Republic of the Philippines

University of Northern Philippines

Tamag, Vigan City, Ilocos Sur

College of Nursing

A CASE STUDY ON

MILD COMPRESSION DEFORMITY L1

In Partial Fulfillment of

the Requirements for the Course

NCM 103 (Care of Clients with problems in Oxygenation,

Fluids and Electrolyte Balance, Nutrition and

Metabolism and Endocrine)

Presented to:

Cecilia B. Anicoche, RN, MAN

Clinical Instructor

Presented by:

Jermaine Maria R. Unciano

BSN III – B Student

I. INTRODUCTION

I chose this case because it is a common disorder which can cause morbidity and

mortality to patients. Moreover, it will provide answers to define ways to prevent, treat

and manage the illness.

It is my goal to identify risk factors that can affect people in making them at risk

for the illness. Also to identify how it is being treated. And by gathering knowledge

through the information I gathered from the patient.

Midline back pain is the hallmark symptom of lumbar compression fractures. The

pain is axial, nonradiating, aching, or stabbing in quality and may be severe and

disabling. The location of the pain corresponds to the fracture site, as seen on

radiographs. In elderly patients with severe osteroporosis, however, there may be no pain

at all as the fracture occurs spontaneously.

Young adults may present with severe back pain following an accident, such as a

fall or a motor vehicle accident. Lower extremity weakness or numbness are important

symptoms of neurologic injury from the fracture.

Vertebral fractures may also cause referred pain. Gibson, et al presented a study of

350 patient encounters in 288 patients with one or more compression fractures without

conus medullaris compromise or spinal nerve compression. They found that nonmidline

pain was present in 240 of the 350 encounters. The pain was typically in the ribs, hip,

groin, or buttocks. Treatment of the fracture with vertebroplasty resulted in 83% of those

patients gaining pain relief. Acute radiculopathy can also be experienced after lumbar

compression fractures; the incidence rises with descending spinal levels.

Alternatively, many compression fractures are painless. Osteoporosis is a silently

progressive disease. Osteoporotic compression fractures are often diagnosed when an

elderly patient presents with symptoms such as progressive scoliosis or mechanical lower

back pain and the physician obtains routine lumbar radiographs.

Finally, patients may present with a known (or unknown) malignancy. Routine

spinal screening via magnetic resonance imaging (MRI: if focal or referred pain occurs),
 or via bone scan (as a survey if pain has not occurred) reveals the pathologic fracture. The

most common malignancies leading to spinal involvement in the form of fractures are

metastasis and multiple myeloma. Often, the compression fracture is the presenting

manifestation that leads to the diagnosis of malignancy. However, patients may also have

unexplained fevers, night sweats, past history of malignancy, or weight loss.

II. OBJECTIVES

A. General Objectives:

The general objective is to develop essential as well as nursing care which is

based on the better and effective approach that will serve a catalyst to promote health,

reduce illness and completely eliminate such disease. It is also up to knowing the

nature of the disease and on how to manage it in such a way that it would be

therapeutic to both client and student nurse.

B. Specific Objectives:

Student Nurse-Centered Objectives

 Perform a comprehensive assessment regarding Mild Compression Deformity L1

 Enumerate the different signs and symptoms of Mild Compression Deformity L1

 List down the different diagnostic procedures that would help in the diagnosis of

Mild Compression Deformity L1

 Identify and understand different types of medical treatment necessary for the

treatment of Mild Compression Deformity L1

 Formulate Nursing Care Plans using the Nursing Process

 Familiarize ourselves with effective interactive skills to emphasize health

promotion and illness prevention

 Patient and Family-Centered Objectives

 Identify measures that could minimize the risk of occurrence of the illness

 Identify possible risk factors that may have contributed to the occurrence of Mild

