T7: Muscular Dystrophy and Acute Low Back Pain and Intervertebral Disc Disease Flashcards
muscular dystrophy
group of inherited diseases characterized by progressive symmetric wasting of skeletal muscles with no evident neurological involvement
(no cure)
what is the blood test for muscles
CK (creatine kinase)
diagnostics for muscular dystrophy
*Creatine kinase
*EMG testing
*Muscle fiber biopsy (Fat and connective tissue deposits and dystrophin)
*ECG
due to progressive weakness and deformity, what my be considered fo muscular dystrophy
ambulatory devices, braces, PT, activity
what is the biggest concern in muscular dystrophy
heart failure and respiratory failure because their intercostal muscles and heart muscles are wasting and getting weak
those with respiratory failure and muscular dystrophy are often…
Ventilator-CPAP dependent with tracheostomy
supportive treatment fro muscular dystrophy
steroids (delay progression for up to two years but increases risk of fracture because steroids leech calcium out of the bone)
localized back pain
*patients will feel soreness or discomfort when a specific area of the lower back is palpated or pressed.
diffuse back pain
*Diffuse pain occurs over a larger area and comes from deep tissue layers.
radicular pain
pain is caused by irritation of a nerve root. Radicular pain is not typically isolated to a single location, but instead radiates or moves along a nerve distribution.
referred pain
*pain is “felt” or perceived in the lower back, but the source of the pain is another location (e.g., kidneys, lower abdomen).
risk factors for low back pain
*Lack of muscle tone
*Excess body weight
*Pregnancy
*Stress
*Poor posture
*Cigarette smoking
*Prior compression fractures
*Congenital spinal problems
*Family history of back pain
thoracic nerve damage may cause
GI or bladder dysfunction
diagnostics for acute low back pain
*Straight-leg raising test
* Crossover straight leg test
* Trendelenburg test
*MRI and CT scan only for trauma or suspected systemic disease
*Lasts 4 weeks or less
symptoms of acute low back pain
*Symptoms usually appear within 24 hours
*Muscle ache to shooting/stabbing pain
*Limited flexibility/ROM
*Inability to stand upright
goals for the patient with acute low back pain
*Satisfactory pain relief
*Return to previous level of activity
*Correct performance of exercises
*Adequate coping
*Adequate self-help management
health promotion for acute back pain
*Proper body mechanics
*“Back School”
*Appropriate body weight
*Proper sleep positioning
*Firm mattress
*Stop smoking
outpatient treatment for acute back pain if not severe
*NSAIDs, muscle relaxants
*Massage
*Back manipulation
*Acupuncture
*Cold and hot compresses
treatment for severe acute low back pain
*Corticosteroids
*Opioids-IV, PO, PCA, Patches, Long acting, Short acting (tramadol patches)
teaching for patients with acute low back pain
*Cause of their pain
*Ways to prevent additional episodes
*Strengthening and stretching exercises
“DOs” of low back pain
*Sleep in a side-lying position with knees and hips bent
*Sleep on back with a lift under knees and legs or back with 10-inch-high pillow under knees to flex hips and knees
*Prevent lower back from straining forward by placing a foot on a step or stool during prolonged standing
*Maintain appropriate body weight
*Exercise 15 minutes in the morning and evening regularly
*Carry light items close to body
*Use local heat and cold application
*Use a lumbar roll or pillow for sitting
“DO NOT” of low back pain
*Lean forward without bending knees
*Lift anything above level of elbows
*Stand in one position for prolonged time
*Sleep on abdomen or on back or side with legs out straight
*Exercise without consulting health care provider if having severe pain
what is an intervertebral disc
*Intervertebral discs separate vertebrae and help absorb shock
intervertebral disc disease
rupture or protrusion of the cushioning disc found between the vertebrae that results in pressure on the spinal cord or spinal nerve roots
Degenerative disc disease (DDD)
*results from increased wear and tear on the intervertebral discs with aging. The discs lose their elasticity, flexibility, and shock-absorbing abilities. Unless it is accompanied by pain, this wear and tear condition is a normal process.
what do we do for bulging discs
reduce inflammation!
-NSAIDS and apply ice
what do we do for herniated discs
corticosteroids and may need surgery (discectomy) to remove the disc
process of Degenerative disc disease (DDD)
Disc becomes thinner as nucleus pulposus dries out → load shifted to annulus fibrosus → progressive destruction →pulposus seeps out (herniates)
what is more causes a more serious issue with herniated discs
radiculopathy because the nerves of the spine become compressed
S/S of radiculopathy
*Radiating pain
*Numbness
*Tingling
*↓ Strength and/or range of motion
Intervertebral Disc DiseaseClinical Manifestations
Low back pain most common
*Radicular pain
*+ Straight leg raise
*↓ or absent reflexes-unilateral or bilateral
*Paresthesia
*Muscle weakness-muscle atrophy (Compare extremities-Grips and Pushes-circumference)
HINT HINT: cauda equina syndrome (multiple root compression)
MEDICAL EMERGENCY- contact provider immediately
requires surgical decompression to reduce to pressure on the nerves to prevent permanent loss of function
Multiple nerve root (cauda equina) compression clinical manifestations
*Sever low back pain
*Progressive weakness
*Increased pain
*Bowel and bladder incontinence
cervical disc disease clinical manifestations
*Pain radiates to arms and hands.
