Spinal Cord Anatomyspinal cord anatomy

Spinal Cord Anatomy

Pathophysiology/Etiology

Function of disc is to allow for mobility of the spine and act as shock absorber

Pathophysiology/Etiology

Located between vertebral bodies

Composed of nucleus pulposus a gelatinous material surrounded by annulus fibrosis- a fibrous coil

Pathophysiology/Etiology

Spinal nerves come out between vertebra

Herniated DiscHerniated nucleus pulposus, slipped disc,

ruptured discHNP- annulus becomes weakened/torn and the

nucleus pulpsus herniates through it.Risk Factors-Standing erect- cumulative effect and daily stressAging changes in disc and ligaments,

osteoarthritisPoor body mechanicsOverweightTrauma

Common Manifestations/Complications

HNP compressesSpinal nerve (sensory or

motor component) as it leaves the spinal cord

Or the cord itself- the white tracts within the cord- rare

Common Manifestations/ComplicationsSensory root or nerve of the spinal nerve is

usually affected resulting in sensory symptoms- pain, parenthesis, or loss of sensation

Motor root or nerve may be affected which results in motor symptoms- paresis or paralysis

Manifestations depend on what nerve root, spinal nerve is being compressed– which dermatomes

Radiculopathy- pathology of the nerve root

Common Manifestations/Complications Lumbar HNPMost common site for HNP is L4-5 disc- the

5th lumbar nerve root

Most common is the posterior sensory nerve or root compressed

Classic symptoms- low back sciatica pain. The pain increases with increase in intrathorasic pressure

herniated disc L4-L5

Other Symptoms Lumbar HNP:Postural changesUrinary/male sexual function changesParesis or paralysisFoot dropParesthesiasNumbnessMuscle spasmsAbsent cord reflexes

Common Manifestations/Complications Cervical HNPC5-C6 disc- affects the 6th cervical nerve

root

Pain- neck, shoulder, anterior upper arm to thumb

Absent/diminished reflexes to the armMotor changes- paresis or paralysisSensory- paresthesias or painMuscle spasms

Therapeutic Interventions- Diagnostic Tests

X-ray identify deformities and narrowing of disk space

CT/MRIMylogram p1336Nerve conduction

studies (EMG) to detect electrical activity of skeletal muscles

Treatment- ConservativeBed rest with firm mattress; log roll; side

lying position with knees bent and pillow between legs to support legs

Avoid flexion of the spine- brace/corset, cervical collar to provide support

Medications- nonnarcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodics and tranquilizers

Treatment- ConservativeHeat/cold therapy to decrease muscle

spasmsBreak the pain-spasm-pain cycleUltrasound, massage, relaxation techniquesProgressive mobilization with approved

exercise program –includes abdominal/thigh strengthening

Teaching good body mechanicsWeight lossTENS unit

Treatment- SurgeryLaminectomy- removal of a portion of the

lamina to relieve pressure and to get to the herniated nucleus pulposus that is protruding out

herniated disc repair

Treatment- SurgerySpinal fusion removes most of the disc and

replaces it with bone usually from the patient iliac crest

Flexibility is lost at the site- requires longer hospital stay

spinal fusion

Treatment- SurgeryForaminotomy

Enlargement of the bony overgrowth at the opening which is compressing the nerve

Microdiskectomy Use of electron microscope through a small

incision to remove a portion of the HNP that is displaced

If cervical HNP, usually use the anterior approach in the neck

Prevention of HNPBack school approach-

Causes of HNPLearn how to prevent Good body mechanicsExercises to strengthen leg and abdominal

muscles

Change in life-style or occupation

Nursing Assessment Specific to HNP Health HistoryAssess for risk factors- The cumulative effect of standing erect

and daily stress Aging changes in disc/ligaments Poor body mechanics OverweightTraumaEmployment History of pain and other neuro changes

Nursing Assessment Specific to HNP Physical Exam Use similar methods to assess as utilized

SCI

Muscle strength and coordinationSensation- sharp/dull of paperclip using

dermatome as referencePain evaluation- pain scalePre/Post-op assessment

Post-Op Assessment for HNP

Sensory/motor assessment- care not to injure op site

Assess for CSF drainage or bleeding from op site

Encourage turn (log roll, cough, deep breath)

Assess for postural hypotension, especially if client was on bed rest for several days/weeks prior to surgery

Post-op Assessment for HNPIf Anterior Cervical-

Assess injury to the carotid, esophagus, trachea, laryngeal nerve (speech- hoarseness)

Assess respiration, neck size, swallowing and speech

If Post-Op Lumbar- Assess bowels sounds, voiding. Minimize stress of post-op site- flat with pillow

between knees, log roll, etc

Nursing Problems/Interventions 1. Acute PainPost surgery the individual may have

similar pain as pre-op due to lack of resiliency of the spinal nerves to ‘bounce’ back quickly

