Neurosurgery
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Neurosurgery. Outline. A & P Pathology Diagnostics/Pre-operative Testing Medications/Anesthesia Positioning/Prepping/Draping Supplies/Instrumentation/Equipment Dressings/Drains/Post-op Care

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Neurosurgery

Neurosurgery


Outline

Outline

  • A & P

  • Pathology

  • Diagnostics/Pre-operative Testing

  • Medications/Anesthesia

  • Positioning/Prepping/Draping

  • Supplies/Instrumentation/Equipment

  • Dressings/Drains/Post-op Care

  • Procedures: Carpal Tunnel Release, Craniotomy, Cervical Discectomy, Lumbar Discectomy, Ventroperitoneal Shunt


Nervous system

Nervous System

  • Functions:

  • Senses changes in environment

  • Interprets changes

  • Stimulates movement to respond to these changes


Organization of the nervous system

Organization of the Nervous System

  • Two systems:

    1. CNS Central Nervous System

  • Two major parts: Brain and Spinal Cord

    2. PNS Peripheral Nervous System

  • Everything else


Peripheral nervous system

Peripheral Nervous System

  • Two major parts:

  • Afferent Nervous System

  • Sensory neurons take info from PNS to CNS

  • Efferent Nervous System

  • Motor neurons take info from CNS to PNS


Efferent nervous system

Efferent Nervous System

  • Motor nervous system

  • 2 parts:

  • Somatic Nervous System

  • Skeletal muscle control

  • Conscious control

  • Autonomic Nervous System

  • Cardiac muscle, smooth muscle, and glands

  • Unconscious control

  • Has 2 divisions:

  • Sympathetic Division

  • Parasympathetic Division


Autonomic nervous system

Autonomic Nervous System

  • Sympathetic vs. Parasympathetic

  • Controlled by hypothalamus and medulla oblongata

  • Both are different nerves going to the same effector or target

  • Are antagonistic

  • Parasympathetic = decreased skeletal blood flow, increased organ blood flow (quietly eating)

  • Sympathetic = increased skeletal blood flow, decreased organ blood flow (eatus interruptus by a bear!) Also called fight or flight; prepares body for emergencies


Spinal cord

Spinal Cord

  • Functions:

  • Info to and from the brain

  • Integration of reflexes

  • Location:

  • Begins at foramen magnum and extends to 2nd lumbar

  • About 16-18” in length


Spinal cord support structures

Spinal Cord Support Structures

  • Vertebra

  • 33 total

  • 7 cervical

  • 12 thoracic

  • 5 lumbar

  • Sacrum formed by 5 fused bones

  • Coccyx formed by 4 fused bones


Intervertebral disks

Intervertebral Disks

  • Separate vertebrae

  • Outer layer is tough and called the annulus fibrosis

  • Inner core is soft and called the nucleus pulposus

  • Bear stress incurred with body weight and when lifting


Spinal cord support structures1

Spinal Cord Support Structures

  • Meninges

  • Between vertebra & spinal cord

  • Epidural space between vertebra and dura mater

  • Dura Mater outermost layer extends to S-2

  • Subdural space between dura mater and arachnoid

  • Arachnoid extends to S-2

  • Subarachnoid space contains CSF

  • Pia Mater adheres directly to spinal cord and extends to L-2

  • Meninges also cover brain/continuous layer/difference epidural space not present


Spinal nerves

Spinal Nerves

  • 31 pair

  • Names and numbers depend on where enter and exit

  • Each has a ventral and dorsal root

  • Ventral root = motor

  • Dorsal root = sensory

  • 8 cervical

  • 12 thoracic

  • 5 lumbar

  • 5 sacral

  • 1 coccygeal


Brain

Brain

  • Protected by the cranium or skull


Brain1

Brain

  • 4 major parts:

  • Brain stem

  • Diencephalon

  • Cerebellum

  • Cerebrum

    Weight about 3 lbs.


Support structures of the brain

Support Structures of the Brain

1. Meninges

  • Continuous layer with spinal cord

  • NO epidural space


Support structures of the brain1

Support Structures of the Brain

2. Cerebrospinal fluid (CSF)

  • About 800ml produced each day by the choroid plexus, a specialized set of capillaries

  • Circulates inside subarachnoid space through central canal of spinal cord and the ventricles of the brain

  • Reabsorbed in arachnoid villus found in the parietal lobe

  • Functions as a shock absorber and circulates nutrients


Support structures of the brain2

Support Structures of the Brain

  • Blood Brain Barrier

  • Specialized set of capillaries exclusive to the central nervous system

  • Less permeable than any other capillaries in the body

  • Advantage = keeps out unwanted chemicals

  • Disadvantage = difficult to diffuse materials out, hence difficulty in treating conditions such as encephalitis


Brain stem

Brain Stem

  • 3 parts:

