SPINAL CORD TUMORS
Tumors within the spine are classified according to their anatomic relation to the spinal cord. They include intramedullary lesions (within the spinal cord), extramedullary-intradural lesions (within or under the spinal dura), and extramedullary-extradural lesions (outside the dural membrane). Tumors occurring within the spinal cord or exerting pressure on it cause symptoms ranging from localized or shooting pains and weakness and loss of reflexes above the tumor level to progressive loss of motor function and paralysis. Usually, sharp pain occurs in the area innervated by the spinal roots that arise from the cord in the region of the tumor. In addition, increasing sensory deficits develop below the level of the lesion.
Neurologic examination and diagnostic studies are used to make the diagnosis. Neurologic examination includes assessment of pain, loss of reflexes, loss of sensation or motor function, and the presence of weakness and paralysis. Helpful diagnostic studies in-clude x-rays, radionuclide bone scans, and MRI. MRI is the most sensitive diagnostic tool and is particularly helpful in detecting epidural spinal cord compression and vertebral bone metastases ( Jacobs& Perrin, 2001; Nevidjon & Sowers, 2000).
Treatment of specific intraspinal tumors depends on the type and location of the tumor and the presenting symptoms and physical status of the patient. Surgical intervention is the primary treat-ment for most spinal cord tumors. Other treatment modalities include partial removal of the tumor, decompression of the spinal cord, chemotherapy, and radiation therapy, particularly for in-tramedullary tumors and metastatic lesions ( Jacobs& Perrin, 2001).
Epidural spinal cord compression occurs in approximately 5% of patients who die of cancer and is considered a neurologic emer-gency (Nevidjon & Sowers, 2000). In the patient with epidural spinal cord compression resulting from metastatic cancer (most commonly from breast, prostate, or lung), high-dose dexametha-sone combined with radiation therapy is effective in relieving pain (Nevidjon & Sowers, 2000).
Tumor removal is desirable but not always possible. The goal is to remove as much tumor as possible while sparing uninvolved portions of the spinal cord. Microsurgical techniques have im-proved the prognosis for patients with intramedullary tumors. Prognosis is related to the degree of neurologic impairment at the time of surgery, the speed with which symptoms occurred, and the tumor origin. Patients with extensive neurologic deficits be-fore surgery usually do not make significant functional recovery even after successful tumor removal.
The objectives of preoperative care include recognition of neuro-logic changes through ongoing assessments, pain control, and management of altered activities of daily living due to sensory and motor deficits and bowel and bladder dysfunction. The nurse as-sesses for weakness, muscle wasting, spasticity, sensory changes, bowel and bladder dysfunction, and potential respiratory prob-lems, especially if a cervical tumor is present. The patient is also evaluated for coagulation deficiencies. A history of aspirin intake is obtained and reported because the use of aspirin may impede hemostasis postoperatively. Breathing exercises are taught and demonstrated preoperatively. Postoperative pain management strategies are discussed with the patient before surgery.
The patient is monitored for deterioration in neurologic status. A sudden onset of neurologic deficit is an ominous sign and maybe due to vertebral collapse associated with spinal cord infarction. Frequent neurologic checks are carried out, with emphasis on movement, strength, and sensation of the upper and lower ex-tremities. Assessment of sensory function involves pinching the skin of the arms, legs, and trunk to determine if there is loss of feeling and, if so, determining at what level. Vital signs are mon-itored at regular intervals.
The prescribed pain medication should be administered in ade-quate amounts and at appropriate intervals to relieve pain and prevent its recurrence. Pain is the hallmark of spinal metastasis. Patients with sensory root involvement or vertebral collapse may suffer excruciating pain, which requires effective pain management.
The bed is usually kept flat initially. The nurse turns the pa-tient as a unit, keeping shoulders and hips aligned and the back straight. The side-lying position is usually the most comfortable because this position imposes the least pressure on the surgical site. Placement of a pillow between the knees of the patient in a side-lying position helps to prevent extreme knee flexion.
If the tumor was in the cervical area, the possibility of postoper-ative respiratory compromise arises. The nurse monitors the pa-tient for asymmetric chest movement, abdominal breathing, and abnormal breath sounds. For a high cervical lesion, the endotra-cheal tube remains in place until adequate respiratory function is ensured. The patient is encouraged to perform deep-breathing and coughing exercises.
The area over the bladder is palpated or a bladder scan is per-formed to assess for urinary retention. The nurse also monitors for incontinence because urinary dysfunction usually implies sig-nificant decompensation of spinal cord function. An intake and output record is maintained. Additionally, the abdomen is aus-cultated for bowel sounds.
Staining of the dressing may indicate leakage of CSF from the surgical site, which may lead to serious infection or to an inflam-matory reaction in the surrounding tissues that can cause severe pain in the postoperative period.
In preparation for discharge, pa-tients are assessed for their ability to function independently in the home and for the availability of resources such as family members to assist in caregiving. Patients with residual sensory involvement are cautioned about the dangers of extremes in temperature. They should be alert to the dangers of heating devices (eg, hot water bottles, heating pads, and space heaters). The patient is taught to check skin integrity daily. Patients with impaired motor function related to motor weakness or paralysis may require training in activities of daily living and safe use of assistive devices, such as a cane, walker, or wheelchair.
The patient and family member are instructed about pain management strategies, bowel and bladder management, and assessment for signs and symptoms that should be reported promptly.
Referral for inpatient or outpatient rehabilita-tion may be warranted to improve self-care abilities. A home care referral may be indicated and provides the home care nurse with the opportunity to assess the patient’s physical and psychological status and the patient’s and family’s ability to adhere to recom-mended management strategies. During the home visit, the nurse determines whether changes in neurologic function have oc-curred. The patient’s respiratory and nutritional status is assessed. The adequacy of pain management is assessed, and modifications are made to ensure adequate pain relief. The need for hospice ser-vices or placement in an extended-care facility is discussed with the patient and family if warranted, and the patient is asked about preferences for end-of-life care (Chart 65-3). Additionally, social workers may be consulted to assist the patient and family mem-bers in identifying support groups and agencies that can provide help in coping with the disease process.
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