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Essentials of Neurosurgery

Essentials of Neurosurgery. Michelle Miller, PA-C Primary Care Associate Program July 12, 2005. Introduction. Conditions treated by Neurosurgery Other surgical specialties Role of Primary Care Providers Diagnosis When to refer Post-operative follow-up Common post-operative conditions.

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Essentials of Neurosurgery

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  1. Essentials of Neurosurgery Michelle Miller, PA-C Primary Care Associate Program July 12, 2005

  2. Introduction • Conditions treated by Neurosurgery • Other surgical specialties • Role of Primary Care Providers • Diagnosis • When to refer • Post-operative follow-up • Common post-operative conditions

  3. Conditions Treated by Neurosurgeons • Hydrocephalus • Trauma to head or spine • Degenerative spine diseases • Disk herniations • Spondylotic disease • Spinal instability • Neurovascular disease • Aneurysms & arteriovenous malformations of the brain & spinal cord • Carotid stenosis • Intracranial hemorrhage of any etiology

  4. Conditions Treated by Neurosurgeons

  5. Conditions Treated by Neurosurgeons • Neurooncology • Tumors • Brain & meninges • Pituitary gland • Spine & spinal column

  6. Conditions Treated by Neurosurgeons • Peripheral nerve injury or entrapment • Carpal tunnel syndrome • Congenital malformations • Medically intractable disorders • Movement disorders (Parkinson’s) • Epilepsy • Chronic pain

  7. Other Surgical Specialties • Orthopedic Surgery • Spinal instrumentation • Traumatic injuries • Plastic Surgery • Peripheral nerve entrapment

  8. Other Surgical Specialties • Vascular Surgery • Carotid endarterectomy (CEA)

  9. Role of Primary Care Provider • Initial diagnosis and treatment • Symptom management • Referral to specialty care • Identification of emergent versus urgent conditions • Coordination of care • Pre-operative clearance • Post-operative care • Healthcare Maintenance • Record-keeping

  10. Case Study 35 year old female presents to your office following her vacation for c/o of chronic headaches, described as “sinus pain,” for approximately 6 months. She denied any recent illness, fever or congestion. She did mention that during her vacation she fell, but denied any injury. She stated, “ I lost my balance.”

  11. Discussion

  12. Brain Tumors • Primary brain tumors • Glial cells • Neuronal cells • Meninges • Benign versus malignant • Primary malignant brain tumors rarely metastasize but are locally invasive of surrounding parenchyma • Benign tumors are encapsulated • Grade IV astrocytoma (glioblastoma) is the most common primary brain tumor of adults

  13. Glioblastoma Multiforme (GBM)

  14. Brain Tumors • Metastatic disease (secondary brain tumors) • Malignancies with the greatest tendency to metastasize to brain • Lung • Breast • Renal • thyroid

  15. Corticosteroids in Neurosurgery • Introduced into Neurosurgery in the 1960’s • Radically improved the acute management of brain tumors • Steroids are used to treat edema caused by recent surgical manipulation • How do they work? • By stabilizing the blood-brain barrier, corticosteroids effectively reduce vasogenic edema in the brain or spinal cord associated with tumors

  16. Corticosteroids in Neurosurgery • Decadron (dexamethasone) • Most commonly used corticosteroid • Pure glucocorticoid with no mineralcorticoid effect (unlike prednisone or hydrocortisone) • Can be given enterally or intravenously • Side effects • GI bleeding • Hyperglycemia • Immunosuppression • Poor wound healing • Psychosis • Long-term steroid use: osteoporosis, fat redistribution, myopathy

  17. Seizures • Caused by synchronous paroxysmal discharge from cerebral cortex • Frequently, a seizure is the first presentation of an intracranial lesion, especially with brain tumors • Anticonvulsant prophylaxis • Before & after surgery • Titrated according to blood levels and seizure control

  18. Anticonvulsants • Dilantin (phenytoin) • Luminal (phenobarbital) • Tegretol (carbamazepine) • Depakote (valproic acid) • Neurontin (gabapentin) • Keppra (levetiracetam)

  19. Dilantin • Most commonly used first-line anticonvulsant for a patient with a new presentation of generalized or focal seizures • Dilantin allergies • Red macular rash • Unexplained fever • Altered liver function • Dilantin overdose • Arrhythmias • Hyperreflexia • Dysarthria • Confusion • Nystagmus • ataxia

  20. Blood Pressure Control • During & after intracranial surgery, control of hypertension is critical for the prevention of brain hemorrhage

  21. Fluid & Electrolyte Management • Volume status • Hyponatremia • Disorders of ADH regulation

  22. Hyponatremia • Should be avoided in neurosurgery patients because it exacerbates brain edema and lowers seizure threshhold • Normal adult values: 135-145 mEq/L

  23. Ventriculoperitoneal (VP) Shunt • A Ventriculoperitoneal shunt is surgically placed to relieve intracranial pressure caused by hydrocephalus • Intracranial hemorrhage, spina bifida, brain tumor, meningitis, encephalitis

  24. Ventriculoperitoneal (VP) Shunt • When ventricles become enlarged with cerebrospinal fluid • Brain tissue becomes compressed against the skull • Excess fluid accumulates around the brain causing an increase in intracranial pressure • Serious neurological problems result • Shunting is necessary to drain the excess fluid and relieve pressure in the brain • Excess pressure can cause a decrease in blood flow to the brain leading to brain damage