*↓ Reflexes and handgrip
*May include shoulder pain and dysfunction
innervation for cervical spine
breathing, heart, diaphragm
what needs to be done to a patient with cervical disc disease
get a collar on them! then X-ray
never remove until c spine is clear
Intervertebral Disc DiseaseDiagnostic Studies
*X-rays
*Myelogram, MRI, or CT scan
*Epidural venogram or discogram
*EMG
conservative therapy for intervertebral disc disease
*Limitation of movement
*Local heat or ice
*Ultrasound and massage
*Skin traction
*Transcutaneous electrical nerve stimulation (TENS)
*Drug therapy
*Epidural corticosteroid injections
*Back-strengthening exercises
*Teach good body mechanics
*Avoid extremes of flexion and torsion
drug therapy for intervertebral disc disease
*NSAIDs
*Short-term corticosteroids
*Opioids
*Muscle relaxants
*Antiseizure drugs, antidepressants (decrease the irritability of the nerve)
when is surgical therapy for intervertebral disc disease indicated
*Conservative treatment fails
*Radiculopathy worsens
*Loss of bowel or bladder control
*Constant pain
*Persistent neurologic deficit
Intradiscal electrothermoplasty (IDET)
*Minimally invasive outpatient procedure
*Needle inserted into affected disc
*Wire threaded into disc and heated → denervates nerve fibers
Radiofrequency discal nucleoplasty (coblation nucleoplasty)
*Needle inserted similar to IDET
*Radiofrequency probe generates energy → breaks up nucleus pulposus
*Up to 20% of nucleus is removed
*Decompresses disc
*Interspinous process decompression system (X Stop)
*Titanium →fits into mount placed on vertebrae
*To treat lumbar spinal stenosis
*Lifts vertebrae off pinched nerve
Laminectomy
*Surgically remove disc through excision of part of vertebra
*Diskectomy
*Surgically decompress nerve root
*Microsurgical or percutaneous technique
Charite Disc
used in patients with lumbar disc disease associated with DDD. This artificial disc has a high-density core sandwiched between two cobalt-chromium endplates
Spinal fusion
*Spine is stabilized by creating an ankylosis (fusion) of contiguous vertebrae
*Uses a bone graft from patient’s fibula or iliac crest or from a donated cadaver bone
*Metal fixation can add to stability
*Bone morphogenetic protein (BMP) to stimulate bone grown of graft
After vertebral disc surgery, postoperative nursing interventions mainly focus on…
maintaining proper alignment of the spine until healing has occurred.
Post lumbar fusion care
*Pillows under thighs when supine
*Between legs when side-lying
reassuring patient after vertebral disc surgery
*The patient often fears turning or any movement that may increase pain by stressing the surgical area. Reassure the patient that proper technique is being used to maintain body alignment. Enough staff should be available to move the patient without undue pain or strain for the patient or staff.
Spinal Surgery: Postoperative
*Opioids for 24 to 48 hours (IV)
*Patient-controlled analgesia (PCA)
*Switch to oral drugs when able
*Muscle relaxants (diazepam (valium))
*Assess and document pain intensity, and pain management effectiveness
what do we monitor for since there is a potential for cerebrospinal fluid leakage after spinal surgery
*Monitor for and report severe headache or leakage of CSF
*Clear or slightly yellow drainage on dressing
*+ For glucose
assessment post op for spinal surgery
*Frequently assess peripheral neurologic signs
*Every 2 to 4 hours during first 48 hours post surgery
*Compare with preoperative status
*Assess circulation (temp, capillary refill, pulses)
*Report changes from baseline or status immediately
when a patient has a CSF leak, what do they complain of
BAD headache
post spinal surgery how is the patient moves
lay flat and log roll
what do we do for a CSF leak
give fluids (takes teh body 72 to turn fluid into CSF)
post op spinal surgery: GI
*Monitor GI and bowel function- PARALYTIC ILEUS
*Administer stool softeners
post op spinal surgery: GU
*Monitor and assist with bladder emptying-possible catherization
*Notify surgeon immediately if bowel or bladder incontinence, numbness or decreased sensation in the perineal area (Loss of tone may indicate nerve damage)
rigid orthosis (thoracic-lumbar-sacral orthosis or chairback brace) teaching
Some surgeons want patients to be taught to apply and remove the brace by logrolling in bed. Others allow their patients to apply the brace in a sitting or standing position. Verify the surgeon’s preferred method before starting this activity.
If surgery is done on the cervical spine, be alert for…
cord edema such as respiratory distress and a worsening neurologic status of the upper extremities.
-may be immobilized in a soft or hard cervical collar.
Donor bone graft site care
*Regularly assess bone graft donor site (Posterior iliac crest or Fibula)
*Usually more painful than fusion area
*Pressure dressing (BONES BLEED)
*Neurovascular assessments if fibula is donor site
*CMS-watch for compartment syndrome
Teaching regarding activity post op from spinal surgery
*Proper body mechanics
*Avoid prolonged sitting or standing.
*Encourage walking, lying down, shifting weight
*No lifting, twisting
*Use thighs and knees to absorb shock
*Firm mattress or bed board
