Disk Disruption

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Disk Disruption

• Anterior Diskectomy

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What is an Anterior Diskectomy?

• Anterior diskectomy is a surgical procedure that
  is performed to decompress the nerve root.
  Partial removal of the lamina to allow access to
  the intervertebral disk.

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Pathophysiology Chronic Low Back Pain

• Degenerative disk disease
• Lack of exercise
• Prior injury
• Structural and Postural abnormalities
• Systemic Disease
• Obesity

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Degeneration of the disk

• Degeneration of the disk causes the
  intervertebral narrowing and a lessening of the
  effectiveness of the disks in ceasing as shock
  absorbers.
• The tough fibrous outer covering of the disk is
  more likely to develop tiny tears as part of the
  degeneration, predisposing the patient to a
  herniated nucleus pulposus.

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MRI of herniated disk
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Clinical Manifestations

• Back pain the most common complain. It is
  described as sharp or throbbing.
• Pain can be from mild to severe, radiating down
  your leg.
• Damage in the middle or lower part of the back
  numbness, tingling or weakness in the buttocks,
  legs or feet.

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Other Symptoms

• Pain can radiate when you cough, sneeze or
  strain.
• Prolonged sitting or standing can trigger pain or
  get worse.
• Depending on the nerve root involved, reflexes
  may be absent or depressed.

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Diagnostic Studies

• MRI or CT, to localize the site of the
  herniation.
• X-Ray, to locate structural defects.
• Electromyogram (EMG) to look for signs of nerve
  damage caused by disk herniation.

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Physical Assessment

• Ambulation may be stiff, may have a limp.
• Inspect for swelling triggered by muscle spsam
  and alignment of the vertebral.
• Check for tenderness.
• Check for sensation, patient may have
  paresthesia.
• Loss of bladder or bowel control.
• Neurological assessment.

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Interventions/Non-Surgical Managment

• Proper alignment
• Exercise
• Anti-inflammatory analgesics
• Hot or Cold therapy
• Diet
• Alternative Therapy
• Percutaneous Laser Disk Decompression

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Proper Alignment and Exercise

• Semi-Fowlers position aka Williams position.
• Firm matress or back board.
• Isometric exercises most effective.
• Typical exercises for chronic low back pain.
  (Chart 43-3, p.928)

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Drug Therapy

• Tylenol-may help control discomfort.
• NSAIDS-Aspirin, Advil, Motrin.
• Muscle relaxants-Flexeril.
• Opioid analgesics and nonsteroidal anaglesics.
• Epidural injection

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Heat and Cold Therapy/Diet Therapy

• Moist heat for 20-30mins, 4xQD.
• Deep heat therapy.
• Ice therapy or ice packs 10-15mins q1-2hrs.
• Chronic pain can be lessened by controlling
  weight

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Alternative Therapy and Percutaneous Laser Disk
Decompression

• Imagery, magnetic field therapy, music.
• PLDD-local anesthetic and laser with a thin
  needle under fluoroscopy. Bed rest for 24 hours
  after procedure.

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Surgery

• Diskectomy-removing portion of disk
• Laminectomy-removing one or more vertebral
  laminae and herniated nucleus.
• Alternative Surgeries
• Percutaneous lumbar diskectomy
• Microdiskectomy
• Laparoscopic lumber diskectomy

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Surgery Cont

• The goal is to stop the herniated disk from
  pressing on and irritating the surrounding
  nerves.
• Anterior Diskectomy-incision made from the
  umbilicus to the mons pubis.
• Divided the subcutaneous tissue and behind the
  peritoneum and outside the peritoneal cavity.

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Surgery Cont

• Exposure of the anterior disk.
• Decortication of the vertebral end plates.
• The iliac vessel and the ureter were both
  protected to avoid iatrogenic injuries.
• Interbody lumbar fusion with synthes femoral ring
  allograft under fluroscopy.
• Estimated loss of blood.

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Diskectomy
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Nurse Management Care Postoperative

• Assess for complications in the first 24-48
  hours.
• Cerebrospinal fluid
• Fluid volume deficit
• Acute urinary retention
• Paralytic ileus
• Fat embolism
• Persisitent nerve root pain
• Infection

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Continued Care

• Pain control-PCA (Morphine)
• Inspect surgical dressing.
• Maintain proper alignment.
• Logrolling
• Deep breathing
• SCDs or PCBs
• Have sufficient staff available to move pt.

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Care Continued

• Frequent monitoring of peripheral signs of
  extremities.
• Assess sensation
• Any new muscle weakness or paresthesis.
• Assess for flatus, BS on all four Quads.

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Health Teaching

• Weight loss if needed with dietitian
• Stop smoking
• Use moist heat
• Perform strengthening exercises
• Proper body alignment by PT
• Take meds as directed
• Healing process may take up to 6-12mo.
• Identify support systems

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Preop Medications

• Dextrose 5 NACL 0.45 1000ml, 60ml/hr with
  Potassium Chloride 20mEq.
• Cefazolin Sodium Injection/1 Gm IV Q8hrs IVPB
  (Mix D5W 50ml infuse over 30mins)
• Lovenox 30MG0.3ml SC QD at 0900.
• Tylenol 6502 tabs PO Q4hrs, temp gt38.
• Ketorolac Injection 30MG1ml IV Q6 PRN

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Labs

• WBC-11.6 (5.0-10.0) Increase r/t surgery, trauma,
  stress, inflammation.
• RBC-2.82 (4.4-5.9) Decrease r/t surgery
• Hgb-8.7 (11-16) Elvated could be affecting value
  as well as decrease in RBC.
• Hct-25.6 (37-47) Same as Hgb.
• Lymophocyte-14.4 (24.4) Possible infection.
• Potassium- 3.4 (3.5-5) Trauma, surgery

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Questions/ 1. A diskectomy surgical procedure is
which of the following.

• A. A surgical excision of part of the posterior
  arch of the vertebra to gain access to part or
  all of the protruding disk to be removed.
• B. A surgical procedure using a tube that is
  passed through the retroperitoneal soft tissue to
  the lateral border of the disk.
• C. A surgical procedure to decompress the nerve
  root. Involving the partial removal of the lamina
  to allow access to the intervertebral disk.
• D. A mircrodiskectomy surgery through a 1-inch
  incision, removing small fragments and decreased
  tissue trauma.

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Question/The nurse assess a patient with a
herniated disk except which of the following.

• A.Walking on heels or toes often causes severe
  pain on affected leg or back.
• B. Sharp low back pain radiating to thigh or
  calf.
• C. Severe pain when raising a straight leg.
• D. May lose handgrip strength.

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References

• Lewis, S.M., and Heitkemper, M.M., and Dirksen,
  S.R., Medical Surgical Nursing Assessment and
  Management of Clinical Problems 5th ed, St.
  Louis Mosby, Inc., 1996, pg 1808-1810.
• Ignatavicius, D.D., and Workman, M.L., Medical
  Surgical Nursing Critical Thinking for
  Collaborative Care 4th ed, Philadelphia W.B.
  Saunders Company.

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Presentation by

• Rebecca Valverde
• Instructor Francisco Felix
• Lecture Mon and Thur