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


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

  • Functions:

  • Senses changes in environment

  • Interprets changes

  • Stimulates movement to respond to these changes


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

  • 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

  • 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

  • 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

  • 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

  • Vertebra

  • 33 total

  • 7 cervical

  • 12 thoracic

  • 5 lumbar

  • Sacrum formed by 5 fused bones

  • Coccyx formed by 4 fused bones


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 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

  • 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

  • Protected by the cranium or skull


Brain

  • 4 major parts:

  • Brain stem

  • Diencephalon

  • Cerebellum

  • Cerebrum

    Weight about 3 lbs.


Support Structures of the Brain

1. Meninges

  • Continuous layer with spinal cord

  • NO epidural space


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 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

  • 3 parts:

  • Medulla oblongata

  • Pons

  • Midbrain


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


Pons

  • Above medulla

  • Switching point for motor neurons

  • Respiratory center


Midbrain or Mesencephalon

  • Above pons

  • Involuntary eye and head movement in response to auditory stimuli


Diencephalon

  • 2 parts:

  • Thalmus

  • Hypothalmus


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

  • 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

  • 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

  • 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


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

  • 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 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 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


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

  • Spondylosis

  • Extrusion of disk


Lumbar Pathology

  • Spondylosis

  • Stenosis

  • Spondylolithesis

  • Disk extrusion


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

  • 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

  • Includes;

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


Spinal Cord Trauma

  • Vertebral Fracture

  • Vertebral Dislocation

  • Herniated disk into spinal canal

  • Laceration from GSW or MVA


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

  • Craniosynotosis “premature closure of the

    cranial sutures” Price, 2004

  • Hydrocephalus result of obstructed CSF flow

  • Spina bifida


Infection

  • Abscess

  • Subdural empyema

  • Post-op infection


Spinal Cord Tumors

  • Intramedullary in the spinal cord

  • Intradural in dura, outside spinal cord

  • Extradural outside spinal cord Price, 2004


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

  • History and physical

  • Symptoms usually specific to area of pathology

  • Electroencephalogram (EEG)

  • X-ray

  • Myelogram

  • CAT Scan

  • MRI

  • Cerebral arteriograms


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

  • General

  • Could be local with MAC for minor laceration suturing


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

  • 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

  • Toweled out

  • Adhesive type drape

  • Specialty drapes: laparotomy, thyroid, craniotomy, lumbar

  • Stockinette for peripheral procedures


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

  • 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

  • See pages 987-990 in PRice


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 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

  • Infection

  • Hemorrhage

  • Nerve damage

  • CSF leakage

  • Meningitis

  • Neurological deficits


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