Assessment of Central Nervous
System and Low Back Pain
1
Dr Ibraheem Bashayreh, RN, PhD
4/1/2011
MEDICAL SURGICAL
NURSING
NERVOUS SYSTEM
Controls and integrates sensory, motor, and
autonomic functions
 Maintains internal homeostasis
 Enables connection and response to external
environment

NEURON
Working cell of the nervous system
 Carries impulses

Sensory (afferent)
 Motor (efferent)


Neurotransmitters (chemicals)

Facilitate or hinder impulse transmission across
synapse
A NEURON.
CENTRAL NERVOUS SYSTEM
Brain
 Spinal cord

BRAIN

Control center of the nervous system
THE FOUR MAJOR REGIONS OF THE BRAIN WITH AN ILLUSTRATION OF THE MENINGES.
BRAIN

Cerebrum; sensation, movement
Left hemisphere; speech, problem solving, reasoning,
calculations
 Right hemisphere; visual, spatial abilities (relating to
the position, area and size of things), Face
recognition, Visual imagery and Music

BRAIN

Diencephalon
Thalamus; sensory relay
 Hypothalamus; regulatory center

Brainstem: vital centers
 Cerebellum

Involuntary muscle activity; fine motor
 Balance and posture

SPINAL CORD

Spinal tracts
Sensory and motor messages
 White matter and gray matter

PERIPHERAL NERVOUS SYSTEM
Cranial nerves
 Spinal nerves
 Somatic nervous system
 Autonomic nervous system



Sympathetic
Parasympathetic
PERIPHERAL NERVOUS SYSTEM
Link between CNS and the body
 Spinal nerves

31 pairs
 Sensory and motor fibers
 Involved in reflexes/reflex arc

DISTRIBUTION OF SPINAL NERVES.
CRANIAL NERVES
Cell bodies in brain/brainstem
 Sensory function, motor function, or both
 Mainly control head and neck functions

AUTONOMIC NERVOUS SYSTEM
Maintains internal homeostasis
 Two divisions

Sympathetic: “flight or fight”
 Parasympathetic: “rest and digest”

NEUROLOGIC ASSESSMENT

LOC always assessed first


Altered LOC leads to inaccuracies
Determine alternate sources of information

Family, caregivers, health care professionals
ASSESSMENT

Subjective

Past medical history
Actual neurologic disorders/family history
 Medication use
 Symptom history; include pain assessment
 Social/environmental data

ASSESSMENT

Subjective
Motor: loss of movement; altered balance,
coordination
 Sensory: numbness, tingling, sight, touch
 Cognitive: memory, speech, intellect, mood

ASSESSMENT

Subjective

Eye
PMH/family history related to the vision
 Changes in vision; use of corrective lenses; irritation


Ear
PMH/family history related to hearing
 Changes in hearing; tinnitus drainage
 Use of hearing aids

ASSESSMENT

Objective

General survey

Appearance, gait, balance, posture
Vital signs
 Cranial nerve assessment

ASSESSMENT

Objective

Cognitive functioning


Sensory functioning


Sight, sounds, touch
Motor functioning


LOC, mental status, mood
Muscle strength, tone symmetry
Reflexes
ASSESSMENT

Objective

Eye
Snellen, Rossenbaum charts
 Inspection


Ear
Rinne, Webber, whisper tests
 Inspection

EXPECTED ALTERATIONS RELATED TO AGING
Slower movement and reflexes
 Forgetfulness
 Changes in sleep patterns
 Changes in motor skills

EXPECTED ALTERATIONS RELATED TO AGING
Ptosis
 Presbyopia
 Decreased tear production
 Changes in eyelids
 Hearing difficulties
 Increased production of cerumen

UNEXPECTED ALTERATIONS RELATED TO
AGING

Significant changes in






Long/short-term memory
Mental status
Coordination/motor skills
Speech
Pain perception
Sleep
UNEXPECTED ALTERATIONS RELATED TO
AGING

Significant changes in
Orientation
 Psychologic status

LABORATORY TEST
Electrolytes
 Complete blood count
 Liver function tests
 Renal panel
 Arterial blood gases
 Cultures
 Urinalysis

IMAGING STUDIES

All radiographic studies
Allergy assessment—shellfish/iodine
 Hydration, renal function
 Pregnancy concerns
 Client teaching about procedure

IMAGING STUDIES

Skull/spine x-rays


Client teaching/explanation
MRI
Assess for implanted metal
 Client teaching: enclosed space; noise

The implants that are most prone to causing
problems for patients with MRIs are the
following:
* Pacemakers or heart valves
* Metal implants in a patient's brain
* Metal implants in a patient's eye or ears
* Infusion catheters

IMAGING STUDIES

CT scan
ID shellfish/iodine allergy
 Assess disorientation
 Medicate for agitation
 Teach: warm sensation with contrast

IMAGING STUDIES

Cerebral angiography





NPO prior
Flushing with contrast media
Close neurologic/VS monitoring post
Pressure dressing/ice
Report bleeding/swelling at site STAT
IMAGING STUDIES

