Lower back pain/Test 4 Flashcards
Gerontologic Considerations: Effects of aging on the musculoskeletal system:
- Bone remodeling is altered
- Muscle mass and strength decrease
- Loss of motor neurons
- Tendons and ligaments less flexible
- Joints more likely to be affected by osteoarthritis
- Osteoarthritis and osteoporosis not normal consequences of aging
Changes with aging:
- Total number of bone cells decrease
- Decline of tissue loses elasticity, muscle lose bulk, tone and strength
- Bone resorbtion is more rapid than bone growth
- calcium is lost from the bone
- calicium loss makes bones softer and prone to fractures
- leads to osteoporosis
- -articular cartilege degenerates in weight bearing joints and heals slower
Acute low back pain:
- Def: activity intolerance d/t LBP or back related symptoms of 3 months or less. It becomes chronic if it last longer than 12 weeks.
- LBP: affects areas below the ribs and gluteus muscles, often radiates to the thigh, sciatic pain from sciatic nerve impairment
Low Back Pain: Etiology:
A common problem because the lumbar region bears most of the weight of the body; is the most flexible region of the spinal column; contains nerve roots that are vulnerable to injury or disease; has an inherently poor biomechanical structure. Often due to a musculoskeletal problem.
Musculoskeletal problems:
- Acute lumbosacral strain
- Instability of lumbosacral bony mechanism
- Osteoarthritis of the lumbosacral vertebrae
- Intervertebral disk degeneration
- Herniation of the intervertebral disk
LBP: Risk factors-
- lack of muscle tone
- excess body weight
- poor posture
- cigarette smoking
- stress
- lifting, vibration and prolonged periods of sitting
- occupational hazards
- osteoporosis
- hyperthyroidism
Causes of LBP:
- Degenerative disk disease
- Herniated intervertebral disk
- Spinal stenosis
- Spondylolisthesis
- spondyloysis
- Rheumatoid arthritis
Herniation of the intervertebral disk-
a protrusion of the nucleus pulpous through a tear or rupture in the annulus, can occur anteriorly or laterally. Extrusion of the disk material may impinge on a nerve root or on the spinal canal.
Spinal stenois:
a narrowing of the spinal canal or intervertebral foramina at any level creating pressure on the involved nerve root, resulting in neurological symptoms
Spondylolisthes:
A forward slipping of one vertebra on another. The forward slip of the vertebra can cause nerve impairment which manifest as motor and sensory deficits at the levels that are involved
Spondyloysis:
Structural defect of the lamina usually in the lumbar spine
Assessment:
- need a detailed history
- Complete physical exam for accurate dx and tx
- asses for neurological deficits
- loss of bladder or bowel control
- ROM
- loss of movement
- sensory loss
- Pain assessment
- Muscle testing
- straight leg raising
- laseque’s sign
Laseque’s Sign
A limitation or straght leg raising usually associated with lumbar nerve root compression. Also, in sciatica, flexion of the hip is painful with the knee extended but painless when the knee is flexed.
Diagnostic test:
- No routine labs
- X-rays may be ordered
- CT and MRI are performed on patients that are having surgery
- Myelograms: radiography of the spinal cord associated nerves after intrathecal injection of a radiopaque dye: water soluble contrast
- water base contrast: post procedural: includes elevating head to prevent seizures and n/v
- contrast inject in subarachnoid space to see compression on the cord or see protrusion of the disk
Collaborative care:
Conservative management:
- *Goal: pain control and return to baseline functioning
- non pharmalogical
- bed rest is not recommended
- back exercises: stretching and extension recommended
- pt referral
- corsets or braces for spinal support
- -lumbar and pelvic traction not beneficial
- application of heat/cold
- -heat and cold the first 48 hours
- -heat after the first 48 hrs
- -helps reduce pain
- massage therapy
- Trigger point therapy
- Spinal manipulation
- do not do if suspected herniated disk risk of increasing neurological deficits
Conservative management:
- Pharmacologic- medications should not be used longer than 12 weeks d/t risk of side effects
- analgesics: NSAIDS
- muscle relaxants: Flexeril, soma, valium
- tricyclic antidepressants and steroid injections have also been used.
Education:
- Proper body mechanics
- lumbar disk herniation: pt should be supine with head slightly elevated and flexion of the knees William’s position.