  • Medulla oblongata

  • Pons

  • Midbrain


Medulla oblongata

Medulla oblongata

  • Contains:

  • 5 of 12 cranial nerves

  • Pyramids: function only with motor neurons/a crossing of the spinal nerve impulses

  • Reflex centers: hiccupping, sneezing, coughing

  • Vital reflex centers:

  • Cardiac center – heart rate

  • Vasoconstrictor center-BP via blood vessel diameter control

  • Respiratory center - breathing


Neurosurgery

Pons

  • Above medulla

  • Switching point for motor neurons

  • Respiratory center


Midbrain or mesencephalon

Midbrain or Mesencephalon

  • Above pons

  • Involuntary eye and head movement in response to auditory stimuli


Diencephalon

Diencephalon

  • 2 parts:

  • Thalmus

  • Hypothalmus


Thalmus

Thalmus

  • Relay center for sensory information

  • Interprets stimuli for example pain from changes in temperature (hot stove)

  • 1st level of reasoning occurs here

  • Recognizes crude touch NOT localized touch


Hypothalmus

Hypothalmus

  • Controls large number of subconscious functions

  • Controls most of Autonomic nervous system

  • Where endocrine and nervous systems interface

  • Homeostasis regulation of the body

  • Controls: body temp, thirst, hunger, sleep and waking habits, psychosomatic disorders, rage and aggression


Cerebellum

Cerebellum

  • 2nd largest part of the brain

  • Primarily a motor area

  • Controls skeletal muscles, subconsciously

  • Receives sensory input from eyes, muscles, joints, and inner ear

  • Posture, balance, coordination, equilibrium

  • Muscle sense tells body where other parts are


Cerebrum

Cerebrum

  • Largest part of brain

  • Motor/sensory/association area

  • 4 Lobes: frontal, parietal, occipital, temporal

  • Each controls a specific function be it motor or sensory

  • Limbic system: controls emotion/functions in cerebral cortex and diencephalon

  • See page 970 Figure 24-4 in Price


Cerebrum lobes function

Frontal

Memory, abstract thinking, ethics, judgement, emotion, expressive speech, motor

Parietal

Sensory, receptive speech, written word

Temporal

Auditory, olfactory

Occipital

Visual cortex

Visual association

Cerebrum Lobes’ Function


Cranial nerves

Cranial Nerves

  • All originate in the brain stem EXCEPT the 1st and 2nd

  • Classified as sensory or mixed (sensory and motor) nerves

  • Directly off of brain

  • Do not go through the spine

  • Identified by Roman numerals and names


Cranial nerves1

Cranial Nerves

  • Olfactory - sense of smell

  • Optic – sense of sight/vision

  • Occulomotor – eyeball, eyelid movement (medial, inferior, superior rectus, inferior oblique), pupil constriction, lens accommodation

    Muscle sense for eyeball

  • Trochlear – eyeball movement (superior oblique)

    Muscle sense for eyeball

  • Trigeminal – masseter muscle control

    Sensory part has 3 branches: ophthalmic (forehead to corner of eye), maxillary (corner of eye to upper lip/teeth), and mandibular (lower lip/teeth/tongue)

    All three convey sense of touch, pain and temp changes

  • Abducens - same as IV eyeball movement (lateral rectus) and eyeball muscle sense

    FYI: EOM formula LR6(SO4)3


Cranial nerves2

Cranial Nerves

  • Facial- facial muscles, lacrimal and salivary glands anterior 2/3 of tongue (taste)

  • Vestibulocochlear -last of totally sensory nerves; has 2 branches: vestibular conveys balance and cochlear which conveys sense of hearing

  • Glossopharyngeal -salivary gland secretion and posterior 1/3 of tongue

  • Vagus – internal organ control motor and sensory; originates in medulla and goes down through neck into chest and abdomen

  • Accessory – controls head and neck movement, speech, and muscle sense for the head

  • Hypoglossal – tongue muscles: swallowing, speech, muscle sense for tongue


Neuro pathology

Neuro Pathology


Cervical spine pathology

Cervical Spine Pathology

  • Very serious

  • Can have severe consequences related to all of the spinal cords’ nerve pathways

  • Spondylosis is osteophyte or bone spur formation in the spinal canal

  • Cervical disk extrusion acute or chronic

  • Treatment errs on the side of caution due to potential extreme consequences of surgical intervention


Thoracic pathology

Thoracic Pathology

  • Spondylosis

  • Extrusion of disk


Lumbar pathology

Lumbar Pathology

  • Spondylosis

  • Stenosis

  • Spondylolithesis

  • Disk extrusion


Neoplasms tumors

Neoplasms/Tumors

  • Two types:

  • Primary

  • Originate in nervous tissue or meninges

  • Secondary

  • Are metastasized from other parts of the body

  • May be classified as benign or malignant


Tumors

Tumors

  • Benign tumors:

