Definition:

A herniated nucleus pulposus is a slipped disk along the spinal cord. The
condition occurs when all or part of the soft center of a spinal disk is forced through a
weakened part of the disk.

The bones (vertebrae) of the spinal column run down the back, connecting the
skull to the pelvis. These bones protect nerves that come out of the brain and travel down
the back and to the entire body. The spinal vertebrae are separated by disks filled with a
soft, gelatinous substance, which provide cushioning to the spinal column. These disks
may herniate (move out of place) or rupture from trauma or strain.

The spinal column is divided into several segments: the cervical spine (the neck),
the thoracic spine (the part of the back behind the chest), the lumbar spine (lower back),
and sacral spine (the part connected to the pelvis that does not move).

Radiculopathy refers to any disease affecting the spinal nerve roots. A herniated
disk is one cause of radiculopathy (sciatica).

Most herniation takes place in the lower back (lumbar area) of the spine. Lumbar
disk herniation occurs 15 times more often than cervical (neck) disk herniation, and it is
one of the most common causes of lower back pain. The cervical disks are affected 8% of
the time and the upper-to-mid-back (thoracic) disks only 1 - 2% of the time.

Nerve roots (large nerves that branch out from the spinal cord) may become
compressed, resulting in neurological symptoms, such as sensory or motor changes.

Disk herniation occurs more frequently in middle-aged and older men, especially
those involved in strenuous physical activity. Other risk factors include any congenital
conditions that affect the size of the lumbar spinal canal.

TYPE/STAGE/CLASSIFICATION

Person who has sustained one disc herniation is statistically at increased risk for
experiencing another. There is an approximate 5% rate of recurrent disc herniation at the
same level, and a lesser incidence of new disc herniation at another level. Factors
involved may be weight related level of physical conditioning, work or behavioral habits.
Since these factors are typically the same after surgery, there is an increased risk of
herniated disc in this group, over the general population. However, the good news is that
the majority of disc herniations (90%) do not require surgery, and will resolve with
conservative, nonoperative treatment, without significant long-term sequelae.
Unfortunately, approximately 5% of patients with herniated, degenerated discs will go on
to experience symptomatic or severe and incapacitating low back pain which
significantly affects their life activities and work. This unfortunate result is not always
specifically the result of surgery. The causes of this unremitting pain are not always clear
or agreed on, and my be from several sources. When this occurs, the prognosis is poor for
returning to normal life activities regardless of age. After a successful laminotomy and
discectomy, 80-85% of patients do extremely well and are able to return to their normal
job in approximately six weeks time. There may be small permanent patches of numbness
in the involved leg which, fortunately, are not disabling. Flare-ups or exacerbations of
less severe and less significant sciatic type pain may develop in the future (usually on an
infrequent basis)

Clinical Manifestations:

SYMPTOMS OF HERNIATED LUMBAR DISK

• Muscle spasm
• Muscle weakness or atrophy in later stages
• Pain radiating to the buttocks, legs, and feet
• Pain made worse with coughing, straining, or laughing
• Severe low back pain
• Tingling or numbness in legs or feet
•

SYMPTOMS OF HERNIATED CERVICAL DISK

• Arm muscle weakness

• Deep pain near or over the shoulder blades on the affected side
• Neck pain, especially in the back and sides
• Increased pain when bending the neck or turning head to the side
• Pain radiating to the shoulder, upper arm, forearm, and rarely the hand, fingers, or
chest
• Pain made worse with coughing, straining, or laughing
• Spasm of the neck muscles
Impaired Immobilty
AGNOSTIC TESTS

• EMG may be done to determine the exact nerve root that is involved.
• Nerve conduction velocity test may also be done.
• Myelogram may be done to determine the size and location of disk herniation.
• Spine MRI or spine CT will show spinal canal compression by the herniated disk.
• Spine x-ray may be done to rule out other causes of back or neck pain. However,
it is not possible to diagnosis herniated disk by spinal x-ray alone.
Surgical treatment

MANAGEMENT

The main treatment for a herniated disk is a short period of rest with pain
and anti-inflammatory medications, followed by physical therapy. Most people
who follow these treatments will recover and return to their normal activities. A
small number of people need to have further treatment, which may include
steroid injections or surgery.