- methods to avoid back injury
- proper way to sit, stand, bend and lift
- use straight back chair not a recliner
- Sleeping place pillows under the knees
- Firm mattress
- Aerobic exercise
- Support groups
Acute LBP: Planning:
- have satisfactory pain relief
- avoid constipation secondary to medication and immobility
- learn back-sparing practices
- return to previous level of activity within prescribed restrictions
Chronic LBP:
*lasts more than 3 months or is a repeated incapacitating episode. Causes include degenerative disk disease, lack of physical exercise, prior injury, obesity, structural and postural abnormalties and systemic disease
Diagnoses: Acute LBP-
- Acute pain r/t herniated nucleus pulposus, muscle spasms, and ineffective comfort measures as exhibited by verbalization of back pain on movement, guarded movements, palpable muscle spasm, decreased physical activity, rating pain as >4 on a 10-point pain scale
- Impaired physical mobility r/t pain as exhibited by limited active joint ROM, movement restrictions, muscle spasms
Diagnoses- Chronic LBP:
- Ineffective coping r/t effects of chronic pain as exhibited by verbalization of inability to cope, irritability, tension, inability to meet role expectations, altered participation in social events, ineffective or inappropriate use of defense mechanisms
- Ineffective therapeutic regimen management r/t lack of knowledge regarding posture, exercises, body mechanics, and weight reduction as exhibited by lack of necessary knowledge to participate in treatment plan, inadequate understanding, or inaccurate follow-through of previous instructions
Pain felt in your lower back may come from:
the spine, muscles, nerves or other structures in that region of you back. It may also radiate from other areas like your mid or upper back, a hernia in the groin, or a problem in the testicles or ovaries. You may feel a variety of symptoms if you hurt your back. You may have a tingling or burning sensation a dull aching or sharp pain. You also may experience weakness in your legs or feet. It wont necessarily be one event that actually causes your pain. You may have been doing things improperly–like standing, sitting, or lifting–for a long time. Then suddenly, one simple movement, like reaching for something in the shower or bending from your waist, leads to the feeling of pain.
Pathophysiology: degenerative disc disease
- As a result of biochemical changes in the intervertebral disc
- The intervertebral disk between L4-5 vertebrae is subjected to tremendous forces and degenerative disease
- When ligaments which surrounds the disk are injured or weakened disk material begins to extrude through the ligaments.
- The exudated nucleus pulpous compress the spinal roots or spinal cord
Herniated disk: risk factors
- lack of muscle tone
- excess body weight
- poor posture
- cigarette smoking
- stress
- lifting, vibration and prolonged periods of sitting
- Occupational hazards
- osteoporosis
- hyperthyroidism
Herniated Intervertebral Disk: Etiology:
-natural degeneration with age or repeated stress and trauma to the spine
Herniated Intervertebral Disk: Clinical manifestations
-low back pain, radiating down the buttock and below the knee along the distribution of the sciatic nerve (radiculopathy)
Herniated Intervertebral Disk: Diagnostic
*disc problem exists therefore more test than just x-rays are needed, myelogram; MRI, CT; possibly epidural venogram or diskogram; EMG of extremities
Herniated Intervertebral: Conservative treatment
- Restricted activity
- Medication
- analgesics
- nonsteroidal antiinflammatory drugs
- muscle relaxants
- Local ice or heat
- Physical therapy
- Surgical treatment- laminectomy with or without spinal fusion
- diskectomy
- percutaneous laser diskectomy
- spinal fusion with or without instrumentation
Slipped disc:
When the soft, gelatinous central portion of an intervertebral disk is forced through a weakened part of a disk it is a conditon 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 LBP. 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
Nursing management: Spinal Surgery:
- Focus on maintaining proper alignment of the spine at all times until healing has occurred.
- flat bedrest with logrolling
- Positioning
- Pain management
- Peripheral neurological assessment
- Bowel/bladder function
Surgical Management:
- Laminectomy
- Discetomy
- Spinal fusion
- Decompression
- Microdisectomy
Laminectomy
Removal of the lamina: posterior arch of the vertebra
Discetomy
removal of all or part of a herniated intervertebral disc
Spinal fusion
*Stabilization of 2 or more vertebrae by insertion of bone grafts with or without hardware
Decompression
Release of pressure impinging on the spinal nerve or cord
Microdisectomy
Smaller surgical incision; removal of the disc
Decompression Laminectomy anterior cervical approach: PC
Airway obstruction r/t post-operative edema
Decompression Laminectomy anterior cervical approach: Assessment
- neurovascular will be upper extremities not lower
- pain neck to arms
- strength and movement of arms need to be assessed
- vascular check: upper arms
Decompression Laminectomy anterior cervical approach: Equipment
*at bedside: airway and suction
C6-7 cervical disk laminectomy-
2 nurses are needed in assisting pt getting up the first day
- prior to getting up- apply cervical collar
- prevent twisting or pulling on the shoulders
To maintain independence for C4 laminectomies with fusion
*use assistive or adaptive devices at home
Posterior Laminectomy: Nursing diagnoses:
- Risk for peripheral neurovascular compromise of blood vessels and nerves d/t the edema and pressure on the spinal nerve root and or spinal cord
- log roll: prevents disruption of spinal alignment and integrity
Posterior Laminectomy: When doing your assessment:
Pt c/o numbness
-check previous assessment