Myelography
Post: elevate HOB, bed rest
 Close neurologic/VS monitoring
 Report leakage/bleeding at site STAT

IMAGING STUDIES

Positron emission tomography (PET): is a nuclear
medicine imaging technique which produces a
three-dimensional image or picture of functional
processes in the body.
NPO 4 hours prior
 IV start
 Post: hydration


Carotid duplex
ELECTROGRAPHIC STUDIES

EEG, evoked potentials


Wash hair prior
Electromyography (EMG) :involves testing the
electrical activity of muscles

Discomfort with needle insertion
VISION TESTS

Fluorescein stain


Visual fields


Tiring
Facial x-rays/CT scan


Potential stinging; staining not permanent
Explain procedure
Ultrasound

Cornea anesthetized
HEARING TESTS

Audiometry


X-ray/CT scan


Explain procedure
Explain procedure
Caloric Testing (Electronystagmography)
Post assessment; vomiting
 Aspiration precautions

4/01/2011
LOW BACK PAIN
Dr Ibraheem Bashayreh, RN, PhD
37
EPIDEMIOLOGY
of adults will experience LBP at some point in
their lives
 5th most common cause of all physician visits
 Peak incidence 20-40 years old; More severe in
older patients
 85% of patients have no definitive anatomic cause
or imaging finding
 Most cases are self limited with serious problems
in < 5%
 Most common cause of work-related disability for
individuals < 45 years old
4/01/2011
 75%
38
ANATOMY REVIEW
4/01/2011
39
Normal Anatomy of the Functional Spinal Unit (L4-5) and Associated Neural Structures
4/01/2011
40
Rathmell, J. P. JAMA 2008;299:2066-2077.
LBP: RISK FACTORS
lifting and
twisting
 Obesity
 Poor physical
fitness/conditioning
 History of low back
trauma
 Psychiatric
history(chronic LBP)
4/01/2011
 Heavy
41
LBP CLASSIFICATION
Etiologic
Mechanical
 Non-Mechanical
 Visceral


4/01/2011

Temporal
Acute
 Chronic

42
MECHANICAL LBP/LEG PAIN
ETIOLOGIES (97%)
usually attributable to musculoligamentous
injuries or age-related degenerative disease in
intervertebral disks and facet joints
 Lumbar strain (70%)
 Degenerative disk and facets (10%)
 Herniated disk (4%)
 Spinal Stenosis (3%)
 Osteoporotic compression fracture (4%)
 Traumatic fracture (<1%)
 Congenital disease (<1%)
Kyphosis
 Scoliosis
4/01/2011


43
NON MECHANICAL LBP ETIOLOGIES (1%)
Inflamatory, infectious our systemic disease effecting
vertebral musculoskeletal structures
 Neoplasia (0.7%)






Infection (<0.01%)




Multiple myeloma
Metastatic carcinoma
Lymphoma / Leukemia
Spinal cord tumors
Primary vertebral tumors
4/01/2011

Osteomyelits
Septic diskitis
Epidural abcess
Inflammatory arthritis (0.3%)




Ankylosing spondylitis
Psoriatic spondylitis
Reiter’s syndrome
Inflammatory bowel disease
44
spondylitis is a chronic,
inflammatory arthritis and autoimmune
disease. It mainly affects joints in the
spine eventual fusion of the spin
syndrome is a chronic form of
inflammatory arthritis three conditions
are combined: arthritis; inflammation of
the eyes (conjunctivitis); and
inflammation of the genital, urinary or
gastrointestinal systems.
4/01/2011
 Ankylosing
 Reiter's
45
VISCERAL DISEASE INDUCED LBP:
ETIOLOGIES (2%)
Process involving anatomic site other that vertebral
musculoskeletal structures

Disease of pelvic organs




4/01/2011

Prostatitis
Endometriosis
Chronic Pelvic Inflammatory Disease
Renal disease



Nephrolithiasis
Pyelonephritis
Perinephric abcess
Aortic aneurysm
 Gastrointestinal disease




Pancreatitis
Cholecystitis
Penetrating ulcer
46
MECHANICAL LBP DIFFERENTIAL DIAGNOSIS :
CLINICAL FEATURES
Herniated disk


Usually occurs in adults aged 30 to 55 years
Sciatica, often associated with leg numbness or paresthesias, is a


highly sensitive (95%) and specific (88%) finding for herniated disk
Exacerbation of pain may occur with




4/01/2011

coughing
sneezing
Valsalva maneuvers : is performed by moderately forceful attempted
exhalation against a closed airway, usually done by closing one's
mouth and pinching one's nose shut
Spinal Stenosis


usually occurs in older adults
characterized by neurogenic claudication (impairment in walking,
or a "painful, aching, cramping, uncomfortable, or tired feeling in
the legs that occurs during walking and is relieved by rest)



radiating back pain and lower extremity numbness
exacerbated by walking and spinal extension
improved by sitting
47
LOW BACK PAIN CLASSIFICATION
(TEMPORAL)
Acute Low Back Pain