MEDICATIONS

• Nonsteroidal anti-inflammatory medications (NSAIDs) and narcotic pain

killers will be given to people with a sudden herniated disk caused by
some sort of injury (such as a car accident or lifting a very heavy object)
that is immediately followed by severe pain in the back and leg.
• NSAIDs are used for long-term pain control, but narcotics may be given if
the pain does not respond to anti-inflammatory drugs.
• Muscle relaxants are usually given if the patient has back spasms. On rare
occasions, steroids may be given either by pill or directly into the blood
through an IV.
• Steroid injections into the back in the area of the herniated disk can help
control pain for several months. Such injections reduce swelling around
the disk and relieve many symptoms. Spinal injections are usually done on
an outpatient basis, using x-ray or fluoroscopy to identify the area where
the injection is needed.

SURGERY

• Diskectomy - removes a protruding disk. This procedure requires general

anesthesia (asleep and no pain) and 2 - 3 day hospital stay.
• Microdiskectomy - a procedure removing fragments of nucleated disk
through a very small opening.
• Chemonucleolysis - involves the injection of an enzyme (called
chymopapain) into the herniated disk to dissolve the protruding gelatinous
substance. This procedure may be an alternative to diskectomy in certain
situations.
Herniated disk repair

When the soft, gelatinous central portion of an intervertebral

disk is forced through a weakened part of a disk, it is a condition
known as a slipped disk. Most herniation takes place in the lumbar
area of the spine, and it is one of the most common causes of lower
back pain. The mainstay of treatment for herniated disks is an initial
period of rest with pain and anti-inflammatory medications followed
by physical therapy. If pain and symptoms persist, surgery to
remove the herniated portion of the intervertebral disk is
recommended.

Lumbar spinal surgery - series: Normal anatomy

The spine is made of bones (vertebrae) separated by soft

cushions (intervertebral discs).
Lumbar spinal surgery - series: Indications

Lumbar (lower back) spine disease is usually caused by

herniated intervertebral discs, abnormal growth of bony processes
on the vertebral bodies (osteophytes), which compress spinal
nerves, trauma, and narrowing (stenosis) of the spinal column
around the spinal cord.

Lumbar spinal surgery - series: Incision

The surgery is done while the patient is deep asleep and

pain-free (general anesthesia). An incision is made over the lower
back, in the midline.
Lumbar spinal surgery - series: Procedure

The bone that curves around and covers the spinal cord
(lamina) is removed (laminectomy) and the tissue that is causing
pressure on the nerve or spinal cord is removed. The hole through
which the nerve passes can be enlarged to prevent further pressure
on the nerve. Sometimes, a piece of bone (bone graft), interbody
cages, or pedicle screws may be used to strengthen the area of
surgery.

NURSING RESPONSIBILITIES

1. Reduce back stress, muscle spasm, and pain.

2. Promote optimal functioning.
3. Support patient/SO in rehabilitation process.
4. Provide information concerning condition/prognosis and treatment needs.
5. Discharge plan DRG projected mean length of inpatient stay: 4.9–6.5 days
considerations: May require assistance with transportation, self-care, and
homemaker/maintenance tasks Refer to section at end of plan for
postdischarge considerations.
Lumbar spinal surgery - series: Aftercare

Patients usually require physical therapy to optimize spinal

mobility after lumbar spine surgery. Results are variable depending
on the disease treated.

NURSING DIAGNOSIS

• Pain acute/chronic related to injuring agents, nerve compression, muscle

spasm
• Impaired physical mobility related to pain and discomfort
• Fatigue related to inability to maintain usual routines, compromised
concentration
• Ineffective coping related to situational crisis
• Knowledge deficit regarding condition, prognosis, and treatment related to
lack of knowledge
Herniated Nucleus Pulposus With Radiculopathy in an Adolescent

http://www.medscape.com/viewarticle/444338_2

Case Report

A 17-year-old white girl in excellent health, with no previous history of back pain,
presented with severe lower back pain almost immediately after lifting a heavy school
backpack. She heard a "pop" in the lumbosacral junction as she attempted to lift the
backpack. She described the severe pain that followed as aching and radiating into the
buttocks and both lateral thighs.

Examination showed intact motor and sensory findings, with no pain on range of motion
for either hip in extension. Reflexes at knees and ankles were 2+, without any obvious
pathologic reflexes about the ankles. Only back pain was present during straight leg
raising (70° on the right, 45° on the left). Evaluation with the patient standing showed no
evidence of scoliosis. Neither flank asymmetry nor hairy patches were noted. She had no
pain with side bending, though pain was present with rotation, particularly to the left.

