted into the days similar to IDET.
Instead of heater wire a special radio frequency probe is used. The core generate energy that breaks the
molecular Bond of the gel in the nucleus pulposus. Up to 20% of the nucleus is removed this decompresses
the disc and reduces pressure on the on the desk and surrounding nerve roots subsequent pain relief varies.
Inter spinous process decompression system (X stop): in this titanium device fits on to amount that is
placed on butterfly in the lower back the eggs stop is used in patience with pain due to lumbar spinal
stenosis. The device work by lifting work of the pinched nerve.
Laminectomy: it is common traditional surgical procedure for lumbar disc disease. It involves surgical
excision of part of the vertebra referred to as the lamina to access and remove the protruding disc.
Laminectomy is often performed as an outpatient procedure but a hospital stay of 1 to 3 days is not
uncommon.
Discectomy: it can be performed to decompress the nerve root. Microsurgical discectomy is a version of
the standard procedure the surgeon uses microscopy for better visualisation of the disc and disk space to
add in removal of the damaged portion this helps maintain bony stability of the spine.
Percutaneous discectomy: it is a safe and effective outpatient surgical procedure.a tube is passed through
the retroperitoneal soft tissues to the disc with the aid of fluoroscopy. a laser is then used on the damaged
portion of the disc. Minimal blood loss occurs because of assess through small stab wounds. The procedure
decreases rehabilitation time.
The goal of artificial deck replacement surgery are
To restore movement and eliminate pain. The charite disc is used in patients with lumbar disc damage
associated with DDD. This artificial disc has a high density core sandwiched between two Cobalt –
chromium endplates. After the damage is removed this device is surgically placed in the spine(usually
through a small incision below the umbilicus). The able stores women at the level of implant. The pro disc
-L is another type of artificial number used to treat DDD.
Option for treatment of DDD of the cervical spine include the prestige cervical disc,Mobi-C disc,and
Secure-C artificial cervical disc.
Spinal fusion may be needed if the spine is unstable the spine is stabilized by creating ankylosis (fusion )of
adjacent vertebrae with a bone graft from the patient's fibula or iliac crest(autograft) or from donated
cadaver bone ( allograft). Metal fixation with road plates for screw may also be placed at the time of spinal
surgery to provide more stability and decrease vertebral motion. Are posterior lumbar fusion may be
performed in patient to provide extra support for bone grafting or a prosthetic device.
Bone morphogenetic protein a genetically engineered protein maybe used to stimulate bone growth of the
graft in spinal fusions. A dissolvable sponge shocked with BMP is implanted into the spine. The protein on
the stimulates the body cells to become active and produce bone. BMP begins the process of fusion which
continues after the protein and sponge dissolve to leave living bone behind.
NURSING MANAGEMENT: VERTEBRAL DISC SURGERY
Intervertebral disc surgery post operative nursing intervention mainly focus on maintaining proper
alignment of the spine until it has healed. Depending on the type and extent of surgery and the
surgeon’s preference, the patient may be able to dangle the legs at the side of the bed, are even
ambulate the day of surgery.
After lambur fusion place pillow under the patient’s thighs when supine and between the when in
the side lying position to provide comfort and ensure alignment. The patient often fears turning or
any movement that may increase pain by stressing the surgical area. Reassure the present that
proper technique is used who made in body alignment. enough staff should be available to move
the patient without undue pain or strain for the patient or staff.
Post operative most patients require opioids Such as morphine IV for 24 to 48 hours. Patient
controlledcontrolled analgesia ( PCA) allows maintenance of optimal analgesic levels and is the
preferred method of continuous pain management. once the patient receives oral fluid, oral drugs
such as acetaminophen with codeine, hydrocodone,or oxycodone may be used. Diazepam may be
prescribed for muscle relaxation. Assess and document pain intensity and pain management
effectiveness.
Because the spinal canal may be entered during surgery, cerebrospinal fluid (CSF) leakage is
possible. Immediately report leakage of CSF on the dressing or if the patient complain of severe
headache CSF appears as clear or slightly yellow drainage on the dressing it has a high glucose
concentration and is positive for glucose when tested with a dipstick. Note the amount colour and
characteristics of drainage.
Frequently assess the patients peripheral neurology condition after spinal surgery moment of the
arm and leg and assessment of sensation should at least equal the preoperative status repeat this
assessment every 2 24 hours during the first 48 hours after surgery and compare with the
preoperative assessment paraesthesia may not be relieved immediately after surgery. report any
new muscle weakness for paraesthesia immediately to the surgeon and document this finding in the
patients medical record. Assess extremity circulation using skin temperature capillary refill and
pulses.
Paralytic ileus and interference with Bhavan function main occurs for several day and main
manifest as nausea abdominal distension and constipation. Opioids can also slow bowel
elimination if the patient is passing gas has bowel sounds in all quadrants and has a flat soft
abdomen stool softener( docusate )and laxatives prevent and relief constipation.
Emptying the bladder may be difficult due to two activity restriction points are anaesthesia.
Encourage men to dangle the legs over the side of the bed or stand to urinate if allowed by the
surgeon. Urge patient to use bedside commode or ambulate to the bathroom when allowed to
promote bladder emptying. ensure that privacy is maintained intermittent catheterization are an
enjoying and enjoying urinary catheter may be needed by patient who have difficulty urinating.
loss of Spencer tone on bladder tone may indicate nerve damage monitor for incontinence or
difficulty with bubble or bladder elimination and immediately report problems to the surgeon.
Nursing care appropriate for a present who had a laminectomy other nursing activities are
indicated if the patient has also had a spinal fusion because a bone graft is usually involved the post
operative healing time is prolonged compared with a laminectomy. Activity limitations may be
needed for an extended time. A rigid orthosis ( thoraciclumbar- sacral orthosis(TLSO) or chairback
brace ) is often used during this period. Some surgeons want patient to be taught to apply and
remove the brace by log rolling in bed. others allowed their patients to apply and the brace in a
sitting or standing position. verify the surgeony’s preferred method before starting this activity.
If surgery is done on the cervical spine, be alert for indication of spinal cord such as respiratory
distress or a worsening neurologic condition of the upper extremities. after surgery, the patient’s
neck maybe immobilized in a soft or hard cervical collar.
in addition to the primary surgical site regularly assess the bone graft donor site the fibula maybe
also be used the donor site usually causes greater pain than the spinal fusion area the donor site is
bandaged with a pressure dressing to prevent excessive bleeding if th donor site is the fibula
frequent neurovascular assessment of the extremity is a post operative nursing responsibility.
After spinal fusion the patient experience some immobility of the spine at the fusion site. instruct
the patient to use proper body mechanics and avoid sitting or standing for prolonged period.
encourage
activities that include walking, lying down and shifting weight from one foot to the other when
standing. instruct the patient on any lifting restrictions after spinal surgery. encourage the patient to
think through an activity before starting any potentially injurious task such as bending or stooping.
any twisting movement of the spine is contraindicated. teach the patient to use the thighs and knees
rather than the back to observe the shock of activity and movement. A firm mattress or bed board
is essential.
