Objectives
 Discuss the anatomy of the spine in relation to
fractures or degenerative disease.
 Identify common nursing goals in care of the
adult spine patient.
 Describe typical nursing concerns for a post-op
spine patient.
Anatomy
 Bony = Vertebrae
 Soft tissue = Discs, ligament
 Cord & Nerve Roots
Definitions
Cervical (7)
Thoracic (12)
Lumbar (5)
Sacral (5)-fused
Definitions con’t
 Normal Curve-”S shaped” looking from lateral
view
 Scoliosis – abnormal lateral curve with rotation
of vertebrae as well
 Kyphosis- anterior curvature of thoracic spine
 Radicular- referred pain from pressure on spinal
nerve root
Spine Fracture
 Etiology:
 Trauma vs non traumatic
• Elderly – Tumors, metabolic, renal, thyroid
 Stable vs unstable
 Neurologic status
3 Column Theory
Anterior
Posterior third
Middle Third
Anterior Third
 Any 2 = unstable
Fractured C-Spine Examples
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Odontoid
Hangman’s
Tear drop
Jefferson’s
Odontoid
 Type I
 Type II
 Most difficult
to healshown
 Type III
Hangman’s
 Hyperextension and
distraction
 Injury occurs in anterior
portion of C2 vertebrae
 Piths spinal cord
Tear Drop
 Hyperflexion
 Anterior Ligament pulls
off corner of anterior
vertebrae
 UNSTABLE
Jefferson’s Fracture
 Burst fracture of C1,
disrupting the ring of the
atlas
 Spinal canal is widened
 50% - NO neuro deficits
 Occasionally requires
fusion of occiput to C1
Complications
 Atlanto-occipital dislocation
 Neurologic damage
 Permanent or temporary
below level of bony injury
 Death
Diagnostic Studies Needed
 X-ray 2 planes
 AP & x table lateral
 May need swimmer’s view
for ? Otontoid fx
 Flexion Extension
 C-spine Ligamentous injury
 Spasm 10-14 days
Diagnostic Studies Needed con’t
 CT scan
 MRI if nerve injury
suspected
Therapeutic Modalities
 Log roll
 Specialty beds
 Braces
 Surgery
Surgical Spinal Fixation
 Halo
 Posterior Spinal fusion
 Rods, Hooks, Screws
 Anterior Spinal fusion
 Plates, Cage
Nursing Interventions
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Neurologic Status Documentation
Sensation level
Motor function
Spasm
Nursing / Body Mechanics
Communication of findings key!!
Sensation Levels
Neurologic Status Documentation
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Sensation levels
Shoulder = C-5
Nipple T-4
Umbilicus T-10
Great toe L-4
Motor Function
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Neurologic Status Documentation
Motor Function
EHL toe extension L4-5
Tighten Anus S 3-5
Thumb pointing up, index
finger straight ahead C-6-8
Nursing Considerations
 Cast Syndrome
 Potentially life threatening syndrome caused by
hyperextension of lumbar spine that results in
compression of the superior mesenteric arterybowel ischemia
 Brace use / skin care / pin care
 Activity / Bowels / Nutrition
Nursing Considerations
 Home Care Instructions
 Neurovascular symptoms to report
 Brace use
 Surgical care
Question #1
Joshua, 19, was involved in a motor vehicle
crash, unbelted. He reportedly has an L-2
burst fracture. As his nurse, you would:
A. Have him use the trapeze to lift himself in
bed.
B. Log roll him side to side as a unit.
C. Have him sit first then dangle his legs to
prevent dizziness.
D. Boost him with help lifting under his armpits.
Answer #1
Joshua, 19, was involved in a motor vehicle crash,
unbelted. He reportedly has an L-2 burst
fracture. You will :
b. Log roll him side to side as a unit.
Rationale: Log rolling a spine patient is essential to
prevent further neurological impairment
Question #2
Joshua is taken emergently to the OR for
decompression and posterior spinal fusion. His postop orders call for a TLSO. Which of the following
instructions about TLSO care is correct?
a. Red and purple marks on skin under brace are
normal.
b. It is acceptable to wear it loose.
c. Take it off when ever you are standing upright.
d. Report any vomiting or abdominal pain immediately.
Answer #2
Joshua is taken emergently to the OR for decompression
and Posterior spinal fusion. His post-op orders call for a
TLSO. Which of the following statements are true?
D. Report any vomiting or abdominal pain immediately.
Rationale: Vomiting or abdominal pain might indicate
compression against the abdominal cavity, causing
vomiting and abdominal pain.
