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PROLAPSE LUMBAR DISC

- also known as slipped disc, spinal disc herniation, or prolapsus disci intervertebralis - a tear in the outer, fibrous ring of an intervertebral disc allows the soft, central portion to bulge out

PATHOPHYSIOLOGY
Risk Factors: 1. Men 2. Increasing Age 3. Obesity 4. Degenerative Disorders 5. Trauma 6. Congenital Predisposition

Rupture of Annulus Pulposus (discs outer ring)

PATHOPHYSIOLOGY
Protrusion of a portion of the Nucleus pulposus (soft, gelatinous inner part)

Pressure on spinal nerve roots

Signs and Symptoms

SIGNS AND SYMPTOMS

Varies with the location and degree of herniation and the course of its progression Some are asymptomatic

SIGNS AND SYMPTOMS

Back pain - In lumbar herniation, often radiating down the posterior thigh and leg, exacerbated by coughing, sneezing, and straining Motor and Sensory Impairment - Muscle weakness, diminished deep tendon reflexes in the lower extremities pin and needle prick sensation

SIGNS AND SYMPTOMS

Nerve Root Pain (Sciatica) - In lumbar disc herniation, pressure on the sciatic nerve produces severe, sometimes debilitating pain - Pain may also be felt on the lower extremities since the Sciatic nerve extends to the gluteal area, going down the posterior leg.

SIGNS AND SYMPTOMS

Cauda equina syndrome - Rare but a medical emergency where the nerves at the very bottom of the spinal cord are pressed on - Causes low back pain and disturbances in bowel and bladder function

DIAGNOSTIC STUDIES
Straight-leg raising test or the LeSegue test result is positive. CT, MRI, or Myelography may reveal the location of herniation.

NURSING MANAGEMENT
Administer prescribed medications. - May include muscle relaxants, narcotic or nonnarcotic analgesics

Provide on-going assessment. - Assess the site, nature, course, and progress of back pain - Monitor motor and sensory status

NURSING MANAGEMENT
Provide conservative management, if indicated. - Encourage bed rest - Position the patient with the head of bed elevated at 30 degrees and knees slightly flexed - Apply heat - Instruct in appropriate exercises to increase muscle strength around the spinal cord (e.g. Pelvic tilts, straight-leg raises)

NURSING MANAGEMENT
- Keep the patient in proper body alignment when in bed (provide firm mattress) and when turning (use log-rolling technique) - Teach proper body mechanics

NURSING MANAGEMENT
Maximize functional abilities. - Prevent complications of immobility - Coordinate with a physiotherapist, chiropractor, or osteopath for manipulation and other physical treatments - Promote self-care

NURSING MANAGEMENT
Provide preoperative and postoperative care if Discectomy is ordered Pre-operative Nursing Interventions: a.1. Avoid taking aspirin or aspirincontaining products for 2 weeks prior to surgery unless approved by physician a.2. Discontinue nonsteroidal antiinflammatory medications 48 to 72 hours before surgery

NURSING MANAGEMENT
Provide preoperative and postoperative care if Discectomy is ordered Pre-operative Nursing Interventions: a.3. Bring a list of current medications being taken a.4. Wear loose clothing that can easily be removed (e.g., avoid clothing that pulls on and off over the head)

NURSING MANAGEMENT
Provide preoperative and postoperative care if Discectomy is ordered Pre-operative Nursing Interventions: a.5. Instruct the patient to bathe/shower/shampoo the evening before or morning of surgery. Men should be cleanly shaved. a.6. Instruct the patient on oral intake

restrictions and medication schedule as ordered

NURSING MANAGEMENT
Provide preoperative and postoperative care if Discectomy is ordered Pre-operative Nursing Interventions: a.7. Inform patient that before going to the operating room he will have to remove: dentures, eye glasses, contact lenses, appliances, prosthesis, make-up, nail polish, hairpins, and undergarments

NURSING MANAGEMENT
Provide preoperative and postoperative care if Discectomy is ordered Post-operative Nursing Interventions: b.1. Monitor vital signs frequently b.2. Activity/diet restrictions b.3. Nursing personnel must assist with initial ambulation b.4. Medications available for pain and nausea upon request

SURGICAL MANAGEMENT
The primary focus of surgery is to remove pressure or reduce mechanical compression on a neural element: either the spinal cord, or a nerve root.

SURGICAL MANAGEMENT
Foraminotomy An incision is made in the back, the muscle peeled away to reveal the bone underneath, and a small hole cut into the vertebra itself. Through this hole, using an arthroscope, the foramen can be visualized, and the impinging bone or disk material removed.