Compression Deformity L1

 Increase knowledge on the risk factors and causes of Mild Compression

Deformity L1

III. PATIENT’S PROFILE

A. Biographic Profile

Name: Christopher C. Palacay

Age: 20

Sex: Male

Address: Darao, San Juan, Ilocos Sur

Date of Birth: February 28, 1997

Place of Birth: San Juan, Ilocos Sur

Civil Status: Single

Religion: Roman Catholic

Nationality: Filipino

Occupation: Footwear Dealer

Weight: 70 kgs

B. Family Profile
 Family Type: Nuclear Family

Parents:

Father’s Name: Policarpio Palacay

Mother’s Name: Maria Palacay

C. Medical Profile

Date of Admission: October 1, 2017

Time of Admission: 1:00 PM

Institution: Ilocos Sur Provincial Hospital – Gabriela Silang

Chief Complaint: pain on both lower extremities and inability to stand

Admission Diagnosis: T/C Guillian Barre Syndrome

Final Diagnosis: Mild Compression Deformity L1

Attending Physician: Dr. Guerrero

IV. NURSING HISTORY OF PAST AND PRESENT ILLNESS

A. History of Past Illness

According to Mr. Palacay he was never hospitalized since he was a child. He

also mentioned that before admission he experienced intermittent fever every

afternoon. Mr. Palacay also mentioned that neither of the families of both the mother

and father had history of hypertension, diabetes mellitus and/or cancer.

B. History of Present Illness

Before admission, patient complained of pain on both lower extremities and

inability to stand claimed by the himself. There were also no medications given to the

patient. Patient was rushed at Ilocos Sur Provincial Hostpital – Gabriela Silang seeks
 for Medical assistance because of both lower extremities and as well as intermittent

fever.

Prior to admission, patient was conscious and having pain on both lower

extremities and inability to stand. According to the patient he was not doing any

extraneous activities before his admission but he was supposed to go to work early in

the morning but can no longer move both lower extremities with the presence of pain.

C. Physical Assessment

Vital Signs:

 Blood Pressure: 110/90 mmHg

 Respiratory Rate: 24 cpm
 Pulse rate: 88 bpm
 Temperature: 36.4°C

General Appearance and Mental Status:

 Conscious, Immobile, Not Irritable

Head, Hair & Scalp:

 Head is symmetrical, in normal contour

 Hair is properly distributed, black in color.

 Facial features are symmetrical

Skin and Nails

 Skin is brown in color

 Nails are clean with good capillary refill time.

Eyes and Ears

 Pupils are equal, round and reactive to light.

 No blurry vision
  Normal hearing ability

 Clean ears with no purulent discharges

Mouth, Throat, and Sinuses

 Tongue is light pink

 Lips are a bit moist

 Throat is midline of the neck

 No problem in swallowing

 Sinuses are non- tender

Thorax and Lungs

Respiratory rate is 24 cpm with no difficulty of breathing

Heart

 Normal heart rate (88 bpm)

 Normal rhythm and pattern of heart rate.

Back

 Curved Posture

Abdomen

 No tenderness

Extremities

 Pain on both lower extremities and inability to stand

V. PEARSON ASSESSMENT

Hospital Date: Home Visit:

ASSESSMENT
October 3, 2017 October 21, 2017
 Patient Christopher Palacay is a
20 year old male residing in
Darao, San Juan, Ilocos Sur

 He was admitted last October 1,  Patient Christopher is

conscious, not irritable
2017 1:00 PM with a chief
 Responsive
PHYSIOLOGICAL complaint of pain on both lower
 Active
extremities and inability to stand
 Sitting position
 Ambulant
 Attending Physician: Dr.
Guerrero