  25. Ventriculoperitoneal (VP) Shunt-Craniotomy for Cerebral Shunt • Performed in the OR under general anesthesia • A flap is cut in the scalp and a small hole is drilled in the skull • A small catheter is passed into a ventricle of the brain • A pump (valve which controls flow of fluid) is attached to the catheter to keep fluid away from the brain

  26. Ventriculoperitoneal (VP) Shunt • The fluid is shunted from the ventricles of the brain into the abdominal cavity • In some cases, the fluid is shunted to the pleural space in the chest • A pump controlling fluid flow is attached to the catheter to keep the fluid away from the brain • Another catheter is attached to the pump • It tunnels under the skin, behind the ear, down the neck and chest and into the abdominal cavity

  27. When to Refer • Emergent referrals • Emergency Department • Mental status changes • Cauda equina syndrome (nerve compression) • Motor deficits • Sensory deficits • Bowel/bladder incontinence or retention • radiculopathy • Urgent referrals • Neurosurgeon • Conservative therapies fail

  28. Post-operative Follow-up • Surgery date? • Suture/staple removal • Wound care • Infection, drainage, swelling, pain? • Laboratory follow-up? • Drug levels • Chemistries • Medication management • Long & short term management • Antiepileptic • Sleep aides • GI upset

  29. Post-operative Follow-up • Pain management • Precautions • Drug interactions • Physical Therapy • DMV clearance • Support groups • Depression • Issues of death & dying • Chemotherapy and Radiation

  30. Catheters • Hickman catheter • Long-term, central venous indwelling catheter with external port(s) • Infusion of blood products, nutrition, chemotherapy • Must be meticulously cared for to prevent infection • Venous placement- subclavian, under clavicle • Placement in OR or via radiology • Fluoroscopy-guided placement • Requires CXR to confirm placement prior to use

  31. Hickman Catheter

  32. Review Questions

  33. Questions A 6 year old male is struck by a car while riding his bicycle. He is reported to be unconscious for 2 min following the accident. He is conscious and alert upon arrival to the ED, but within 45 min, he begins to vomit and shortly thereafter he becomes completely unresponsive. Which of the following most likely explains the child’s injury?

  34. Answer Acute subdural hematoma Chronic subdural hematoma Acute epidural hematoma Acute traumatic subarachnoid hemorrhage Grade III concussion

  35. Answer Acute subdural hematoma Chronic subdural hematoma Acute epidural hematoma Acute traumatic subarachnoid hemorrhage Grade III concussion

  36. Answer This is a classic history of an epidural hematoma. The typical presentation is that of a child who sustains a hard blow to the head and experiences a brief loss of consciousness, followed by a lucid interval, when the child is awake and alert. As the hematoma expands, the patient experiences a headache followed by vomiting, lethargy and hemiparesis and may progress to coma if left untreated. This injury usually results from a temporal bone fracture with a laceration of the middle meningeal artery or vein and less often a tear in a dural venous sinus. Epidural hematomas are treated with surgical evacuation of the clot and ligation of the bleeding vessel.

  37. Question Which of the following is/are true of lumbar disc herniation?

  38. Answer Most common at the L5-S1 disc Radiating pain to the buttocks, thigh, calf, and foot Often associated with a positive straight leg raise test May be complicated by cauda equina syndrome All of the above

  39. Answer Most common at the L5-S1 disc Radiating pain to the buttocks, thigh, calf, and foot Often associated with a positive straight leg raise test May be complicated by cauda equina syndrome All of the above

  40. Answer A herniated lumbar disc compresses the nerve root, resulting in a radicular pain called lumbar radiculopathy. The pain characteristically radiates to the buttock, thigh, leg, and foot. When the pain is severe, the pain can be worsened by straight leg raising and may be limited to 20 to 30 degrees. The patient may have decreased or absent reflexes, weakness, and paresthesias or decreased sensation in a dermatomal distribution. It is most common at the L5-S1 disc followed by the L4-L5 disc.

  41. Question The most common intracerebral neoplasm is:

  42. Answer Glioma Meningioma Lymphoma Metastasis adenoma

  43. Answer Glioma Meningioma Lymphoma Metastasis adenoma

  44. Answer Glioma account for nearly 50% of primary brain tumors. The remainder are meningiomas (15%), pituitary tumors (7%) and other tumors.

  45. Break

  46. Essentials of Cardiothoracic Surgery Michelle Miller, PA-C Primary Care Associate Program July 12, 2005

  47. Conditions Treated by Cardiothoracic Surgeons • Coronary Artery Bypass Graft (CABG) • Valve Replacement or Repair • Tissue • Xenograft (porcine or bovine) • Homograft (cadaveric human) • Mechanical • Video Assisted Thoracotomy (VATS) • Tumor ressection • AAA Repair • Trauma • Transplant Surgery • Heart • Lung

  48. Coronary Artery Bypass Graft • Cardiac bypass surgery is an operation to restore the flow of blood through the arteries that supply blood to the heart, when a blockage or partial blockage occurs in these arteries. • The arteries that supply the heart muscle with oxygen and nutrients are known as the coronary arteries. The word "coronary" means a crown, and is the name given to these arteries that circle the heart like a crown. The narrowing of the arteries of the heart is known as coronary artery disease, which is the most common form of heart disease.

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