SURGICAL MANAGEMENT
Discectomy This is the surgical removal of herniated disc material that presses on a nerve root or the spinal cord. The procedure involves removing the central portion of an intervertebral disc, the nucleus pulposus, which causes pain by stressing the spinal cord or radiating nerves.

THE CASE
Patients Initials: AAAA Age: 49 years old Nationality: Indian Consultant Surgeon: Dr. Khalid Saeed Date of Admission: 8/6/2011 Diagnosis: Prolapsed Lumbar Disc L4-5 Right

THE CASE
A 49 years old, Indian male was admitted in the MDH Surgical Ward with a 3-month history of hip pain radiating to the feet, occurring alternately without numbness, paresthesia or motor power disturbance. He sought conservative treatment in the past but was unrelieved. Non smoker, claims no allergies to food and medications, and with no previously related medical history.

THE CASE
Vital signs upon admission: Temp: 36.8C per orem Pulse: 86 beats/min RR: 22 breaths/min SPO2: 100 % Bp: 110/70 mmHg

General Appearance: - Appears thin and not in distress, ambulatory

THE CASE
Physical Examination: Head: No significant findings Chest: Clear breath sounds Heart: no murmur noted (S1 + S2 + 0) Abdomen: soft, non tender Extremeties: No significant findings Nervous system: GCS = 15, verbally responsive, conscious and coherent

THE CASE
Routine and Diagnostic Investigations: Hgb Serum Electrolytes BUN Hepatitis Profile BT RBS Serum Creatinine 14.2 within normal limits within normal limits no significant findings within normal limits within normal limits within normal limits

THE CASE
Routine and Diagnostic Investigations: Urinalysis PT and INR Chest X-ray ECG MRI within normal limits within normal limits no significant findings no significant findings Disc dehydration and minor posterior disc bulge and annular tear at L5/S1 but no significant foramen or canal narrowing

THE CASE
Course in the Surgical Ward: June 8, 2011 Patient was kept on bed rest. Normal diet was given. Vital signs were taken. All Pre-operative investigations were done. He was started on antibiotics and pain relievers and was posted for Discectomy on 9/6/2011.

THE CASE
Course in the Surgical Ward: June 9, 2011 Patient was shifted to Operating Theater at 0900H. At 1300H, patient was received from the recovery room, status post Fenestration and Discectomy L4-5 with Foraminotomy. He had IVF of DNS 500 cc to run for 6 hours, with Porto-Vac drain, and Foleys catheter connected to urobag.

THE CASE
Course in the Surgical Ward: June 9, 2011 He was placed on hard mattress, on complete bed rest. Vital signs, intake and output were monitored. On antibiotics of Cefizox 1 gm 1 vial IV BID, and Tavanic 500 mg 1 vial IV OD, with pain reliever Tramal 50 mg 1 amp IM BID, and Olfen 75 mg 1 amp IM BID. At 2100H, he was placed on liquid diet as tolerated.

THE CASE
Course in the Surgical Ward: June 10, 2011 (1st POD) Dressing was mildly soaked PVAC drained to 30 cc, blood stained FC 900 cc clear Vital Signs are stable, not in distress

THE CASE
Course in the Surgical Ward: June 11, 2011 (2nd POD) Started ambulation exercises Surgical dressing was changed, Wound appears clean FC was removed PVAC drained to 7 cc, serous Vital Signs are stable, not in distress Started with normal diet and oral medicines

THE CASE
Course in the Surgical Ward: June 12, 2011 (3rd POD) Ambulation was well-tolerated (+) non productive cough noted Surgical dressing was changed, Wound appears dry and clean PVAC drained to 10 cc, serous Vital Signs are stable, not in distress

THE CASE
Course in the Surgical Ward: June 13,2011 (4th POD) Vital Signs are stable, not in distress PVAC was removed June 14, 2011 (5th POD) Vital Signs are stable, not in distress Defecated

THE CASE
Course in the Surgical Ward: June 15, 2011 (6th POD) No pain as verbalized Ambulated Wound is clean and dry For discharge

THE CASE
Discharge Orders: Celebrex 1 tab BID for 15 days Sirdalud 2 mg 1 tab BID for 15 days Dorofen cap 1 tab TID for 30 days Osteocare 1 tab BID for 30 days Tavanic 500mg 1 tab OD for 5 days Sickleave for 6 weeks Follow up after 1 week

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