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Back to Basics for Surgery Neurosurgery

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Title: Back to Basics for Surgery Neurosurgery


1
Back to Basics for SurgeryNeurosurgery
  • R. Moulton

2
Principles of Neurological Diagnosis
3
Questions
  • What is the lesion
  • Where is the lesion

4
  • History
  • Physical (Neurological) Examination
  • Special Tests

5
Presentation of Neurosurgical Illness
  • Raised ICP
  • Headache, vomiting
  • papilloedema
  • Neurological Dysfunction
  • General level of consciousness
  • Focal sensory or motor loss
  • Seizures
  • Pain

6
  • What is the lesion history
  • Where is the lesion neurological exam

7
History (What is the lesion?)
  • Symptoms
  • Mode of onset
  • Speed of onset
  • Prior relevant illness
  • Progression/regression of symptoms

8
Neurological Examination (Where is the Lesion?)
  • Level of Consciousness GCS
  • Mental status orientation, memory,
    concentration, abstraction, calculation
  • Cranial Nerves
  • Motor examination
  • Upper vs. lower motor neuron
  • Cerebellar function
  • Gait
  • Sensory examination
  • light touch, pain temp, joint position sense
  • Cortical sensory modalities

9
Cranial Nerves
  • I Olfactory
  • II Optic
  • III Oculomotor
  • IV Trochlear
  • V Trigeminal
  • VI Abducens
  • VII Facial
  • VIII Acoustic
  • IX Glossopharyngeal
  • X Vagus
  • XI Accessory
  • XII Hypoglossal

10
Motor Examination
  • Upper Motor Neuron
  • Weakness (distal gt proximal) antigravity muscles
    preserved
  • Increased reflexes and tone (spasticity)
  • Disuse atrophy
  • Loss of coordination (ataxia)
  • Apraxia
  • Upgoing plantar response

11
  • Lower Motor Neuron
  • Weakness
  • Decreased tone
  • Decreased reflexes
  • Denervation atrophy
  • Coordination usually intact

12
Sensory Examination
  • Special senses cranial nerves
  • Basic Modalities
  • Light touch, pain temp, vibration
    proprioception
  • Dermatomes, peripheral nerve distribution
  • Cortical Modalities
  • Graphaesthesia, stereognosis, simultaneous
    appreciation of tactile stimuli,
    somatotopognosis, agnosagnosia, neglect

13
Special Tests
  • Biochemical, hematological, microbiology
  • Blood
  • CSF
  • Imaging
  • Plain x-rays
  • CT
  • MRI
  • Angiography
  • Electrophysiology
  • EMG, nerve conduction, EEG etc.

14
Neurological Examination of the Comatose Patient
  • Level of Consciousness
  • Glasgow Coma Score
  • Brainstem Integrity
  • Pupillary Reaction
  • Ocular Movement
  • Corneal reflexes
  • Gag/breathing

15
  • Eye Opening
  • spontaneous 4
  • to voice 3
  • to pain 2
  • none 1
  • Verbal Response
  • oriented 5
  • confused - sentences 4
  • words only 3
  • sounds 2
  • none 1
  • Movement
  • obeys 6
  • localises 5
  • flexion withdrawal 4
  • abnormal flexion 3
  • extension 2
  • none 1

16
Rostral-Caudal Deterioration
  • Midbrain
  • Bilateral pupillary abnormalities
  • Oculomotor abnormalities
  • Pons
  • Loss of corneal reflexes
  • Medulla
  • Loss of gag reflexes
  • Respiratory and vasomotor collapse

17
Brain Tumour Classification
  • Intra-axial (frequently malignant)
  • Primary
  • Glial
  • Choroid plexus
  • Neuronal or mixed glial-neuronal
  • PNET/medulloblastoma
  • CNS lymphoma
  • Pineal region
  • hemangioblastoma
  • Metastatic

18
Brain Tumour Classification
  • Extra-axial (usually benign)
  • Meninges
  • Cranial nerves (Schwannoma)
  • Pituitary
  • skull

