Transcript Neurosurgery

Pathologies, Procedures
and Room Set-Up
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Degenerative diseases - arthritis, osteoperosis
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Herniated disks or bulging disk
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Commonly occur at L4-5, L5-S1
Spinal stenosis
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Most common cause for neck pain and back pain
Narrowing of spinal canal
Common in cervical & lumbar regions
Tumors
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Most common are metastatic
Cord compression causing pain and weakness
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Most common injuries are
fractures, subluxation, disk
herniation
Cervical spine most
vulnerable to injury
Need early stabilization to
minimize cord trauma
Spinal cord injury
Complete: lacks sensation,
position sense, & voluntary
motor function below level
of injury
 Incomplete: still has some
sensory, position sense &
motor impulses present
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Removal of one or more vertebral lamina from
to expose spinal canal to treat
Used to treat:
Compression fracture
 Degenerative changes
 Dislocation
 Herniated disk
 Tumor causing pressure on spinal cord
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Removal of ruptured
annulus fibrosus or
herniated nucleus
pulposus
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Often replaced with
bone graft
Herniated or ruptured
disk most common
injury seen by
neurosurgeons
Most occur in lower
lumbar region
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Stabilization of spine by locking vertebrae
together
Uses:
Plates
 Screws
 Rods
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May be indicated following injury or excision
of bone
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Anterior Cervical Spine
Supine with mayfield pins or horseshoe on radiolucent
table or regular bed
 May need cervical traction
 Arms tucked to side
 Pillow under knees
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Anterior Lumbar/Thoracic
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Supine
Pillow under knees
Radiolucent table
Rails clear for retractor (bookwalter, omni)
General surgeon needed to gain access to spine
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Posterior cervical
Prone with head in mayfield pins or face on foam pillow
 Gel chest rolls, wilson, or jackson frame
 Arms tucked down to side
 Radiolucent table
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Posterior lumbar/thoracic
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Prone on gel chest rolls, Jackson, Wilson frame, or
Cloward
 Arms overhead not extended greater than 90 degrees
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Radiolucent table
Make sure there are enough people to safely
transfer
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XLIF (eXtreme
lumbar interbody
fusion)
Incision on
patient’s side
Lateral decubitus
position (90º)
Secure body so no
moving
Iliac crest at break
in bed
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Bovie, suction and warmer at foot of bed
C-arm available
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May use flat plate instead
Midas
Headlight
May use microscope
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Blood clot causing increase ICP
and compression of brain
Three types
Epidural
 Subdural
 Intracerebral
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Burr Holes or Craniotomy or
Craniectomy to decompress
brain and remove/drain blood
clots
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Tumors within the brain or
its membranes
Metastatic tumors more
common than primary
Classified by histologic type
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glioblastoma, menegioma
Symptoms
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Progressive neurologic
deficit
 motor weakness
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Headaches and seizures
Diffuse increase in ICP
Depends on location
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Excessive accumulation of CSF in ventricles resulting
in increased ICP
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Reasons
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Congenital abnormalities, aqueductal stenosis, tumor,
subarachnoid hemorrhage, meningitis
Common among young children and older adults
Acute or Chronic
Infants
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Due to obstruction, poor absorption, or overproduction of CSF
Enlarged head, seizures, vomitting, sleepy
Adults
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Impaired balance, memory loss, poor coordination, headache
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Bur Holes
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Craniotomy
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Small hole for minimum
exposure to brain
Hematoma, VP shunt
Remove bone flap and is
replaced at end of case
with plates/screws
Hematoma, aneurism,
tumor
Craniectomy
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permanent removal of
section of skull
Severe head injury, tumor,
infected bone
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Supine
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Prone
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Approach most commonly for frontal, parietal and
temporal lobes
Mayfield pins or horseshoe or head on gel doughnut
Approach for occipital lobe
Head in mayfield pins
Semi fowlers
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Head in mayfield pins
For occipital approach
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Mayfield pins
Bacitracin ointment for pins
 Surgeon will place pins and have control of head
while transferring patient
 Do not move the patient after pins placed and head
locked in place, could break neck
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May turn the bed 90 or 180 degrees
At least 1 arm tucked
Clip hair
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Save hair for patient
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Mayfield with pins or horseshoe headrest
Bovie, suction and warmer at foot of bed
Midas
Microscope
Headlight
Clippers
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Supine
Arms tucked
Pillow under knees
Head on pillow or in
mayfield
May turn bed
Often assisted by an
ENT surgeon
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Bovie, suction and
warmer at foot of bed
Microscope
Stereostatic
navigation
Mayo prep stand to
include:
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Local, bayonet
forceps, nasal
speculum, syringe
and neuro patties
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Catheter placed in ventricle through bur hole and
connected to external drainage system
One way valve system drains CSF away from
ventricle into the peritoneum
Supine
May need access to abdomen
 Arms tucked
 Pillow under knees
 May turn bed
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May send CSF
Confirm implant with surgeon
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Local
Bacitracin ointment
Bacitracin irrigation
Hemostatic agents
Bone grafts
Crani plates
Fusion hardware
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Electosurgery:
monopolar, bipolar
Bone wax
Sponges
Cottonoids
Hemaclips
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Thrombin
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Floseal/Surgiflo
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Catalyzes conversion of
fibrinogen to fibrin
Soak cotton patties or
gelfoam in thrombin and
then apply topically
Gelatin matrix is mixed
with thrombin
Topical gel that clots
bleeding site
Gelfoam
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Absorbable gelatin
sponge placed topically
over bleeders, often
soaked in thrombin
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Avitene
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Surgicel
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Collagen hemostat,
usually a loose fibrous
form that is placed
topically with bleeding
surface, attracts
platelets to the area
Oxidized regenerated
cellulose pad, placed
topically & forms clot,
as absorbs it becomes
gel
Local Anesthetic with
epinephrine
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Cancellous bone chips
DBX bone putty
Demineralized Bone Matrix used
to fill gaps or voids in bone
 Absorbs as bone grows and
takes up the space
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BMP
Bone Morphogenetic Protein
(synthetic) is reconstituted then
absorbed into a collagen sponge
 The BMP stimulates bone
growth and the sponge gets
absorbed
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Osteocel
Contains stem cells so acts like
autographs because biologically
active
 Kept in freezer
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