HERNIATED NUCLEUS PULPOSUS 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 awakened part of the disk. A slipped disc, or herniated nucleus pulposus, is a condition in which part or the entire soft, gelatinous central portion of an inter vertebral disk (the nucleus pulposus) is forced through a weakened portion of the disk, resulting in back and leg pain caused by nerve root irritation. HNP, or a herniated nucleus pulposus, is the more medically oriented term for what most people refer to as a herniated disc. The nucleus pulposus is the gel-like inner material found within the thick, outer wall of each inter vertebral disc, which are soft, sponge-like bodies responsible for providing support and flexibility along the entire length of the spine. Due to the gradual deterioration of these discs over time as part of the natural aging process, these discs develop a tear and the nucleus pulposus can push through the disc wall and extrude into the spinal canal a condition known as a herniated nucleus pulposus. Alternative Names Lumbar radiculopathy Cervical radiculopathy Herniated intervertebral disk Prolapsed intervertebral disk Slipped disk Ruptured disk

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. A herniated nucleus pulposus is a slipped disk along the spinal cord. The condition occurs when all or partof the soft center of a spinal disk is forced through aweakened part of the disk. Causes These disks may herniate (move out of place) or rupture from trauma or strain Brought about by as a car accident or lifting a veryheavy object *Radiculopathy refers to any disease affecting thespinal nerve roots. A herniated disk is one cause of radiculopathy (sciatica) Lumbar area Most herniation takes place Occurs 15 times more often thancervical (neck) disk herniation It is one of the most common causes of lower back pain

Cervical disks 8% of the time and the upper-to-midback(thoracic) disks only 1 - 2% of the time*Nerve roots (large nerves that branch out from the spinal cord) o may become compressed, resultingin neurological symptoms, such assensory or motor changes

Prevalence INCIDENT RATE 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 becomecompressed resulting in middle-aged and older men involved in strenuous physical activity congenital conditions that affect the size of the lumbar spinal canal

Risk Factors
Age Middle age is the most common age group 35 45, due to degenerative disks. Weight Cause more stress on the disks

Smoking Decreases oxygen levels in your blood, which deprives them of vital nutrients Height Men taller than 5 11 and women taller than 5 7 have increased chances of a herniated disk Physically demanding jobs that require repetitive movements or sitting or standing too long.

unfortunate result is not always specifically the result of surgery. The causes of thisunremitting 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 regardlessof age. After a successful laminotomy and discectomy, 80-85% of patients do extremelywell and are able to return to their normal job in approximately six weeks time. Theremay 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 sciatictype pain may develop in the future (usually on an infrequent basis) DIAGNOSTIC STUDIES EMG may be done to determine the exact nerve root that is involved.

MANIFESTATION SYMPTOMS OF HERNIATED LUMBAR DISK Muscle spasm Muscle weaknessor 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 numbnessin legs or feet

SYMPTOMS OF HERNIATED CERVICAL DISK Arm muscle weakness Deep pain near or over the shoulder bladeson 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

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 atthe 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 notrequire surgery, and will resolve with conservative, nonoperative treatment, withoutsignificant long-term sequelae. Unfortunately, approximately 5% of patients withherniated, degenerated discs will go on to experience symptomatic or severe andincapacitating low back pain which significantly affects their life activities and work. This

Electromyography is a test that measures muscle response to nervous stimulation. A needle electrode is inserted through the skin into the muscle. Each muscle fiber that contracts will produce an action potential. The presence size, and shape of the wave form of the action potential produced on the oscilloscope, provides information about the ability of the muscle to respond to nervous stimulation.

Nerve conduction velocity test may also be done.

The nerve conduction velocity test is performed toevaluate nerve function. It tests the speed impulses travelthrough a nerve.

CT stands for computerized tomography. In thisprocedure, a thin X-ray beam is rotated around the area of the body to be visualized. Using very complicated mathematical processes called algorithms, the computer isable to generate a 3-D image of a section through the body.CT scans are very detailed and provide excellent informationfor the physician. 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 MANAGEMENT The main treatment for a herniated disk is a short period of rest with pain andanti-inflammatory medications, followed by physical therapy. Most people who followthese 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 killerswill 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 immediatelyfollowed by severe pain in the back and leg. SAIDs are used for long-term pain control, but narcotics may be given if thepain does not respond to anti-inflammatory drugs. Muscle relaxants are usually given if the patient has back spasms. On rareoccasions, steroids may be given either by pill or directly into the blood throughan IV.

Myelogrammay be done to determine the size and location of disk herniation.

The contrast dye makes the spinal canal clearly visiblein this X-ray image. A herniated disc can be seencompressing the spinal nerves. Spine MRIor spine CTwill show compression by the herniated disk. spinal canal

 Steroid injections into the back in the area of the herniated disk can help controlpain for several months. Such injections reduce swelling around the disk andrelieve many symptoms. Spinal injections are usually done on an outpatientbasis, using x-ray or fluoroscopy to identify the area where the injection isneeded.SURGERY Diskectomy - removes a protruding disk. This procedure requires generalanesthesia (asleep and no pain) and 2 - 3 day hospital stay. Microdiskectomy- a procedure removing fragments of nucleated disk through avery small opening. Chemonucleolysis - involves the injection of anenzyme(called chymopapain)into the herniated disk to dissolve the protruding gelatinous substance. Thisprocedure may be an alternative to diskectomy in certain situations. 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 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: 4.96. 5 daysconsiderations: May require assistance with transportation, self-care, andhomemaker/maintenance tasks Refer to section at end of plan for postdischargeconsiderations. LIFESTYLE CHANGES

Any extra weight being carried by anindividual, especially up front in the stomacharea will make back pain worse. Diet and exercise are crucial to improvingback pain in overweight patients Training on how to properly lift, dress, walk,and perform other activities Work on strengthening the muscles of theabdomen and lower back to help support thespine. Flexibility of the spine and legs is taught inmany therapy programs. Back braces to help support the spine *overuse of these devices canweaken the abdominal and backmuscles, leading to a worsening of the problem. Weight belts can be helpful in preventinginjuries in those whose work requires liftingof heavy objects Prevention

Safe work and play practices, proper liftingtechniques, body mechanics andweight controlmayhelp to prevent back injury in some people Normal Disc vs. herniated Disc