Situation: Mr.

Alcantara, a retired marine officer is sent to the emergency room af ter complaining an extreme lower back pain radiating to his abdomen. according to mr. alcantara, this is not the first he experienced lower back pain , "i experience this before but not this much pain, when i sit, i feel pain and it wont go away until i stand or change position. Sometimes when i pick or carry items i feel back pains, i just thought this was normal due to my age. " The nurse conduct a physical examintion for the patient. while doing the PE, com plains of numbness, tingling and muscular weakness in the lower region. the nurse assessed for his patellar reflex and result is (-)knee jerk movement. the physician ordered a diagnostic exam of X-ray in the lumbar area, x-r ay shows a (+)disc displacement and a probable prolapse in the L4 area of the lu mbar region. the physician also ordered an MRI for further diagnosis, but the patient refuse to take for MRI is an expensive test and agreed to proceed to treatment. the phy sician concluded that mr. alcantara is sufferring from herniated lumbar disc specifically in L4-L5 vertebrae. Factors affecting Herniated lumbar disc: Modifiable: - Exercise, routine weight lifting of objects. - Life style, sports related injuries or work place related. - Diet, inadequate intake of vitamins and minerals can lead to early deg eneration of spine. Non modifiable: - Age: Advancing age. The process of aging of the discs in the lower bac k, as well as repeated injury to the discs and spinal muscles, makes a person mo re likely to have low back problems, which usually begin in midlife. - Sex: male gender are more affected. - genetics: Mutation in genes coding for proteins involved in the regula tion of the extracellular matrix, such as MMP2 and THBS2, has been demonstrated to contribute to lumbar disc herniation. Causes of herniated lumbar disc: - Disc herniations can result from general wear and tear, such as when p erforming jobs that require constant sitting and squatting. - Minor back pain and chronic back tiredness are indicators of general w ear and tear that make one susceptible to herniation on the occurrence of a trau matic event, such as bending to pick up a pencil or falling. - A sudden heavy strain or increased pressure to the lower back. Sometim es a sudden twisting movement or even a sneeze will force some of the nucleus (t he material inside the disc) out through the disc's outer layer (annulus or caps ule). - Activities that are done over and over again that may stress the lower back, including poor lifting habits, prolonged exposure to vibration, or sports -related injuries. Clinical Manifestations: - back pain (usually on the affected area) - pain from a herniated disc is usually continuous or at least is continuous in a specific position of the bo dy. - 95% are commonly on lumbar area (L4-L5 and L5-S1) - second most common site is the cervical area (c5-c6, c6-c7) - the thoracic region account for only 0.15% to 4% of cases. - Numbness

- tingling - muscular weakness - paralysis - paresthesia - affection of reflexes (sometimes reflex loss) - Sciatica(lumbar radiculopathy) set of symptoms including pain that may be caused by general compression or irritation of one of five spinal nerve root s that give rise to each sciatic nerve, or by compression or irritation of the l eft or right or both sciatic nerves. -sciatica: Lower back pain, buttocks pain, and pain,numbness or weakness in various parts of leg and foot. - permanent nerve damage or paralysis: if cauda equina compression occur s - cauda equina syndrome: The nerve damage can result in loss of bowel an d bladder control as well as sexual dysfunction. Diagnostics: Diagnosis is made by a practitioner based on the history, symptoms, and physical examination. At some point in the evaluation, tests may be performed to confirm or rule out other causes of symptoms such as spondylolisthesis, degeneration, t umors, metastases and space-occupying lesions, as well as to evaluate the effica cy of potential treatment options. Physical Examination: - Straight leg raise also called Lasegue's sign, Lasegue test or Lazarev ic's sign -test: done during the physical examination to determine whether a patient with low back pain has an underlying herniated disk, often located at L5 (fifth lumbar spinal nerve). -technique: With the patient lying down on his or her back on an examination table or exam floor, the examiner lifts the patient's leg while the knee is straight. A variation is to lift the leg while the patient is sitt ing. -interpretation: If the patient experiences sciatic pain when th e straight leg is at an angle of between 30 and 70 degrees, then the test is pos itive and a herniated disc is likely to be the cause of the pain. - Reflex examination in the lower extremeties: checks muscle reflexes if they are slower or missing. absence of or weak reflex can point to lumbar herni ation disc. X-ray: - plain X-rays are limited in their ability to image soft tissues such a s discs, muscles, and nerves, they are still used to confirm or exclude other po ssibilities such as tumors, infections, fractures, etc. In spite of these limita tions, X-ray can still play a relatively inexpensive role in confirming the susp icion of the presence of a herniated disc. If a suspicion is thus strengthened, other methods may be used to provi de final confirmation. - may be done to rule out other causes of back or neck pain. However, it is not possible to diagnose a herniated disk by a spine x-ray alone. Computed Tomography (CT SCAN): - Spine CT will show that the herniated disk is pressing on the spinal c anal. MRI: - An MRI performed with a high magnetic field strength usually provides the most conclusive evidence for diagnosis of a disc herniation. T2-weighted im ages allow for clear visualization of protruded disc material in the spinal cana

