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The intervertebral disc is the largest avascular structure in the body. It arises from
notochordal cells between the cartilaginous endplates, which regress from about 50% of the
disc space at birth to about 5% in the adult, with chondrocytes replacing the notochordal
cells. Intervertebral discs are located in the spinal column between successive vertebral
bodies and are oval in cross section. The height of the discs increases from the peripheral
edges to the center, appearing as a biconvex shape that becomes successively larger by about
11% per segment from cephalad to caudal (ie, from the cervical spine to the lumbosacral
articulation). A longitudinal ligament attaches to the vertebral bodies and to the intervertebral
discs anteriorly and posteriorly; the cartilaginous endplate of each disc attaches to the bony
endplate of the vertebral body.
The disc's annular structure is composed of an outer annulus fibrosus, which is a
constraining ring that is composed primarily of type 1 collagen. This fibrous ring has
alternating layers oriented at 60° from the horizontal to allow isovolumic rotation. That is,
just as a shark swimming and turning in the water does not buckle its skin, the intervertebral
disc has the ability to rotate or bend without a significant change in volume and, thus, does
not affect the hydrostatic pressure of the inner portion of the disc, the nucleus pulposus.
The nucleus pulposus consists predominantly of type II collagen, proteoglycan, and
hyaluronan long chains, which have regions with highly hydrophilic, branching side chains.
These negatively charged regions have a strong avidity for water molecules and hydrate the
nucleus or center of the disc by an osmotic swelling pressure effect. The major proteoglycan
constituent is aggrecan, which is connected by link protein to the long hyaluronan. A fibril
network, including a number of collagen types along with fibronectin, decorin, and lumican,
contains the nucleus pulposus.
The hydraulic effect of the contained, hydrated nucleus within the annulus acts as a
shock absorber to cushion the spinal column from forces that are applied to the
musculoskeletal system. Each vertebra of the spinal column has an anterior centrum or body.
The centra are stacked in a weightbearing column and are supported by the intervertebral
discs. A corresponding posterior bony arch encloses and protects the neural elements, and
each side of the posterior elements has a facet joint or articulation to allow motion.
The functional segmental unit is the combination of an anterior disc and the 2
posterior facet joints, and it provides protection for the neural elements within the acceptable
constraints of clinical stability. The facet joints connect the vertebral bodies on each side of
the lamina, forming the posterior arch. These joints are connected at each level by the
ligamentum flavum, which is yellow because of the high elastin content and allows
significant extensibility and flexibility of the spinal column.
mlinical stability has been defined as the ability of the spine under physiologic load to
limit patterns of displacement so as to avoid damage or irritation to the spinal cord or nerve
roots and to prevent incapacitating deformity or pain caused by structural changes. Any
disruption of the components holding the spine together (ie, ligaments, intervertebral discs,
facets) decreases the clinical stability of the spine. When the spine loses enough of these
components to prevent it from adequately providing the mechanical function of protection,
surgery may be necessary to reestablish stability.
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The exact cause of herniated nucleus pulposus is unknown, however, it can be
attributed to the following risk factors:
£? ! $ ! Direct trauma to the vertebra affecting the intervertebral
contents.
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Demands extra effort in the weight-bearing functions of the vertebra.
&? '!"Disrupts the equal distribution of pressure within
the intervertebral contents.
Î? ()*They engage in activities that strains the back.
+? !"Impairs the perfusion of oxygen in the bones affecting bone
strength.
,? oss of calcium ions affecting bone strength.
-? ü autation in genes coding for proteins involved in the regulation of the
extracellular matrix
, such as MMP2 and THB2, has been
demonstrated to contribute to lumbar disc herniation.
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Herniated nucleus pulposus can be traced back from different risk factors. mommonly,
HNP is caused by trauma on the intervetebral discs such as accident or injury, being
overweight and engaging in various activities that demand a lot of effort from the spine.
Accident or injury causes direct trauma on the spine which can also affect or injure the
intervertebral discs. Being overweight, on the other hand, puts on a lot of weight on the spine,
demanding constant exertion of pressure from the spine to carry on the extra weight.
Activities that strain the vertebra is also a very crucial predisposing factors in the
development of HNP since such activities disrupts the equal distribution of pressure on the
intervertebral discs because these activities increase the pressure on the discs. In connection
to the latter, males have higher chances of developing the disease since they engage in such
type of activities more frequently than females. These three factors result in the compression
of the anterior side of the disc. Because of the compression, the contents of the intervertebral
disc, most especially the nucleus pulposus, will be pressed against the already thinned (due to
stretching) annulus pulposus on the posterior part.