  • “Craniopharyngiomas, epidermoids, hemangiomas, menigiomas, acoustic neuromas, and pituitary microadenomas” Price, 2004

  • Malignant tumors:

  • “Astrocytes or gliomas” Price, 2004

  • Benign usually excisable via craniotomy

  • Malignant normally cannot be completely removed but efforts are made to remove most


Head trauma

Head Trauma

  • Includes;

  • Scalp lacerations, fractures, hematomas (epidural or subdural), and brain injuries


Spinal cord trauma

Spinal Cord Trauma

  • Vertebral Fracture

  • Vertebral Dislocation

  • Herniated disk into spinal canal

  • Laceration from GSW or MVA


Cerebrovascular disease

Cerebrovascular Disease

  • #3 cause of death in US

  • Symptoms reflect ischemia (TIAs) or hemorrhage

  • Intracranial aneurysm

  • Arteriovenous malformations

  • Brain hemorrhage

  • Stroke or cerebrovascular accident (CVA)


Congenital pathology

Congenital Pathology

  • Craniosynotosis “premature closure of the

    cranial sutures” Price, 2004

  • Hydrocephalus result of obstructed CSF flow

  • Spina bifida


Infection

Infection

  • Abscess

  • Subdural empyema

  • Post-op infection


Spinal cord tumors

Spinal Cord Tumors

  • Intramedullary in the spinal cord

  • Intradural in dura, outside spinal cord

  • Extradural outside spinal cord Price, 2004


Peripheral nerve pathology

Peripheral Nerve Pathology

  • Carpal tunnel syndrome - compression of the median nerve

  • Ulnar nerve compression – compression of ulnar nerve by the ligament of Osborne

    Price, 2004


Diagnosis

Diagnosis

  • History and physical

  • Symptoms usually specific to area of pathology

  • Electroencephalogram (EEG)

  • X-ray

  • Myelogram

  • CAT Scan

  • MRI

  • Cerebral arteriograms


Medications

Medications

  • Lidocaine 1% with epinephrine

  • Topical hemostatic agents: gelfoam, avitene, surgicel, bone wax

  • Antibiotic irrigants

  • Topical papaverine for prevention of spasm during intracranial artery surgery

  • Methyl methacrylate with cranioplasty

  • Heparin saline irrigation again with intracranial artery surgery

  • Contrast solutions with cerebral arteriography

  • Gliadel wafers (tumor bed of glioblastoma)


Anesthesia

Anesthesia

  • General

  • Could be local with MAC for minor laceration suturing


Positioning

Cranial Surgery

Supine primarily, with a specialty headrest and or fixation devices

Can be lateral or semi-lateral

Sitting

Prone

Varies with location of access

Spinal surgery

Anterior procedures require supine

Posterior procedures require prone

Positioning


Preps

Preps

  • Will require shave especially on head

  • Varies with surgeon preference: betadine, alcohol, chlorohexidine

  • Care taken NOT to get in patient’s eyes or facial orifices


Draping

Draping

  • Toweled out

  • Adhesive type drape

  • Specialty drapes: laparotomy, thyroid, craniotomy, lumbar

  • Stockinette for peripheral procedures


Supplies

Supplies

  • Marking pen

  • Disposable bi-polar cord

  • Monopolar pencil/bovie

  • Cottonoids/patties

  • Raney clips

  • Hemostatic clips

  • Shunt catheters, tubing, connectors

  • Cotton balls

  • Hemovac drain

  • Nerve stimulator

  • Telfa

  • Microscope drape

  • C-Arm drape

  • Ultrasound wand drape


Instruments

Instruments

  • Minor tray if laminectomy and craniotomy trays do not have basic instrumentation

  • Laminectomy tray

  • Craniotomy tray

  • Basic ortho tray

  • Plates and screws

  • Specialty self-retaining retractor trays: Greenburg


Miscellaneous instrumentation

Miscellaneous Instrumentation

  • See pages 987-990 in PRice


Equipment

Equipment

  • microscope

  • Video tower

  • YAG or CO2 laser

  • Positioning equipment: Mayfield headrest, Gardner-Wells

  • Operative Ultrasound machine

  • Stereotaxis system

  • CUSA Cavitron ultrasonic aspirator

  • Bipolar and monopolar ECU

  • Nitrogen source for power equipment (saws/drills)

  • Mayfield overbed table

  • Headlight and light source

  • C-Arm and monitor

  • Cell saver

  • Fluid warming and temperature regulating equipment


Dressings drains post op care

Dressings/Drains/Post-op Care

  • Dressings surgeon preference

  • Drains surgeon preference

  • Post-op care: keep field sterile until patient has left the OR

  • Careful with moving patient to avoid patient injury and hemorrhage


Post operative complications

Post-operative Complications

  • Infection

  • Hemorrhage

  • Nerve damage

  • CSF leakage

  • Meningitis

  • Neurological deficits


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