 He was conscious, not irritable

 No IFC
 No diaper
 Patient didn’t void within the  NO IFC
shift.
 Voiding normally noted.
 The patient didn’t defecate
ELIMINATION  No vomiting noted.
within the shift
 No diaphoresis noted.
 No vomiting noted.
 No diaphoresis noted.
 No surgical drainage connected
to the patient.
Activities:
 Stands without
Activities: support
 Cannot stand  Sits without support
 Sits with support  Goes to work
ACTIVITY AND without pain and
Rest: difficulty of
REST
 With sleep disturbance due movement on both
to pain on both lower lower extremities
extremities. Rest:
 Takes a nap every afternoon.  Takes a nap every
afternoon
 Go to bed for rest
SAFETY AND  No known allergies to foods and  Goes to work at 8:00
SECURITY medications AM to 3:30 PM
 No side rails.  V/S:
  V/S: BP: 110/90 mmHg,
BP: 110/90 mmHg, RR: 26 cpm, PR: 84
RR: 24 cpm, PR: 88 bpm, Temp: bpm, Temp: 36.0 C via
36.3°C via axilla axilla
 Without difficulty of breathing  Without difficulty of
OXYGENATION  Without nasal canula breathing
 Good capillary refill
 Eats a lot of vegetables
 Diet as tolerated
NUTRITION and fruits
 Increase OFI
 Increase OFI
VI. DIAGNOSTIC PROCEDURES

A. Ideal Examination

 Spine X-Ray

- These may show bone growths called spurs that push against spinal

nerves. Also show an abnormal alignment of the spine.

 Magnetic Resonance Imaging

- Magnetic resonance imaging of spine will give a more detailed look at the

spinal cord and the structures surrounding it.

B. Actual Examination

 BUN AND CREATININE

Results:

TEST RESULT NORMAL INDICATION/SIGNIFICANCE

VALUE
Serum Na+ 133.0 135-145 Hyponatremia
Serum K+ 4.26 3.5-4.5 Within normal range
Serum Cl- 95.3 98-107 Hypocloremia

Impression:

- Slight Hyponatremia

- Slight Hypocloremia

Nursing Responsibilities:
 Test Result Normal Value Indication/Significance
White blood High white blood cell count indicates the
H 16.2 4.0-10.0
Cell presence of infection in a person’s body
Granulocyte H 14.2 2.0-7.0 Presence of infection
Lymphocyte
L 9.4% 20.0-40.0 Presence of infection
percentage
Mid size cell
L 2.9% 3.0-9.0 Presence of infection
Percentage
Granulocyte
H 87.7 50.0-70.0 Presence of infection
Percentage
Red Blood
H 6.09 4.00-5.50 Presence of infection
Cell
Mean
Corpuscular
L 69.5 82.0-95.0 Presence of infection
(erythrocyte)
Volume
Mean
Corpuscular
L 23.0 27.0-31.0 Presence of infection
(erythrocyte)
Hemoglobin
Platelet H 331 110-300 Presence of infection

Nurses may need to ensure appropriate collection of samples, must be

precise in sample identification and reduce the anxiety of patients especially if

fear of needles is present.

 Complete Blood Count

Results:

Impression:

- Presence of infection because of low WBC Levels

Nursing Responsibilities:

Nurses may need to ensure appropriate collection of samples, must be

precise in sample identification and reduce the anxiety of patients especially if

fear of needles is present.

VII. ANATOMY AND PHYSIOLOGY

Anatomy and Physiology of the Spine

Human Spine

All of the elements of the spinal column and vertebrae serve the purpose of protecting the

spinal cord, which provides communication to the brain and mobility and sensation in the body

through the complex interaction of bones, ligaments and muscle structures of the back and the

nerves that surround it. The normal adult spine is balanced over the pelvis, requiring minimal

workload on the muscles to maintain an upright posture.

Humans are born with 33 separate vertebrae. By adulthood, we typically have 24 due to

the fusion of the vertebrae in the sacrum. The top 7 vertebrae that form the neck are called the

cervical spine and are labeled C1-C7. The seven vertebrae of the cervical spine are responsible
for the normal function and mobility of the neck. They also protect the spinal cord, nerves and

arteries that extend from the brain to the rest of the body. The upper back, or thoracic spine, has

12 vertebrae, labeled T1-T12.The lower back, or lumbar spine, has 5 vertebrae, labeled L1-L5.

The lumbar spine bears the most weight relative to other regions of the spine, which makes it a

common source of back pain. The sacrum (S1) and coccyx (tailbone) are made up of 9 vertebrae

that are fused together to form a solid, bony unit.