It is also highly considered that HNP is caused by general wear and tear such as the
different degenerative changes that occur in aging. These degenerative changes primarily
include loss of calcium from the bones which eventually lead to loss of bone strength. Also,
the effects of smoking is related in this regard since smoking, especially lone-term smoking,
reduces bone strength because of the disruption of oxygen perfusion into the bones given that
the cigarette-smoking can lead to vasoconstriction. The loss of the strength of the bones
compromises the function of the vertebra to protect the different intrevertebral contents, one
of which, the nucleus pulposus. Because of the latter, there will be the asymptomatic
fissuring and fragmentation within the disk which will lead to the compression of one side of
the intervertebral disc and exertion of pressure to the other side. Degeneration of the annulus
pulposus can also be considered which will then disrupts the isovolmic rotation of the
vertebra.
It is also considered that mutation in genes coding for proteins involved in the
regulation of the extracellular matrix or the annulus pulposus, such as MMP2 and THB2,
has been demonstrated to contribute to lumbar disc herniation. Weak annulus pulposus means
a compromise in the functions of the said structure which then results to a disruption in the
isovolmic rotation of the vertebra.
These factors will eventually lead to the herniation of the disk into the spinal canal or
the neural foramen. ince the outer annulus pulposus suffers from the pressure exerted by the
nucleus polpusus, the latter will then gradually prolapsed through the annulus pulposus
leading to its innervation which will then be manifested by mild to severe back pain that
radiates to the pelvis and the legs. The innervations of the annulus pulposus allow disk
fragment to herniate through it which will then lead to a diminished tension on the annulus
that is manifested by weakness on the affected part. The decrease in the tension of the
annulus leads to its rupture allowing the nucleus pulposus to potrude resulting now to spinal
nerve compression that leads to the different manifestations of HNP. uch manifestations
include back pain that radiates across the buttock and down the leg, weakness of leg and foot
on the affected side, numbness and tingling of toes, asegue¶s sign, depressed or absent
Achilles reflex, muscle spasm in the lumbar area, shoulder pain that radiates down the arm to
hand, paresthesia and sensory disturbances.
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eg pain that occurs when you sit down on an exam table and lift your leg
straight up usually suggests a herniated lumbar disk.
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X-ray is a test that uses radiation to produce images of the bones and
organs of the body. pine X-rays provide detailed images of the bones of the
spine, and can be taken separately for the three main parts of the spine--cervical
(neck), thoracic (mid back) and lumbar (lower back).
pine X-ay is done to rule out other causes of back or neck pain. However, it
is not possible to diagnose a herniated disk by spinal x-ray alone.
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0 agittal view of the
cervical spine demonstrating an anterior
cervical disc herniation at m2- m3 level, plus
osteophyte formation with calcification of the
anterior longitudinal ligament. The epiglottis
(e) indicates narrowing of the airway
(between arrows).
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0 A decrease in the electrical activity of the muscles is highly
possible when a patient is suspected of HNP. The presence of spinal nerves in the
affected portion of the spine implies the affectation of the functions of the said nerves,
one of which, motor functions. These spinal nerves innervate the different muscles of
the body, hence, the compression of which leads to decreased release of impulses to
the different muscles.
/
0 Any peripheral neuropathy can cause abnormal results, as can
damage to the spinal cord and disk herniation (herniated nucleus pulposus) with nerve
root compression.
/
0 mT has proved to be as good as or even better than
myelography alone in the diagnosis of herniated disk. mT scanning with myelography
is superior to either one alone.
a.? !, images show a focal, smooth, outward
displacement of the disk margin in the spinal canal, in the neural foramen, or
lateral to the neural foramen. mT scans may further demonstrate calcification or,
less commonly, gas in the herniation.
b.? " !, mT scans show a soft-tissue mass with effacement of the
epidural fat and displacement of the thecal sac. If the fragment is no longer
restrained by the P but is still in contact with the disk margin, an irregular,
lobulated excrescence on the disk margin is seen. A separated disk fragment is
often detected in the epidural fat adjacent to the dural sac or sheath of a nerve
root. The disk margin may appear normal. The attenuation of the nuclear
fragments of a fragmented disk is usually 80-120 HU.
Deformity of the dural sac and nerve sheath, along with the bony changes,
help in the diagnosis:
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pine MI or spine mT will show spinal canal compression by the herniated
disk.
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0 A positive MI result shows the extruded disc material as a
dark mass, and this is the true value of an MI ± revealing the exact location and
severity of nerve compression produced by a herniated intervertebral disc.
In cases of disk bulging, early findings on MI include loss of the normal
posterior disk concavity. Moderate bulges appear as nonfocal protrusions of disk
material beyond the borders of the vertebrae; bulges are typically broad based,
circumferential, and symmetric.
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These drugs are used for long-term pain control and 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.