l. Myelogram: - may be done to determine the size and location of disk herniation. - An x-ray of the spinal canal following injection of a contrast materia l into the surrounding cerebrospinal fluid spaces. By revealing displacement of the contrast material, it can show the presence of structures that can cause pre ssure on the spinal cord or nerves, such as herniated discs, tumors, or bone spu rs. Electromyelogram: - These tests measure the electrical impulse along nerve roots, peripher al nerves, and muscle tissue. This will indicate whether there is ongoing nerve damage, if the nerves are in a state of healing from a past injury, or whether t here is another site of nerve compression. TREATMENT: Pharmacological approach: -NSAIDS: NSAIDs are used for long-term pain control, but narcotics may b e given if the pain does not respond to anti-inflammatory drugs. (EX. Ibuprofen, Naproxen and celecoxib) -Muscle relaxers: Muscle relaxants such as diazepam (Valium) or cycloben zaprine (Flexeril, Amrix) also may be prescribed if you have back or limb spasms . Sedation and dizziness are common side effects of these medications. -Steroid Injections: Epidural steroid injections "may result in some imp rovement in radicular lumbosacral pain when assessed between 2 and 6 weeks follo wing the injection, compared to control treatments. (EX. Cortisone) Surgical approach: -Chemonucleolysis: Chymopapain(It is a medication used to treat herniate d lower lumbar discs in the spine.) injections are normally given under local, r ather than general, anaesthesia. The dose for a single intervertebral disc is 2 to 4 nanokatals, with a maximum dose per patient of 8 nanokatals. - this dissolves the protruding disc. -intradiscal electrothermal annuloplasty(IDET): form of annuloplasty con sisting of the insertion in the affected disc of a hollow needle, through which a heating wire is passed; once this has reached the disc, the wire is heated to 90C for approximately fifteen minutes. The heat is intended to seal any ruptures in the disc wall and may also burn nerve endings, which can make the area less s ensitive to pain. -discectomy: is the surgical removal of herniated disc material that pre sses on a nerve root or the spinal cord. The procedure involves removing the cen tral portion of an intervertebral disc, the nucleus pulposus, which causes pain by stressing the spinal cord or radiating nerves.Also to relieve nerve compressi on -spinal fusion surgery or Lumbar fusion: this is is designed to stop the motion at a painful vertebral segment, and to correct spinal problems including lumbar disc displacement. -laminotomy: procedure that removes part of a lamina of the vertebral ar ch in order to decompress the corresponding spinal cord and/or spinal nerve root in patient with spinal herniation. -Tessy's Method: the surgeon removes the herniated portions of the disc using posterior lateral endoscopic access. This surgical method for spinal disc herniations is especially gentle for the patient. During the procedure, the pati ent is positioned either in the lateral or prone position and local anesthetic i s administered, usually in combination with sedation. The patient remains respon sive and typically, general anesthesia is not necessary. The surgeon removes the herniated disc tissue through an

access tube of mere millimeters via the intervertebral foramen. Nursing Interventions: - Assess complaints of pain, location, duration of attacks, precipitatin g factors / which aggravate. Set scale of 0-10 - Maintain bed rest, semi-Fowler position to the spinal bones, hips and knees in a state of flexion, supine position - Use logroll (board) during a change of position - Give / aids patients to perform passive range of motion exercises and active - Demonstrate the use of auxiliary equipment such as a cane. - Collaboration: analgesics, traction, physiotherapy - Assist patients in ambulation activity progressively - Note the emotional responses / behaviors in immobilizing - Frequent assessment of reflexes and neurological status of the patient . - instruct patient to limit activity, further movement may cause further damage and pain. - Note the emotional responses / behaviors in immobilizing - Review of secondary problems that may impede the desire to heal and ma y hinder the healing process. Health Teaching: - Explain the process of disease and prognosis, and restrictions on acti vities - Discuss about treatment and side effects. - Give information about your own body mechanics to stand, lift and use the shoes backer. - Teach relaxation techniques - Give information about the signs that need attention such as puncture pain, loss of sensation / ability to walk. - teach the client to avoid lifting heavy objects. - instruct the patient to ask for assistance to pick up items, this is t o avoid bending that may cause back pain. - instruct client to eat High-fiber diet can reduce constipation; calori erestrictions promote weight control/reduction, which can decrease pressure on d isc.