19
Glial Tumours
  • Astrocytoma (gliobastoma multiforme)
  • Oligodendroglioma
  • Ependymoma
  • Mixed tumours
  • Gr. I - IV

20
Treatment
  • Supportive
  • Specific
  • Corticosteroids (dexamethasone)
  • Surgical
  • Biopsy
  • Excision
  • Internal decompression

21
Treatment contd.
  • Radiotherapy
  • Conventional
  • Stereotactic focused
  • Chemotherapy
  • Temazolamide (malignant glial tumours)
  • Lymphoma protocols
  • Specific to tissue of origin for metastases
  • Observation

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No Contrast
With Contrast
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Stroke Classification and Management
29
Stroke Definition
  • Sudden onset of a neurological deficit due to
    disease or injury of the blood supply of the
    brain.

30
Stroke Classification
  • Ischemic
  • Bland
  • Hemorrhagic transformation
  • Hemorrhagic (hemorrhage is 10 event)
  • Hypertension
  • Amyloid angiopathy
  • Aneurysmal
  • AVM
  • Other

31
Ischemic Stroke (Infarction)
  • Thrombotic (local vessel disease)
  • Embolic
  • Artery to artery (usually carotid)
  • Heart to artery (atrial fibrillation)
  • Paradoxical (vein to artery)
  • Other (air, foreign body, iatrogenic)

32
Intracerebral Hemorrhage
  • Hypertensive
  • Occurs in long narrow perforating arteries (basal
    ganglia, thalamus, pons, cerebellar nuclei)
  • Charcot-Bouchard aneurysms
  • Related primarily to duration of hypertension

33
Intracerebral Hemorrhage
  • Amyloid angiopathy
  • Age related change in cerebral vessels
  • Lobar hemorrhage
  • Most commonly in posterior part of cerebral
    hemispheres

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Intracerebral Hemorrhage
  • AVM
  • Berry aneurysm
  • Subarachnoid hemorrhage
  • Usually exclusively subarachnoid
  • May have intracerebral component
  • Occasionally exclusively intracerebral

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Management
  • Diagnosis
  • History
  • Physical Examination
  • Special tests (imaging)
  • Treatment

40
Stroke Diagnosis
  • History
  • Rapid onset fixed deficit ischemic
  • Rapid onset progressive deficit hemorrhage
  • Sudden severe headache, nausea/vomiting/photophobi
    a /- neurological deficit - SAH

41
Stroke Physical Examination
  • Focal deficits
  • Most often ischemic stroke or ICH
  • Much less common in SAH
  • Alteration in level of consciousness
  • SAH
  • ICH
  • Delayed swelling from large infarcts

42
Stroke Investigation
  • CT scan
  • First line imaging to distinguish infarct from
    hemorrhage
  • 1st choice for confirming SAH, LP if negative
  • Other
  • Cerebral angiography, doppler for carotids
  • MRI in special circumstances

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Acute Stroke Treatment
  • Supportive
  • Airway
  • Blood pressure
  • Definitive
  • Thrombolysis
  • Hematoma evacuation (limited circumstances)

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Stroke Treatment
  • Prevention
  • Risk factor modification
  • Hypertension, smoking, diabetes,
    lipids/cholesterol
  • Antiplatelet agents (artery-artery embolism,
    local occlusive disease)
  • Anticoagulation (heart to artery emboli)
  • Surgical prevention
  • Carotid endarterectomy, stenting
  • Aneurysm obliteration
  • AVM excision

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Skull Fracture
54
Primary Impact Injury
  • Shear (diffuse) injury of axons
  • Laceration/contusion of cortical surface

55
Blumbergs, Head Injury, 199745
56
Cerebral Contusions
57
Secondary Insults
  • Hypoxia
  • Ischaemia
  • Intracranial hematomas
  • Raised intracranial pressure
  • Seizures
  • Infection
  • Fluid and electrolyte disturbance

58
Respiratory Changes in Head Injury
  • Depression/abolition of gag and cough reflexes
  • Hypercarbia 2o to respiratory centre depression
  • Hypoxemia -- systemic causes
  • inadequate airway management
  • chest trauma
  • aspiration

