Herniated Nucleus Pulposus (HNP) is defined as the protrusion of the nucleus pulposus (central part of intervertebral disk) into

spine causing compression of spinal nerve roots. It occurs when all or part of the spinal disk is forced through a weakened part of the disk which places pressure on nearby nerves. The compression of the nerve roots as well as the affectation of the adjacent nerves result in back pain and nerve root irritation. The disease can also be called as to the following: -Lumbar radiculopathy -Cervical radiculopathy -Herniated intervertebral disk -Prolapsed intervertebral disk -Slipped disk -Ruptured disk -Herniated dic The disease is considered as radiculopathy since it affects spinal nerve roots. A herniated disk is one cause of radiculopathy. It is specifically called as sciatica. Pathophysiology The intervertebral disk is the largest avascular structure in the body. It arises from notochordal cells between the cartilaginous endplates, which regress from about 5% in the adult, with chondrocytes replacing the notochordal cells. Intervertebral dics 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 (i.e 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 discs 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 degrees 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 predominatly 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 INCIDENCE AND PREVALENCE A herniated intervertebral disc or nucleus pulposus may occur at any adult age. However, it is more common as people enter middle age and age-related changes occur. The nucleus pulposus loses fluid content, and the disks are less able to absorb shocks. The disks become smaller and slip out of place more easily. Aging causes degeneration in the annulus fibrosus and the posterior longitudinal ligaments, and the vertebrae and disks are less able to respond to movement and are more easily injured. Herniated intervertebral disks are more common in men than in women. Most clients are between the ages of 30 and 50. The majority of herniated disks occur in the cervical region, they most commonly do so at C6 to C7. Multiple herniations are not common, occurring in only about 10% of clients (Hickey, 2003). PATHOPHYSIOLOGY The intervertebral disks, located between the vertebral bodies, are made of an inner nucleus pulposus and an outer collar (the annulus fibrosus). The disks allow the spine to absorb compression by acting as shock absorbers. A herniated intervertebral disks occurs when the nucleus puplosus protrudes through a weakened or torn annulus fibrosus of an intervertebral disk. This protrusion may occur anywhere along the vertebral column, but herniation of thoracic disks is uncommon. The protrusion may occur spontaneously or as a result of trauma, with trauma (such as lifting heavy objects or falling) causing about half of all cases. Rupture of the disk allows herniation of the nucleus pulposus in a posteolateral direction, with compression of the associated nerve root. The resulting pressure on adjacent spinal nerves causes characteristic manifestations, which vary with the location oand the amount of protruding disk material. Occasionally the herniation is central rather than posterolateral, with pressuer on the spinal cord. The herniation may be abrupt or gradual. Lifting incorrectly or suddenly twisting the spine can cause rupture with immediate intense pain and muscle spasms. Gradual herniation is the result of degenerative changes, osteoarthritis, or ankylosis spondulitis. Clients with gradual herniation have a slow onset of pain and neurologic deficits. Manifestations of a Ruptured Intervertebral Disk L4 to L4 Level (Affects 5th Lumbar Nerve Root) -Pain in hip, lower back, posterolateral thigh, anterior leg dorsal surface of foot, great toe -Muscle spasms -Paresthesia over lateral leg and web of great toe

-Footdrop (rare) -Decreased or absent ankle reflex -Cauda equine syndrome (with complete nerve root compression): bowel and bladder incontinence, paralysis of lower extremities L5 to S1 Level (Affects 1st Sacral Nerve Root) -Pain in midgluteal region, posterior thigh, calf to heel, plantar surface of the foot to the 4th and 5th toes -Paresthesias in posterior calf and lateral heel, foot, and toes -Difficulty walking on toes C5 to C6 Level (Affects 6th Cervical Nerve Root) -Pain in neck, shoulder, anterior upper arm, radial area of forearm, thumb -Paresthesia of forearm, thumb, forefinger and lateral arm -Decreased biceps and supinator reflex -Triceps reflex normal to hyperactive LUMBAR DISK MANIFESTATIONS The classic manifestation of a ruptured lumbar disk is recurrent episodes of pain in the lower back. The pain typically radiates across the buttock and down the posterior leg, although it may be experienced only in the leg. Sciatica is a term used to describe lumbar back pain that radiates down the posterior leg to the ankle and is increased by sneezing or coughing (the result of pressure on nerve roots L4, L5, S1, S2, or S3, which give rise to the sciatic nerve). Sciatica may be elicited by straight-leg flexing the foot of that leg. Sciatica pain varies in intensity, ranging from mildly uncomfortable to excruciating. It is aggravated by a variety of positions and activities, including sitting, straining, coughing, sneezing, climbing stairs, walking, and riding in a car. Other manifestations include postural deformity, motor deficits, sensory deficits, and changes in reflexes. In about 60% of clients with ruptured lumbar disks, the normal lumbar lordosis is absent. When standing, the client typically has a slight flexion of the hip and knee on the affected side, and paravertebral muscle spasms (Hickey, 2003). Motor deficits include weakness and in some clients problems with se3xual function and urinary elimination. Sensory deficits include paresthesias and numbness. Knee and ankle reflexes are decreased or absent. CERVICAL DISK MANIFESTATIONS Cervical disk that herniate laterally cause pain in the shoulder, neck, and arm. Other manifestations of lateral cervical herniation include paresthesias, muscle spasms and stiff neck, and decreased or absent

