NCP Herniated Nucleus Pulposus (Ruptured Intervertebral Disc)

A herniated disc (herniated nucleus pulposus) [HNP] is a major cause of severe, chronic, and recurrent back pain.

Herniation, either complete or partial, of the nuclear material in the vertebral areas of L-4 to L-5, L-5 to S-1, or C-5 to C-6, C-6 to C-7 is most common and may be the result of trauma or degenerative changes associated with the aging process.


Most disc problems are treated conservatively at the community level, although diagnostics and therapy services may be provided through outpatient facilities. Brief hospitalization is restricted to episodes of severe debilitating pain/neurological deficit.


Disc surgery

Psychosocial aspects of care

Patient Assessment Database

Data depend on site, severity, whether acute/chronic, effects on surrounding structures, and degree of nerve root compression.


May report: History of occupation requiring heavy lifting, sitting, driving for long periods

Need to sleep on bedboard/firm mattress, difficulty falling asleep/staying asleep

Decreased range of motion of affected extremity/extremities

Inability to perform usual/desired activities

May exhibit: Atrophy of muscles on the affected side

Gait disturbances


May report: Constipation, difficulty in defecation

Urinary incontinence/retention


May report: Fear of paralysis

Financial, employment concerns

May exhibit: Anxiety, depression, withdrawal from family/SO


May report: Tingling, numbness, weakness of affected extremity/extremities

May exhibit: Decreased deep tendon reflexes; muscle weakness, hypotonia

Tenderness/spasm of paravertebral muscles

Decreased pain perception (sensory)


May report: Pain knifelike, aggravated by coughing, sneezing, bending, lifting, defecation, straight leg raising; unremitting pain or intermittent episodes of more severe pain; radiation to leg/feet, buttocks area (lumbar), or shoulder or head/face, neck (cervical)

Heard “snapping” sound at time of initial pain/trauma or felt “back giving way”

Limited mobility/forward bending

May exhibit: Stance: Leans away from affected area

Altered gait, walking with a limp, elevated hip on affected side

Pain on palpation


May report: History of previous back problems


May report: Lifestyle sedentary or overactive

Discharge plan DRG projected mean length of inpatient stay: 4.9–6.5 days considerations: May require assistance with transportation, self-care, and homemaker/maintenance tasks Refer to section at end of plan for postdischarge considerations.


Spinal x-rays: May show degenerative changes in spine/intervertebral space or rule out other suspected pathology, e.g., tumors, osteomyelitis.

CT scan with/without enhancement: May reveal spinal canal narrowing, disc protrusion.

MRI: Can reveal changes in bone, discs, and soft tissues and can validate disc herniation/surgical decisions.

Provocative tests (discography, nerve root blocks): Determine site of origin of pain by replicating and then relieving symptoms. Can also be used to rule out sacroiliac joint involvement.

Electrophysiological studies—electromyoneurography (EMG) and nerve conduction studies (NCS): Can localize lesion to level of particular spinal nerve root involved; nerve conduction and velocity study usually done in conjunction with study of muscle response to assist in diagnosis of peripheral nerve impairment and effect on skeletal muscle.

Myelogram: Rarely performed, but when done, may be normal or show “narrowing” of disc space, specific location and size of herniation.

Epidural venogram: May be done for cases where myelogram accuracy is limited.


1. Reduce back stress, muscle spasm, and pain.
2. Promote optimal functioning.
3. Support patient/SO in rehabilitation process.
4. Provide information concerning condition/prognosis and treatment needs.


1. Pain relieved/manageable.
2. Proper lifting, posture, exercises demonstrated.
3. Motor function/sensation restored to optimal level.
4. Disease/injury process, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.