Common Neurosurgical Hospital Consult Diagnoses

Common Neurosurgical HospitalConsult Diagnoses Jeff Crecelius Neurosurgeon Goodman Campbell Brain and Spine

Disclosures • None really • Will use word Kyphoplasty which is commercial but in widespread use • No financial interest in Kyphon, but did first case in Lafayette, and received free barbecue at training course in Memphis many years ago

Brain Bleeds • Sounds dramatic, and sometimes it is; but often not. • Epidural • Subdural • Subarachnoid • Intracerebral

Epidural Hematoma • Relatively uncommon-only1-2% of TBI • Good prognosis if “pure” i.e. isolated • Lucid interval is classic, but uncommon (20%) • Prompt surgery is important • Usually in younger patient with relatively low energy trauma

Subdural Hematoma • Acute in high energy injury associated with other brain involvement • Acute in low energy may be tolerated if in elderly with atrophy and room to spare • Subacute (from clot to red liquid) may be treated with “just” burr hole • Chronic (crankcase fluid) commonly recognized in elderly weeks after minor injury

Subarachnoid Hemorrhage • Traumatic usually from high energy injury • Spontaneous from many sources • Aneurismal cause in about 75% • Others causes include AVM, tumor, vasculitis Cause usually apparent from CT pattern and history—if likely from aneurysm, we transfer to Indianapolis for evaluation

Intracerebral • Hypertensive • Ischemic • Vascular Malformations (AVM, Cavernous) • Amyloid Angiopathy • Trauma (DTICH) • Tumor • THIN Blood (growing incidence of iatrogenic)—another day for that!

Normal Pressure Hydrocephalus • Misnomer and really a spectrum of disease • Triad of symptoms • Gait Disturbance=“Stuck”, but not unique • Incontinence (which is common with immobility) • Dementia • Difficult diagnosis (especially in hospital otherwise ill with co morbidity) • Clinical • Imaging (CT, MR, Isotope Cisternogram) • Tap Test vs. Ambulatory Lumbar Drainage

Radiculopathy • Common especially C6&C7, L5&S1 • Red Flags • Age<20,>50; Weight loss; Fever; Worse at rest • Cauda Equina Syndrome • Rare but increasingly reported • Insurance restriction of MR>PCP staff overwhelmed>Street knowledge of incontinence as the key to cut the red tape. • Uncommon to have normal reflexes and exam though

No Red Flag Radiculopathy • Brief rest (2-3days) • Walk • PT if gentle (but conditioned to be Aggressive) • Analgesic • Muscle relaxants • Education/reassurance • SMT • Steroids? (IV, oral, ESI)

Osteoporotic Thoracolumbar Compression Fractures • Risk Factors • Low Weight • Cigarettes • Family History • Female (especially postmenopausal) • Alcohol • Steroids • Inactivity

Evaluation of Fracture • X-ray • Compare if available • MRI • Acuity? • CT and Bone Scan • If MR contraindicated (ex. Implants like pacemaker)

Treatment of Fracture • Non-invasive • Rest with DVT prophylaxis • Analgesics • PT • Brace • Typical time course about 6 weeks • Follow up x-rays about 2 week intervals • Assess progression

Treatment of Fracture • Invasive (augmentation) • Vertebroplasty • Kyphoplasty • Multilevel Stabilization • Rare

Indications for Augmentation • At least 5% height loss • Intractable Pain • Activity related and at fracture site • Acute or Subacute on MR or Bone Scan • Also may be used for hemangiomas, myeloma, or metastases (off label)

Contraindications to Augmentation • Healed (cold on bone scan/old on MR) • Coagulopathy • Evolving leniency by IR re anti-platelet agents • Retropulsion • Planum

Questions • Thanks

Common Neurosurgical Hospital Consult Diagnoses