arm reflexes. Central cervical hernaitions result in mild, intermittent pain; however, the client may also experience lower extremity weakness, unsteady gait, muscle spasms, urinary elimination problems, altered sexual function, and hyperactive lower extremity reflexes. DIAGNOSTIC TESTS Diagnostic tests are ordered to differentiate the cause of back pain; for example, back and leg pain is also caused by spinal tumors, degenerative processes, or abdominal disease. Assessing pain is an important part of diagnosis. Flat-plate X-ray films may be taken of the lumbosacral or cervical area to identify skeletal deformities and narrowing of the disk spaces. CT scans are used to identify disk rupture or protrusion and may provide definitive diagnosis. However, if the client has had previous back surgery or if more than one disk is involved, a CT scan may not clearly identify the ruptured disk. MRI is used to image the vertebral elements, thecal sac, disks, cerebrospinal fluid, nerve roots, and spinal cord. This noninvasive examination is increasingly being used to provide initial diagnosis. Myelography with contrast medium illustrates areas of herniation but does not provide the detail found with CT or MRI. However, myelography is diagnostic in 80% to 90% of all cases and is used to both rule out tumors and locate the herniation. A myelogram is a radiologic examination of the subarachnoid space of the spinal canal, using a contrast agent. A myelogram is performed to visualize the lumbar, thoracic, or cervical area, or the whole spinal axis. It is used in the diagnosis of a spinal cord tumor, a herniated intervertebral disk, or a ruptured disk. Any obstruction of the flow of the contrast medium can be seen on X-ray film. To perform a myelogram, a lumbar puncture is performed and about 10mL of cerebrospinal fluid is removed. A water-based contrast medium such as jopamidol (Isovue) is injected into the subarachnoid space. When the medium is injected, it diffuses up through the CSF and penetrates the nerve root sleeves, nerve rootlets, and narrow areas of the subarachnoid space. The head of the X-ray table is kept elevated at 30 degrees and the client is kept quiet to prevent rapid upward dispersion. If the contrast medium entered the cranial vault, it could cause seizures. The contrast medium is absorbed through the bloodstream and eliminated by the kidneys. Nursing implications for the care of a client having a myelogram are outlined in the box below. Electromyography (EMG), which measures electrical activity of skeletal muscles at rest and during voluntary contraction, may be conducted to identify specific muscles affected by the pressure of the herniation on the nerve roots. MEDICATIONS

The client with a ruptured intervertebral disk is treated with medications to relieve pain and reduce swelling and muscle spasms. Pain is usually managed with nonsteroidal anti-inflammatory drugs. Muscle spasms are treated with muscle relaxants. Treatment A ruptured intervertebral disk may be treated conservatively or with surgery. Conservative Treatment A ruptured intervertebral disk is usually managed conservatively with bed rest and medication unless the client is experiencing severe neurologic deficits. The goals of treatment are pain relief and healing of the involved disk by fibrosus. Conservative treatment is usually prescribed for 2 to 6 weeks. After that time, surgery may be considered. The treatment regimen depends on the severity of the manifestations but usually includes one or more of the following (Hickey, 2003): -Decreasing activity leve -Avoiding flexion of the spine (e.g do not lift, bend, or twist) -Wearing a support garment, such as a corset or cervical collar -Following a prescribed exercise program -Using a firm matress -Taking prescribed medications for pain, inflammation, and muscle spasms Some clients achieve pain relieve with transcutaneous electrical stimulation (TENS) or transcutaneous neural stimulation (TNS). Another pain relief intervention is bed rest. It is important that the client use a firm mattress. The client should lie so that the pull on the affected nerve is reduced. Clients with lumbar involvement should usually flex the knees and elevate the head of the bed to about 30 degrees. After 4 days or less of bed rest, the client may begin walking and an exercise program designed by the physical therapist. This program includes teaching proper body mechanics and positioning, exercises to strengthen the back and decrease muscle spasms, massage, and the application of heat. Most clients report a good recovery after conservative management. Medications used to treat back pain include nonnarcotic analgesics, anti-inflammatory drugs such as NSAIDs, muscle relaxants, and sedative-tranquilizers.