Vertebrae

The vertebrae support the majority of the weight imposed on the spine. The body of each

vertebra is attached to a bony ring consisting of several parts. A bony projection on either side of

the vertebral body called the pedicle supports the arch that protects the spinal canal. The laminae

are the parts of the vertebrae that form the back of the bony arch that surrounds and covers the

spinal canal. There is a transverse process on either side of the arch where some of the muscles

of the spinal column attach to the vertebrae. The spinous process is the bony portion of the

vertebral body that can be felt as a series of bumps in the center of a person’s neck and back.

Intervertebral Disc

Between the spinal vertebrae are discs, which function as shock absorbers and joints.

They are designed to absorb the stresses carried by the spine while allowing the vertebral bodies

to move with respect to each other. Each disc consists of a strong outer ring of fibers called the

annulus fibrosis, and a soft center called the nucleus pulposus. The outer layer (annulus) helps

keep the disc’s inner core (nucleus) intact. The annulus is made up of very strong fibers that

connect each vertebra together. The nucleus of the disc has a very high water content, which

helps maintain its flexibility and shock-absorbing properties.

Facet Joint

The facet joints connect the bony arches of each of the vertebral bodies. There are two

facet joints between each pair of vertebrae, one on each side. Facet joints connect each vertebra

with those directly above and below it, and are designed to allow the vertebral bodies to rotate

with respect to each other.

Neural Foramen

The neural foramen is the opening through which the nerve roots exit the spine and travel

to the rest of the body. There are two neural foramen located between each pair of vertebrae, one

on each side. The foramen creates a protective passageway for the nerves that carry signals

between the spinal cord and the rest of the body.

Spinal Cord and Nerves

The spinal cord extends from the base of the brain to the area between the bottom of the

first lumbar vertebra and the top of the second lumbar vertebra. The spinal cord ends by

diverging into individual nerves that travel out to the lower body and the legs. Because of its

appearance, this group of nerves is called the cauda equina – the Latin name for “horse’s tail.”

The nerve groups travel through the spinal canal for a short distance before they exit the neural

foramen.

The spinal cord is covered by a protective membrane called the dura mater, which forms

a watertight sac around the spinal cord and nerves. Inside this sac is spinal fluid, which surrounds

the spinal cord.

The nerves in each area of the spinal cord are connected to specific parts of the body.

Those in the cervical spine, for example, extend to the upper chest and arms; those in the lumbar

spine the hips, buttocks and legs. The nerves also carry electrical signals back to the brain,

creating sensations. Damage to the nerves, nerve roots or spinal cord may result in symptoms

such as pain, tingling, numbness and weakness, both in and around the damaged area and in the

extremities.
VIII. PATHOPHYSIOLOGY

A. Algorithm

Predisposing Factors Precipitating Factors

 Age  Diet
 Sex  Lifestyle
 Nature of work
 stress

Pressure on spine

Compression of the spinal cord

Disruption of overstretching of the

neural tissue

Spasms

Loss of motor or sensory action

 B. Explanation

Regarding my patient, he is a teen at the age of 20 and all he does it to deliver

slippers to various places from 8:00 in the morning until 4:00 in the afternoon. Due to

heavy lifting of slippers in huge packages and frequent bending it contributed in

increasing pressure in the lumbar area of the spine which disrupted in the overstretching

of the neural tissues which causes spasms and the patient complained pain in the affected

area which resulted to loss of motor action of the patient.

IX. MANAGEMENT

A. Medical Management

Ideal Management

1. Non-steroidal Anti-Inflammatory Drugs (NSAIDs) that relieve pain and swelling, and

steroid injections that reduce swelling

2. Muscle relaxant used to treat spasms and sensitive reflexes

Actual Management

 Omeprazole

 Gabapentin

 Eperisone
 B. Surgical Management

Ideal Management

1. Back bracing provides external support to limit the motion of fractured vertebrae

2. Vertebroplasty is effective for relieving pain from spinal compression fractures and helping

to stabilize the fracture

3. Kyphoplasty helps correct the bone deformity and relieves the pain associated with spinal

compression fractures

Actual Management

 No surgical management was done to the patient

C. NCP
D. Promotive and Preventive

 Primary Prevention

o Natural ways to prevent spinal compression fractures include

taking calcium supplements, getting more vitamin D, quitting smoking,

preventing falls, and doing weight-bearing and strength-building exercises.

