DEGENERATIVE DISC DISEASE

Low back pain is a significant public health disorder. Acute low back pain lasts for less than 3 months or longer. Most back pains are due to disc disease.

CLINICAL MANIFESTATION

Pain occurs in the involved part of the spinal cord.ie..Cervical, thoracic or lumbar. The clinical manifestations depends on the location, rate of development (acute or chronic)and the effect on the surrounding structures.

PATHOPHYSIOLOGY

1. The intervertebral disc is a cartilaginous plate that forms a cushion between the vertebral bodies. This tough fibrous material is incorporated in a capsule. A ball like cushion in the centre of the disc is called nucleus pulposus.
2. In herniation of the intervertebral disc (ruptured disk) the nucleus of the disc protrudes into the annulus (fibrous ring around the disk)with subsequent nerve compression.
3. Protrusion or rupture of the nucleus pulposus usually is preceded with degenerative changes that occur with aging.
4. Loss of protein polysaccharides in the disc decreases the water content of the nucleus pulposus.
5. Radiating cracks develops in the annulus weakens resistance to the nucleus herniation.
6. With the degeneration the capsule pushes back into the spinal canal.
7. This sequence produces pain due to radiculopathy(pressure in the area of disturbance of the involved nerve endings.

ASSESSMENT AND DIAGNOSTIC FINDINGS

• A Thorough health history and physical examination
• CT Scan and MRI
• Neurological examination
• Electromyelography

MEDICAL MANAGEMENT

Herniation of the cervical and lumbar disc occurs commonly and are managed with bed rest and medication

SURGICAL MANAGEMENT

Surgical management is usually done if there is progressive neurologic deficit, muscle weakness or atrophy, loss of sensory and motor function, loss of sphincter control and continuing pain or sciatica(leg pain resulting from sciatic nerve involvement)The goal is to reduce the pressure on the nerve root to prevent pain. The following surgeries are usually performed.

• Disectomy-Removal of the herniated or extruded fragments of the intervertebral disc.
• Laminectomy-Removal of the bone between the spinal process and the facet pedicle junction to expose the neural elements in the spinal canal, this allows the surgeon to inspect the spinal canal, identify and remove the pathological tissue, and relieve the compression of the spinal cord and the nerve roots.
• Hemilaminectomy-Removal of the part of the lamina and part of the posterior arch of the vertebra.
• Partial laminectomy or Laminotomy-Creation of a hole in the lamina of the vertebra.
• Dissectomy with Fusion-A bone graft(from the iliac crest or the bone bank)is used to fuse the vertebral spinous process.
• Foraminotomy-Removal of the intervertebral foramen to increase the space for exit of the spinal nerve, resulting in reduced pain, compression and edema.

HERNIATION OF THE CERVICAL INTERVERTEBRAL DISC

The cervical spine is subjected to stressors that result from disc degeneration(due to aging, occupational stress)and spondylosis(degenerative changes occurring in a disc and other supportive structures)Cervical disc degeneration can lead to lesions that can cause damage to the spinal cord and its roots cervical disc degeneration usually occurs at C5-C6 and C6-C7interspaces.

CLINICAL MANIFESTATIONS

• Pain and stiffness in the neck and the top of the shoulders and the region of the scapula.Sometimes the pain is interpreted as signs of heart problem and bursitis.
• Pain in the upper extremities and the head accompanied by parasthesia.(Tingling or a pins or needle sensation.Cervical MRI confirms the diagnosis.

MEDICAL MANAGEMENT

The goal of the medical management is to rest and immobilize the cervical spine to give the soft tissues time to heal. And to reduce the inflammation in the subcutaneous tissues and the affected nerve roots in the spinal cord.

• Bedrest is recommended and the patient s head should be supported.
• The cervical spine can be immobilized by a cervical collar,cervical traction and a brace.The collar increases the vertebral separation and thus relieves the pressure on the nerve roots.
• The head should be elevated and counter traction should be given.If the skin becomes irritated the halter can be padded.A male patient should be told not to shave because beard offers a natural form of padding.