Spondylolysis / Spondylolisthesis
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Define:
Spondylo = vertebrae
Lysis = broken
Listhesis = slipped
forward
Spondylolysis / Spondylolisthesis
 M = F Teens or Elderly
 Genetics, stress, degenerative
 Gymnasts, football lineman, weight
lifters
 Elderly OA of facets > loose joints,
repetitive stress on vertebrae
Spondylolysis / Spondylolisthesis
 Chronic or acute LBP
 Often radicular in nature
 Exam
 Spasms + SLR
 Tight hamstrings
Spondylolysis / Spondylolisthesis
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Treatment- Conservative
Rest 3 days maximum!! /Back Brace
Analgesics / Antispasmodics / ice or heat
Physical therapy / Back School (Education)
Avoid painful activities
Spondylolysis / Spondylolisthesis
 PSF with or
without
instrumentation
 ASF for severe
slips or failed PSF
Question #3
The surgeon has chosen to fix a spine with pedicle
screws and posterior spinal fusion. During a post-op
nursing assessment, which one of the following
would be urgently reported to the surgeon?
a. Absent or sluggish bowel sounds.
b. Pain and spasm in lower mid back.
c. Inability to feel side of left thigh or move left leg.
d. Burning on urination.
Answer #3
The surgeon has chosen to fix a spine with pedicle screws
and posterior spinal fusion. During pre-op nursing
assessment you note this (these) urgently reportable
changes related to fracture site.
C. Inability to feel side of left thigh or move left leg
Rationale: This would be indicative of neurological
impairment and are essential to be reported
immediately. The other problems are expected and/or
not emergent.
Herniated Nucleus Pulposa
 M > F 20-45yrs
 Etiology
 Degeneration
 Abnormal body mechanics
 Deconditioned - Poor muscle tone
 Trauma
Herniated Nucleus Pulposa
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History- Some Event
Back and leg pain
Numbness and/or dysesthesias
Muscle weakness-nerve distribution
^ with sitting / sneezing, coughing
Worse with valsalva
Herniated Nucleus Pulposa
Exam “Classic Sign”
Painful SLR
Won’t lean forward
Change in sensation,
strength or reflexes
 Bowel or Bladder changes
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Herniated Nucleus Pulposa
 Radiographs / MRI /EMG
Herniated Nucleus Pulposa
 Treatment- Conservative (80%)
 Rest 3 days max
 Analgesics / Antispasmodics / ice or heat
 Physical therapy / Education
 Avoid painful activities
 Epidural Steroids
 Surgical
 Laminectomy no fusion
Question #4
Fred c/o pain, which is horrible if he sneezes. He can’t
even sit in his car. He was dx with a herniated disc,
hates hospitals & wants to know what else can be done
besides surgery. Which of the following is the best
response?
a. Rest, analgesics, antispasmodics, and back care
education help 80% of the people.
b. He should continue all activity even if it is painful for 3
days.
c. There is no other treatment. He needs a fusion.
d. Steroid injection it works 100% of the time.
Answer #4
Fred c/o pain, which is horrible if he sneezes. He
can’t even sit in his car. He was dx with a
herniated disc, hates hospitals & wants to know
what else can be done besides surgery. You
explain:
A. Rest, analgesics, antispasmodics, and back
school help 80% of the people.
Rationale: For this type of problem, conservative
treatment is the most beneficial.
Degenerative Disc Disease
M >F Not Always Elderly
 water content in disc
Annular ligament fiber failure
Hx: back pain w/ activities for
a while
 May have radicular symptoms
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Spinal Cord Problems
 SCI
 Spinal Stenosis
Spinal Cord Injury
 Traumatic M>F
 Complete vs Incomplete
 Meaning some sparing
of neurological function,
either sensory or motor
 Level is everything!
Levels
 Spinal Cord – C1-L1
 Conus Medularis Dist spinal cord
 Bowel Bladder
 Cauda Equina Lesions = Roots below Conus L-2
Spinal Stenosis
 Etiology: congenital vs acquired (degenerative)
 Lumbar region most common
 Also called neurogenic claudication
Spinal Stenosis
 Back pain, leg pain when upright
 Walking usually makes symptoms
worse-“neurogenic claudication”
 Relieved by bending, sitting
 Nocturnal leg cramps
Spinal Stenosis
 Exam normal
 Can be abnormal if severe hypertrophy of
bone in foramen, causing nerve root
compression
 Check pulses r/o PVD- may need ABIs
 Check for hip OA
 X-ray: normal for age but may demonstrate
hypertrophy of bone in foramen
 MRI to eval. nerves
Spinal Stenosis Treatment
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Activity modification
Altered expectations
Therapy to improve endurance, strength
Epidural steroids
Surgery: Decompression
 +/- fusion
Degenerative Scoliosis
 Lateral curvature of the
spine
 40-50 ° may require
surgery
 Etiol: Degenerative disc
Kyphosis (45°)
 Posterior “hump” thoracic region
 Etiology
 Congenital
 Scheuermann’s disease
 Neuromuscular
 Ankylosing spondylitis
 Metabolic (Osteoporosis)
 Tumor
Ankylosing Spondylitis
 M>F
 Inflammatory disease
Surgical Intervention
 ABC’s, normal Post-op
 Often serious cardiopulmonary compromise
 Neurologic exams
DOCUMENT
 Pain control, positioning
 Bowel & bladder
Questions
Thank You!