%? ! "!. May be given if the pain does not respond to anti-
inflammatory drugs. And this are drugs taken to relieve discomfort, distinct from
anesthetics (drugs that deaden feeling) and sedatives (drugs that aid relaxation or
sleep).
. 0 The precise mechanism of action is unknown although the
narcotics appear to interact with specific receptor sites to interfere with pain impulses.
/? . !(
. 0 This drug travel in the blood that are attached to protein
carriers. When steroid hormones arrive at their target cells, they dissociate to their
protein carriers and pass through the plasma membrane of the cell. ome steroid
hormones bind to specific receptor proteins in the cytoplasm and then move as a
hormone receptor complex into the nucleus. Other steroids travel directly into the
nucleus encountering their receptor proteins.
! $) " ! ! "* These
can help control pain for several months. It can also reduce swelling around the disk
and relieve many symptoms.
urgery may be an option for the few patients whose symptoms persist despite
other treatments.
£? "
¦? evere leg pain or numbness that badly affects activities of daily living
¦? Weakness in muscles of the lower leg or buttocks
¦? An inability to control bowel movements or urination
This procedure may be done when the following conditions are met:
urgery may be considered if tests show that the symptoms are due to a
herniated disc and the doctor thinks surgery may help relieve the symptoms. The
following factors are often considered when deciding to have surgery.
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This type of surgery is the most often performed. It is the removal of the part
of the vertebral lamina. The surgery is done to relieve pressure on the nerves.
When the spinal cord or other nerves get irritated, they can cause weakness,
numbness and pain in the arm or leg.
pinal fusion may be recommended for persistent pain that does not get better
with other treatments. It may be done in the following cases:
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Foraminotomy is the enlargement of the opening between the disk and facet
joint to remove bony overgrowth compressing the nerve. The location and size of the
incision is according to the physicians preference and location and size of the ruptured
disk. The posterior approach is taken for lumbar surgery.
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Diet and exercise must be encouraged to the patient since they are crucial and
improving back pain. This is because extra weight being carried by an individual
makes back pain worse.
Exercise, also, may help improve posture. Appropriate exercise can help take
pressure off inflamed nerve structures, while improving overall posture and
flexibility.
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Back braces help support the spine by aiding the spine to bear the weight of
the head. However, overuse of these devices can weaken the abdominal and back
muscles leading to a worsening of the problem. This, nevertheless, can be addressed
by using weight belts which are helpful in preventing injuries.
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Traction is used to decrease pressure on the affected disk and may also address
muscle spasms. However, it does not directly reduce the HNP.
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a.? A lumbar support can be helpful for a herniated disk at this level as a temporary
measure to reduce pain and improve posture.
b.? Bed rest on firm mattress with bed boards.
,? !'
Health care providers must assure that efficient circulation and must be
vigilant, especially prevent, the development of bed sores especially if hospital
admission was indicated.
2? !.
1.? Administer analgesics and other medications as ordered in order to prevent the
sensation of pain and maintain the comfort of the client.
2.? Use a firm mattress and bed board under the client in order to assure the alignment of
the disks and to avoid exacerbations.
3.? Make certain that traction and/or braces are correctly applied and maintained and that
weights hang freely in order for the traction and the braces to be efficient.
.? Use the fracture bedpan to avoid lifting of hips.
5.? Use frequent and extensive back care to relax muscles and promote circulation
6.? upport body alignments at all times in order not to exacerbate the condition.
7.? Use log-rolling methods to turn the client (instruct the client to fold arms across the
chest, bend the knee on the side opposite the direction of the turn, and then roll over)
in order for the client to avoid extra effort in lifting his or her body.
8.? Teach the importance of weight loss, wearing low-heeled shoes, and appropriate body
mechanics in order to avoid extra pressure on the affected disks.
9.? Increase fluid intake and encourage diet rich in nutrient-dense foods such as fruits,
vegetables, whole grains, and legumes to improve and maintain nutritional status as
well as prevent constipation; if necessary use stool softener to prevent straining.
10.?Provide special care for the client undergoing repair or removal of a disc.
a.? Explain that pain may persist postoperatively for some time because of edema
b.? Place the bedside table, phone, and call bell within reach to prevent twisting
c.? Observe the dressing for hemorrhage and leakage of spinal fluid; notify the
physician immediately if either occurs
d.? Observe for inadequate ventilation, especially in clients who have undergone a
cervical laminectomy
e.? Assess the patient for changes in neurologic functioning
11.?Allow the client to be dependent, but foster independence to maintain or uphold the
over-all well-being of the client.
12.?Encourage the patient to perform exercises as prescribed to strengthen abdominal
muscles for back support
13.?Encourage the client to express feelings about altered functioning and self-image as
well as their fears about the present condition and future disability to allay anxiety.