 Secondary Prevention

o In patients with an established osteoporotic fracture, it is important

to control pain and encourage early gait so that muscle exercise and stability

of the fracture can be attained. Patients with acute lower back pain should be

confined to bed for 2 to 3 days and accompanied by the use of analgesics,

hot packs, massage, and lumbar orthosis. For the treatment of chronic pain,

the back muscles should be strengthened with weight-bearing activities

including exercising and walking. Shoes or heels should be supported by a

soft, elastic pad to prevent sliding. In addition, swimming and bicycling will

help improve muscle strength and balance, which will help to reduce the

occurrence of a fall injury. The use of a walking assistance device or

orthosis can also help prevent patients with osteoporosis from sustaining a

fall injury. Finally, patients with osteoporotic fractures may feel lethargy,

anxiety, or depression due to the limitations in their daily lives and the

alterations in their physical appearance. Therefore, the emotional support of

family members is also essential for treating osteoporotic fractures.

 Promote Healthy Lifestyle; Instruct patient to:

 o Put skid-proof mats under area rugs to prevent slipping, make sure

floors are free of clutter, use a non-skid rubber mat in the shower, and make

sure your home is well-lit

o Stop smoking it's contributing to the weakening of her bones and

increasing her fracture risk.

o Increase calcium and vitamin D in diet. These nutrients

work together to maintain and build healthy bones. And even if you already

have osteoporosis, it's still helpful to boost your intake of calcium and

vitamin D. The typical recommendation is 1500 mg of calcium and 800

units of Vitamin D daily.

X. DRUG STUDY
XI. DISCHARGE PLAN

MEDICATION He is going to maintain taking his medications

like his muscle relaxant
EXERCISE Upon discharge of the patient,he should be in a
safe environment. It’s significant others is advised
to lower the patient’s risk for further occurrence of
illness
TREAMENT Patient is continuing medications as ordered by
the physician.
HEALTH TEACHINGS The patient is advised with general health
teachings like:
- Minimize bending and
lifting heavy objects
- Observe proper body
mechanics upon lifting
objects
OUT PATIENT The patient should attend his follow-up checkup
in order for the physician to see the progress of the
patient and to advise what to do.
DIET A high calcium diet can increase the strength of
bones
SAFE AND SECURITY Encouraged relatives to stay strong, not to lose
SPIRITUAL hope, seek the help of God to guide their family
and enough courage to face the problem.
XII. UPDATES

"Spinal cord compression is a debilitating condition that many patients with advanced

cancer experience. Until now, patients often had to spend multiple days traveling back and

forth to undergo radiation treatments. This study means that without compromising care,

we can help patients have more time to focus on the things they enjoy instead of on the

cancer," said Joshua A. Jones, MD, MA, ASCO Expert.

A common complication in people with metastatic cancer, spinal cord compression is a

major detriment to quality of life. Radiation treatment is widely used to relieve pain and other

symptoms, but there is no standard recommended schedule, and approaches currently vary.

Findings from a phase III clinical trial show that a single radiation treatment is as effective as a

full week of radiation.

The study will be featured at the 2017 American Society of Clinical Oncology (ASCO) Annual

Meeting.

"Our findings establish single-dose radiotherapy as the standard of care for metastatic

spinal canal compression, at least for patients with a short life expectancy," said lead study

author Peter Hoskin, MD, FCRP, FRCR, an oncologist at the Mount Vernon Cancer Centre in

Middlesex, United Kingdom. "For patients, this means fewer hospital visits and more time with

family."