Given these observations at this initial examination, the impression was that of a muscle
strain in her back. Ibuprofen (800 mg tid) was prescribed, but it caused a headache and
did not alleviate the back pain. Muscle relaxants were prescribed but had little or no
benefit.

Approximately 5 days after injury, the pain worsened and extended through the low back
and into the right leg around the lateral aspect of the right knee. On examination, straight
leg raising caused back pain, and dural stretching elicited some lateral right leg pain.
Sacroiliac joint maneuvers were negative. The pain in the right leg extended down the
posterolateral aspect of the thigh, with no radiation past the knee and no paresthesia
associated with the pain. The right leg appeared somewhat weaker than the left.
Examination of the lumbosacral spine region revealed that she had limitations due to
pain, particularly in flexion. Extension and lateral flexion to the right and left were not as
limited but were also painful. She was walking with a flexed hunched-over position in an
attempt to relieve the back pain, though further flexing of her head downward caused
some increased back discomfort. Neurologically, motor and sensory responses were
intact. Pulses were within normal range, no lower extremity edema was noted, no bowel
or bladder changes had occurred, and neither fever nor chills were present.

Radiographs of the lumbar spine, including oblique views, showed no evidence of any
spondylosis or spondylolisthesis. Even though it is relatively uncommon to see disk-type
pain and disk problems in an adolescent, the patient's symptoms suggested lumbar
discogenic pain.

Because the patient's pain was still unimproved approximately 3 weeks after injury, MRI
of the lumbar spine was done, showing possible minimal narrowing of the L3-4 disk
interspace, as well as minimally decreased fluid in that disk. At L4-5, a central disk
herniation was seen compressing the anterior margin of the theca, predominantly midline,
but somewhat eccentric to the right. The L4-5 disk herniation appeared to be touching the
L5 nerve as it emerged from the theca. The impression was that of lumbar radiculopathy.

Various nonsteroidal anti-inflammatory drugs and analgesics were administered while

attempting to manage the pain and minimize the side effects. These included etodolac,
oxaprozin, rofecoxib, acetaminophen combinations with codeine, hydrocodone, and
oxycodone, and a muscle relaxant. None of these yielded any benefit, and most caused
headaches. Additionally, a short course of oral steroids (prednisone) yielded no benefit.

During a subsequent physical examination, spasm of the paraspinal musculature was

noticed, but no point tenderness or other abnormalities. Lower extremities continued to
show good motor strength (5/5 bilaterally throughout). Reflexes remained symmetric and
equal. Findings on straight leg raising were positive on the right, with radiation of pain
down the posterolateral thigh and occasional radiation past the knee to midcalf. Straight
leg raising on the left was negative.

Treatment by epidural steroid injection was discussed, but put off by the patient since she
was seeking the most minimally invasive treatment. Therefore, it was agreed that
conservative therapy, consisting of an aggressive physical therapy program, would be the
best first approach. The physical therapy program consisted of lumbar traction modalities
and moist heat. When her acute pain subsided, a range of motion and strengthening
regimen was added to this initial aggressive program.

Coincident with the physical therapy program, a complete blood count with differential
and erythrocyte sedimentation rate (ESR) were ordered to rule out any possibility of
occult infection. Results of blood studies were within normal limits except for those
shown in the Table . The ESR was mildly elevated, but there was no evidence of diskitis
or infection. On subsequent reevaluation, the ESR remained mildly elevated. Given the
slight thyrotropin (TSH) elevation, a small dose of levothyroxine was administered to
evaluate for response to the back pain. Some improvement in the pain was noted.

Because of the patient's immobility and associated inability to sit for any period of time,
home schooling was initiated for the next 6 weeks. She responded to the aggressive
nonsurgical treatment and had complete resolution of the radicular pain approximately 4
months after the onset.

Reaction:

This article warn us also to be ware of our posture and use body mechanics,
simple wrong positionings may lead to other complications. The 13 yrs old adolescent
student never knew that bringing her heavy back pack may lead to her illnesses. It has
been documented that an aggressive physical rehabilitation program for treatment of HNP
of a lumbar intervertebral disk with radiculopathy can be treated successfully with
aggressive nonoperative care. It has been further substantiated by this particular case and
suggests that for adolescents, aggressive nonsurgical treatment is a viable first method of
treatment for HNP.