4/01/2011

< 6 week duration
Chronic Low Back Pain

> 6 week duration
48
ACUTE LBP
History
Time-course of onset (associated
activity; time of day)
 Pain
Location (site, radiation)
Nature (sharp, throbbing, dull, etc.)
Severity
Aggravating/relieving factors
 Prior injuries
 Age

4/01/2011

49
ACUTE LOW BACK PAIN
Three clinical groups of Acute LBP
Symptoms of potentially serious spinal condition
(tumor, infection, fracture)
 Sciatica (discomfort radiating to legs)
 Nonspecific back symptoms (most common is strain
of soft tissue elements)

4/01/2011

50
CLINICAL ASSESSMENT ACUTE LBP
Neurologic sensation, muscle
strength(dorsiflexion of foot and great toe)
 Peripheral pulses
 Stance and gait
 Flexibility
 Focal tenderness
 Straight leg raise


4/01/2011
 Physical Exam
 Should be comprehensive, but focus on:
Non-physiologic symptoms

consider depression, mental illness
51
CLINICAL ASSESSMENT OF PERSISTENT
(CHRONIC) LBP
History
 Additionally consider
 History of cancer
 Age > 50 (malignancy, osteoporotic fracture)
 Recent unexplained weight loss (underlying
malignancy)
 Recent IV drug use (Osteomyelits, Septic
diskitis,Paraspinous or Epidural abcess)
 Presence of chronic infection (as above)
 Prior treatments and their effectiveness
 Pain unrelieved with positional
changesconsider infection, cancer (not specific, 52
however)
4/01/2011

CLINICAL ASSESSMENT OF ETIOLOGY





Systemic
Inflammatory
Infectious
Neoplastic
Severe mechanical injury
4/01/2011
Is this likely to represent a serious illness?
53
Clinical Assessment of Etiology
Risk factors
Major trauma:


Corticosteroid use:


Greater risk for underlying malignancy
Unexplained weight loss:


Greater risk for malignancy, osteoporotic fracture
History of cancer:


Greater risk for osteoporotic fracture
Age >50 y:


Possible fracture
4/01/2011

Greater risk for malignancy or infection
Fever, immunosuppression, immunodeficiency, injection
54
drug use, or active infection:

Risk for spinal infection
CLINICAL ASSESSMENT: PSYCHOSOCIAL
4/01/2011
Are there complicating psychosocial factors that may impede
treatment or prolong pain and predict poor outcomes?





history of failed treatment,
depression, and somatization (a psychiatric diagnosis applied to
patients who persistently complain of varied physical symptoms
that have no identifiable physical origin).
Substance abuse,
job dissatisfaction
ongoing litigation or compensation claims
55
WHEN TO USE RADIOLOGY?
4/01/2011
Age >50 years
 Recent significant trauma
 Neurologic deficits
 Systemic symptoms
 Fever
 Unexplained weight loss
 History of cancer, substance abuse, chronic
corticosteroid use

56
TREATMENT





LBP
Superficial heat, deep heat, cold packs
NSAIDs mainstay, narcotics only if severe pain and
only for short duration
Reevaluate treatment after 4 weeks
90% get better within 4 weeks
Physical Therapy
 Persistent
4/01/2011
 Acute
LBP
Intensive exercise (poor compliance)
 Treatment of concomitant mental illness if present
 Patient education
 Referral to pain center (combination of modalities) 57

INTERVENTIONAL PAIN THERAPIES
Corticosteriod Injection
 Facet injection
 Intrathecal Analgesia
4/01/2011
 Epidural
Chronic refractory non-cancer pain
Limited quality of evidence (observational)
 Should be reserved for patients refractory to other
interventions


 Intradiskal

Electrothermal Therapy
39% of Chronic LBP diskogenic
 Thermal
sensory nerve ablation
58
INDICATIONS FOR SURGERY
Primary indication:

Severe or increasing neurologic deficit
4/01/2011

Sciatica and herniated disk
 Spinal stenosis
 Spondylolysthesis



Spinal stenosis symptoms
Severe, persistent pain or sciatica for 12 months or more
59
PREVENTION STRATEGIES
and
strengthening
exercises
 Weight loss?
 Smoking cessation?
 Improvement of
strenuous and
stressful working
conditions
 Back braces are
ineffective in
prevention
4/01/2011
 Exercise
60
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61
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62
SITTING POSTURE
4/01/2011
When sitting in any
position, the three
back curves need to
be maintained.
 If you cannot sit
without slouching
forward or backward,
you need to support
yourself with hands
and arms or lean
against a wall or chair
back.
63
SITTING POSTURE
4/01/2011
64
SITTING POSTURE:
4/01/2011
65
4/01/2011
LYING POSTURE:
 Avoid propping head or
upper body up on an arm
and hand.
 Head should remain
relaxed. Legs should be
together.
66
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67