When cancer spreads to the bones, it most commonly affects the spine. Tumors in the

spine can put pressure on the spinal canal, causing back pain, numbness, tingling, and difficulty
walking. Many patients with advanced solid tumors develop bone metastases, and up to 10% of

all patients with cancer will have metastatic spinal cord compression.

About the Study

The study enrolled 688 patients with metastatic prostate (44%), lung (18%), breast (11%),

and gastrointestinal cancers (11%). The median age was 70 years, and 73% were male. The

researchers randomly assigned patients to receive external beam spinal canal radiation therapy

either as a single dose of 8 Gy or as 20 Gy split in five doses over five days. The primary

endpoint of the study was ambulatory status, measured on a four-point scale:

 Grade 1: Able to walk normally

 Grade 2: Able to walk with walking aid (such as cane or walker)

 Grade 3: Has difficulty walking even with walking aids

 Grade 4: Dependent on wheelchair

At study entry, 66% of patients had ambulatory status 1 to 2.

Key Findings

At eight weeks, 69.5% of patients who received single-dose radiation therapy and 73.3%

of those who received five doses had ambulatory status 1 to 2, showing that both shorter- and

longer-course radiation treatments helped patients stay mobile. The median overall survival was

similar in the two groups -- 12.4 weeks with single dose vs. 13.7 weeks with five doses (the

difference was not statistically significant). The proportion of patients with severe side effects

was similar in the two groups (20.6% vs. 20.4%), but mild side effects were less common in the

single-dose group (51% vs. 56.9%). Prof. Hoskin emphasized that early recognition and prompt

treatment of spinal cord compression symptoms are critical to achieve best results with radiation

therapy.
Study Limitations and Next Steps

"Longer radiation may be more effective for preventing regrowth of metastases in the

spine than single-dose radiation. Therefore, a longer course of radiation may still be better for

patients with a longer life expectancy, but we need more research to confirm this," said Prof.

Hoskin.

Patients with metastatic breast cancer were under-represented in this clinical trial, as were

younger patients. For certain patients with spinal cord compression, surgery instead of or in

addition to radiation therapy may be recommended.

This study was funded by Cancer Research UK.

XIII. BIBLIOGRAPHY

1. Andrew L Sherman, MD, MS (August 4, 2017) Lumbar Compression Fracture

Clinical Presentation: History, Physical, Causes Lumbar Compression
Fracture Clinical Presentation Retrieved October 27, 2017
https://emedicine.medscape.com/article/309615-clinical

2. Grant Cooper, MD (May 24, 2017) TitleNonoperative Treatment of Osteoporotic

Compression Fractures: Overview of Osteoporotic Compression Fractures, Treatment
Assessment, Nonoperative Therapies Nonoperative Treatment of Osteoporotic
Compression Fractures Overview of Osteoporotic Compression Fractures Retrieved
October 27, 2017 https://emedicine.medscape.com/article/325872-overview

3. Andrew L Sherman, MD, MS (August 7, 2017) Practice Essentials, Pathophysiology,

Epidemiology Lumbar Compression Fracture Retrieved October 27, 2017
https://emedicine.medscape.com/article/309615-overview

4. NeuroSpine Institute (2017) Pioneers in Minimally Invasive Spine Surgery Spine

Anatomy & Physiology NeuroSpine Institute Retrieved October 29, 2017
http://neurospineinstitute.org/spinal-procedures/spine-anatomy-physiology/
5. George M Ghobrial, MD (July 19, 2017) Practice Essentials, Background,
Epidemiology Vertebral Fracture Retrieved October 29, 2017
https://emedicine.medscape.com/article/248236-overview

6. Isador H. Lieberman, MD, MBA, FRCSC (November 23rd, 2009) SpineUniverse

Preventing Recurring Osteoporosis Fractures Retrieved October 31, 2017
https://www.spineuniverse.com/blogs/lieberman/preventing-recurring-osteoporosis-
fractures

7. Park YS, Kim HS (June 2014) Asian Spine Journal Prevention and Treatment of
Multiple Osteoporotic Compression Fracture Retrieved October 31, 2017
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4068861/