V. Anusha selvin mary.,[Link] (N).

,
Assisstant Professor,
Jubilee Mission College of Nursing
 define IVDP
 Illustrate IVDP
 enlist the incidence of IVDP
 enumerate the etiology of IVDP
 describe the Pathophysiology of IVDP
 classify the types of IVDP
 discuss the Clinical manifestation of IVDP
 listdown the diagnostic measures of IVDP
 explain the stages of Disc Herniation
 describe the medical and surgical management of IVDP
 formulate nursing care plan for IVDP
 Intervertebral disc (or intervertebral
fibrocartilage) lies between
adjacent vertebrae in the vertebral column.
 Each disc forms a fibrocartilaginous joint,to
allow slight movement of the vertebrae, and
acts as a ligament to hold the vertebrae
together.
 Their role as shock absorbers in the spine.
 Inter Vertebral disc prolapse is also
known as Spinal Disc Herniation is a condition
in which the fibrous ring of the
intervertebral disc allows the soft central
portion (nucleus) to bulge beyond the
damaged outer ring
 Persons at the age of 60
 Men suffer more than women
 Persons between 30 to 50 years of age suffer
much about IVDP
 Multiple herniation occurs with 10% of
patients
 Lumbar Disc occurs 15 times more than
cervical disc
 Degenerative disc disease

Disc loose their elasticity, flexibility, and shock

absorbing capabilities
 Repeated stress and Trauma to spine

Nucleus pulpous may first bulge

 Spinal stenosis

Narrowing of spinal canal creates a bulging of the

intervertebral disc
 Constant sitting, squatting
 Sedentary lifestyle like driving
 Jobs requires lifting
 Pofessional Athelets like abrupt bending and torsion
 Falling on the buttocks or back
 Flexion extension injury of the nerve
 History of trauma
 Osteoarthritis
 Congenital anomalies such as scoliosis
Cervical disc herniation:
 It occurs in the neck between the C5- C6 and
C6-C7 vertebral bodies
 Symptoms can affect the back of the skull,
the neck, the shoulder girdle, scapula, arm
and hand
 The nerve of the cervical plexus and brachial
plexus are affected
Lumbar Disc Herniation:
 It occurs in the lower back most often in the L4- L5 or
between the L5 and sacrum
 Symptoms can affect the lower back, buttocks, thigh,
anal/ genital region may radiate into foot or toe
 Sciatic nerve is the most commonly affected nerve
causing the symptoms of sciatica
 Femoral nerve cause the patient to experience numb,
tingling feeling throughout one or both legs
Symptoms depends upon the location and soft tissue

Involved,
 Little or no pain- if only tissue injured
 Low back pain -common
 Unrelenting neck or lower back pain which radiates
into region which serves by the particular nerve
 Pain in thighs, knees or face
 Numbness tingling , parasthesia
 Motor changes such as muscle weakness ,paralysis
 Sciatica
 L3- L4: Back to buttocks to posterior thigh to inner
calf
 L4-L5: Back to buttocks to dorsum of foot and big toe
 L5- S1: Back to buttocks to sole of foot and heal
 Reflexes may be depressed or absent,
depending on the spinal nerve root involved
 Parasthesia or muscle weakness
 Multiple nerve root compression may be
manifested as bowel and blader incontinence
or impotence
1. History Collection:
 Location, quality and severity of pain
 Precipitating event if any
 Alleviating and aggravating factors
 History of trauma

2. Neurological Assessment

3. MRI scan: It provides better visualization of soft tissues

4. CT scan : Localizes the damaged site

5. X- ray: its not specific, but can indicate narrowing of

the intervertebral disc space, hypertrophic Osteo
arthritis

6. EMG with nerve conduction study can be performed

to determine the severity of nerve irritation or to
rule out pathologic conditions such as peripheral
neuropathy
Stage 1: Degeneration:
 As the disc dehydrates with age, it begins to lose elasticity and becomes
brittle.

Stage 2: Bulging Disc Herniation:

 Over time tiny tears may form in the outer, fibrous ring (annulus
fibrosus) of an intervertebral disc
 It allows the soft, gel-like central portion (nucleus pulposus) to bulge out
or produce a "bubble" along the tough fibrous outer layer. This is often
referred to as a "bulging" disc or contained herniation or sub-
ligamentous herniation.
 A bulging disc is often informally and misleadingly called a "slipped disc."
Stage 3: Extrusion:
 Next, a disc extrusion occurs when part of the nucleus
breaks through the tough fibrous outer layer (annulus
fibrosus ) but still remains within the disc.