Donor site (illiac crest) may cause more pain than laminectomy

Individual may be in a pain-spasm-pain cycle, therefore may need both antispasmodic as well as analgesic

2. Chronic PainSurgery may not relieve pain

Nonpharmalogical methods to control pain

Pain clinic

3. ConstipationAs a result of bed rest and decreased

mobility and fear of pain with straining of stool

Constipation prevention methods– fluids, diet, etc

4. Home CareWhen riding in a car, take frequent stops

to move and stretchPrevention– Back school approachMay have to deal with pain as a chronic

conditionMay need to make life/job changes

Spinal Cord Tumors Patho- Normal Cord & Cord Tumors

CNS is made up of neural tissue (neurons) and support tissue (glial)

These tissues undergo changes and result in spinal cord tumors

Blood vessels and bone (vertebra) also can be part of the tumor

Classification of Spinal Cord Tumors by Anatomical AreaIntramedullary- arise from neural

tissues of the spinal cord

Extramedullary- arise from tissues outside the spinal cord may be benign or malignantIntradural-from the nerve roots or meninges in

subarachnoid spaceExtradural- from the epidural tissue or

vertebra

Classification of Spinal Cord Tumors by OriginPrimary-

originating in the spinal cord or meninges that is not relieved by bed rest

Secondary- metastases from other parts of the body

Spinal Cord TumorsMost spinal cord

tumors are found in the thoracic region

Spinal cord tumors can compress (benign), invade the neural tissue, or cause ischemia to the area because of vascular obstruction

Common Manifestations/ComplicationsSymptoms depend on the anatomical level of

the spinal column, the anatomical location, the type of tumor and the spinal nerves affected

Pain that is not relieved by bed rest is the most common presenting symptom

Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor

Common Manifestations/ComplicationsManifestations of thoracic cord tumor

Paresis & spasticity of one leg then the otherPain back & chest, not relieved by bedrest Sensory changes Babinski reflexBowel (ileus); bladder dysfunction (UMN in

type)

Therapeutic Interventions

Diagnostic tests include:X-ray of the spinal columnMyelogramLumbar puncture with CSF analysis

Therapeutic InterventionsMedications spinal tumors

Control pain- narcotic analgesics, may be given epidural catheter, PCA, NSAID’s

Reduce cord edema and tumor size- steroids dexamethasome (Decadron) high dose for a few days, then taper off with a Medrol dose pack

Therapeutic InterventionsSurgery for spinal cord tumors

Laminectomy to remove or to decrease the size (decompression laminectomy) of the spinal cord tumor

Spinal fusion or the insertion of rods if several vertebra involved and the column is unstable

Radiation to reduce size and control pain

Nursing AssessmentHealth history

Pain, motor and sensory changes, bowel and bladder changes, Babinski reflex.

Physical examSimilar to physical assessment for HNP

Nursing Problems/Interventions1. Anxiety

Metatastic tumor vs benign spinal cord tumorEducation and support system

2. Risk for constipationFrom spinal cord compression, narcotics, bed

restAdjust fluid and diet

Nursing Problems/Interventions3. Impaired physical mobility

From bed rest and motor involvementBasic nursing- ROM, etc

4. Acute painFrom compression or invasion of tumorAssess and treat

5. Sexual dysfunctionMale sacral reflex ark (S 2,3,4) interferenceSimilar care as discussed with SCI

Nursing Problems/Interventions6. Urinary retention

Reflex arc (S2,3,4) interference can cause neurogenic bladder as discussed with SCI

7. Home careRehabilitationHome evaluationSupport groups

Nursing Care Plan: A Client with a Ruptured Intravertebral Disc

http://wps.prenhall.com/wps/media/objects/737/755395/intervertebral_disk.pdf

Added Critical thinking questions Nursing Care Plan: A Client with Ruptured Intervertebral Disc1. If Marees’ C6-C7 disk is herniated, where does the

dermatome for C7 spinal nerve supply?

2. Is Marees’ anterior or posterior nerve root being compressed by the herniation?

3. Why is Maree Ivans prescribed both analgesics and muscle relaxants around the clock when awake?

4. How does a cervical collar help? What else may help relieve the pain?

5. If the conservative methods did not work, what else might the physician have done?

6. Why are conservative methods tried for a period of time rather than immediate surgery?

7. Where is the posterior/anterior nerve root?8. Where is the lamina? 9. Would the Dr use the anterior or posterior surgical route to get to her disc?

LeMone Blackboard: Media Links

http://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.html

http://www.spine-health.com/