PHARMACOLOGICAL THERAPY

• Analgesics,NSAID,propoxyphene(Darvon),Oxycodone(Tylox)orHydrocodone(Vicodin)is given to relieve the pain.
• Sedatives are administered to relieve anxiety associated with cervical disc disease.
• Muscle relaxants(Cyclobenzaprine,Methocarbamol,Metaxalone)
• Corticosteroids are prescribed to relieve inflammation.Hot moist compresses(for 10-20 minutes)is applied to the back of the neckseveral times daily to increase the blood flow.

SURGICAL MANAGEMENT

A cervical dissectomy with or without fusion is performed to relieve the symptoms.An anterior or a posterior approach may be used.Potential complications associated with anterior approach are carotid or vertebral artery injuryrecurrent laryngeal nerve irritation,esophageal perforation and airway obstruction. Complications of posterior approach are damage of the nerve root of the spinal cord due to retraction or contusion.Micro surgery ,such as endoscopic micro dissectomy is performed in certain patients with their magnifying effect.

NURSING PROCESS

THE PATIENT UNDERGOING CERVICAL DISSECTOMY

• Assessment-The patient is asked regarding the past injuries to the neck (whiplash) 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 the pain and assessing for parasthesias,limited movement ,and
  • diminished function of the neck,shoulders,and upper extremities.The patient should be educated about the surgical management. Strategies of pain management should be informed.
  
  
  

  NURSING DIAGNOSIS

  • Acute pain related to surgical procedure.
  • Impaired physical mobility related to post operative surgical regimen.
  • Deficient knowledge about the post operative course and home care management.
  Complications-Hematoma at a surgical site, resulting in cord compression and neurological deficit. Reccurent or persistent pain after the surgery.
  
  

  NURSING INTERVENTIONS

  Relieving pain and discomfort-

  • The patient must be kept flat in the bed for 12-24hours.
  • If the patient has pain monitor the donor site for hematoma formation, administering the prescribed analgesic agent, positioning the patient and reassuring the patient that the pain will be relieved. If the patient experiences a sudden pain extrusion of the graft may have occurred which requires reoperation. A sudden increase in the pain should be reported to the surgeon
  • The patient may experience sore throat, hoarseness and dysphagia due to temporary edema.This symptoms are relieved by throat lozenges, voice rest and humidification. A pureed diet can be given if the patient has dysphagia.
   
  

  Improving mobility

  • Postoperatively a cervical collar is worn resulting in limited neck movement. The patient is instructed to turn the body rather than the neck while turning from side to side. The patient s neck should be kept in neutral position.
  • The patient is assisted during position changes to make sure that the head, shoulders and thorax are kept aligned. While keeping the patient in sitting position the nurse supports the patient s neck and shoulders.
  
  

  Monitoring and managing potential complications

  • The patient is evaluated for bleeding and hematoma formation by assessing for excessive pressure in the neck or severe pain in the incision area. The dressing is checked for serosanguinous drainage, which suggests a dural leak. A complaint of headache requires careful evaluation.
  • Neurological checks are made for swallowing deficits and upper and lower extremity weakness because cord compression may produce rapid or delayed onset of paralysis.
  • The patient should be monitored thoroughly for signs of respiratory difficulty, because retractors used during the surgery may injure the laryngeal nerve resulting in hoarseness and inability to clear the cough effectively.
  • The blood pressure and pulse are monitored to evaluate the cardiovascular status.
  • Severe pain which is not relieved by anaesthesia should be reported to the physician. A change in the neurological status should be reported to the physician because hematoma formation can result in permanent sensory and motor deficits.
  • Promoting home and community based care.

  Teaching patients self care

  • The patient and the family members should be educated regarding the care.
  • If a cervical collar is worn care has to be given. Instruct the client to limit the body movements with tasks that require greater body movement.
  • The patient is instructed about the signs of complications and regarding pain management
  • The nurse should assist in activities of daily living.
  • A discharge teaching plan has to be maintained. Topics include proper body mechanics, maintenance of optimal body weight, proper exercise techniques and modification in activity. The patient is instructed to see the physician at regular intervals and to document for complications.
  
  

  EVALUATION AND EXPECTED PATIENT OUTCOMES

  • Reports decrease severity in the frequency of pain.
  • Is knowledgeable about the post operative complications, and home care management
  • Reports absence of complications.

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