Stage 4: Sequestration:
 Finally, a disc sequestration occurs when the leaking gel-
like material (nucleus pulposus) breaks through the tough
outer layer (annulus fibrosus) and is loose within the spinal
canal. This may also be referred to as a free fragment.
Two Possible treatments:

1. Conservative treatment

2. Surgery
 It is tried for atleast 4 to 6 weeks
 There are 3 cornerstones of management

a. Education

b. Reassuance

c. Patient comfort and readjusting activity

 Modify general activity for a short time
 Self apply heat alternating with cold therapy, Apply
each temperature for 20 minutes, use heat prior to
exercise and cold after exercise
 For low back pain: Avoid excessive lifting, bending or
twisting
 For neck pain: Ensure good posture and avoid neck
flexion such a s desk work
 Initiate exercise programme like aerobic,
stretching and strengthening exercise.
 Avoid smoking
 Maintain adequate height and weight
 Reduction of psychological stressors
 Patient with severe symptoms is treated with
bed rest for a short time.
 Limitation of extremities of spinal movement
 Ultrasound and massage
 Traction
 Transcutaneous electrical nerve stimulation
Conservative treatment can result in healing over
damaged area if not due to DDD
 NSAIDs
 Short term opiods
 Muscle relaxants
 Epidural cortico steroid injection may be effective in
reducing inflammation and in releiving pain
Surgery may be indicated in the following conditions
 Radiculopathy becomes progressively worse
 Loss of bowel or bladder control(Cauda equina)is
documented
 Cervical herniation that causes significant spinal cord
copresssion
 Compressions resulting in quadriceps weakness or
foot drop
Lumbar:
 Microdisectomy
 Hemilaminectomy
 Laminectomy

Cervical:
 Anterior approach
 Posterior approach
Intradiscal electro thermoplasty:

The procedure involves the insertion of a

needle into the affected disc with the guidance of an
X ray.A wire is then threaded through the needle and
into he disk. The wire is then heated which is meant
to destroy the nerve fibers and toughen the disc
tissue, sealing any small tears
Radiofrequency discal nucleoplasty:
 Also known as coblation therapy
 A needle is inserted into the disc under fluoroscopic guidance
 A special radiofrequency probe (like a mini microwave oven) is inserted
through the needle into the disc.
 This device generates enough energy to break up the molecular bonds of
the gel in the disc, essentially vaporizing some of the tissue.
 The result is that the disc size is reduced by 10-20%, which
decompresses the disc and reduces the pressure both on the disc and the
surrounding nerve roots. Nucleoplasty can actually reduce the disculge
[Link]:
 Manage mild to severe pain
 NSAIDs
 Narcotic analgesics like acetaminophen with codeine
30 mg or Acetaminophen with hydrocone 5mg

[Link] laxatives which helps straining stools which

can exaberate pain
3. Anti- Infalmmatory Drugs:
 Ibuprofen
 Naproxen

4. Muscle Relaxant:

Cyclobenzaprine, Methocarbmol,

5. Sedative tranquilizer are administered to decrease

anxiety which in turn decrease muscle tension and pain
 Acute or Chronic pain related to inflammation or rupture of
intervertebral disc
 Risk for trauma related to improper body mechanics
 Risk for constipation related to bedrest
 Impaired physical mobility r/t pain numbness, fatigue and
muscle weakness
 Sensory / peceptual laterations related to diminished
interpretation of tacktile sensatio secondary to
inflammation or injury of spinal nerve
 With the patient and doctor, plan a pain control regimen.
 Encourage the patient to express his concerns about the disorder.
 Urge the patient to perform as much self-care
 Help the patient identify and perform care and activities that
promote rest and relaxation.
 Use antiembolism stockings, as prescribed, and encourage the patient
to move his legs, as allowed.
 Assess the patient’s pain status and his response to the pain-control
regimen.
 Perform neurovascular checks of the patient’s legs such as color,
motion, temperature, and sensation.
 Monitor vital signs, and check for bowel sounds and abdominal
distention.
 Teach the patient about treatments, which include bed rest and
pelvic traction.
 Urge the patient to maintain an ideal body weight to prevent lordosis
caused by obesity.
 Discuss all prescribed medications with the patient.
 If surgery is required, explain all preoperative and postoperative
procedures and treatments to the patient and his family.
1. Joanne V. Hickey, “The Clinical Practice of
Neurological and Neuro surgical Nursing” 6 th
Edition, Lippincott william and wilkins publishers,
page No: 460

2. Joyce M. Black’s, “Medical Surgical Nursing- Clinical

Management for Positive Outcomes” I south Indian
Edition, Elsivier publishers, page No:1883

3. Brunner and Suddarth’s, “Text book of Medical

Surgical Nursing” Wolter Kluver publications, page
No:1818