59
Recommendations for Treatment
Resuscitate aggressively with appropriate fluids
Brain oedema is not a concern
Manage source of bleeding in unstable patients
prior to transfer
Do not use mannitol in presence of
hypotension or you will further destabilise the
patient
Consider transient use of vasopressor drugs
while restoring volume and controlling
haemorrhage
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Trauma Craniotomy Incision
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Pressure Volume Curve
Pressure
Vskull Vbrain Vblood VCSF Vmass
Volume
67
Trans-Tentorial Herniation
68
Use of Mannitol
  • .5 - 1 gm./kg of 20 solution
  • give as a bolus
  • urinary catheter
  • Contraindications
  • Shock
  • Anuria

69
Other ICP Therapies
  • CPP therapy
  • Barbiturate Coma
  • Decompressive Craniectomy

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Back to Basics For Surgery
  • Spine

72
Pain Generators
  • Myofascial
  • Disc
  • Facet Joint
  • Nerve
  • Visceral
  • Vascular

73
Physical Examination The Spine
  • Inspect deformity
  • Palpate deformity, local tenderness
  • Range of motion (limitation, pain)

74
Myelopathy
  • a general term denoting functional disturbance
    and/or pathological changes in the spinal cord

75
Myelopathy Important Questions
  • Level of lesion
  • Nature of lesion
  • Surgical (spondylotic, neoplastic, infectious,
    hematoma, traumatic)
  • Treatment frequently curative
  • Non-surgical (degenerative, inflammatory)
  • Degree of patient disability
  • Rate of progression
  • History, physical examination, special
    investigations

76
Myelopathy History
  • Patient Complaints
  • Numbness (loss of sensation, alteration of
    sensation paraesthesia, awkwardness)
  • Ataxia (awkwardness, clumsiness)
  • Usually
  • Gait (imbalance, unsteadiness, unable to move
    quickly)
  • Fine movements of hands (doing up buttons,
    handwriting)
  • Weakness usually a late finding

77
Myelopathy History
  • Patient Complaints
  • Numbness (loss of sensation, alteration of
    sensation paraesthesia, awkwardness)
  • Ataxia (awkwardness, clumsiness)
  • Usually
  • Gait (imbalance, unsteadiness, unable to move
    quickly)
  • Fine movements of hands (doing up buttons,
    handwriting)
  • Weakness usually a late finding

78
Myelopathy History
  • Limbs involved lower (may be thoracic or
    cervical), upper and lower (always cervical)
  • Onset gradual, rapid or sudden
  • Associated pain
  • Activity related spondylotic
  • Nocturnal neoplastic
  • Associated radicular pain
  • Previous or concurrent neurological
    symptoms/illness

79
Myelopathy Physical Examination
  • Motor
  • Strength weakness is usually late finding in
    slowly evolving surgical conditions, occurs in
    corticospinal distribution
  • Reflexes (change occurs early) hyperactive
    distal to lesion in gradually evolving lesions
  • In disc disease may be hypoactive at level of
    lesion

80
Myelopathy Physical Examination
  • Tone (early) increased distal to lesion
  • Coordination (early) impaired distal to lesion
  • Plantar responses up-going (reliability?)
  • Sensation
  • Proprioception frequently impaired in lower
    limbs impossible to establish precise level
  • Pinprick extremely useful in thoracic lesions

81
Special Investigations
  • Plain x-rays (bone destruction, fracture,
    subluxation, spondylotic changes), n.b. no
    visualization of nervous tissue
  • CT scan (same indications/contraindications as
    x-ray)
  • MRI usually the definitive investigation
  • CT-myelography (most useful for looking at bone
    and disc relation to spinal cord/nerve roots)

82
Myelopathy Surgical Decision-Making
  • Nature of the lesion
  • Natural history of the lesion
  • Trauma static/improving unless spine unstable
  • Neoplastic progressive, rate variable depending
    on histology
  • Infectious usually rapidly progressive
  • Spondylotic myelopathy, usually gradually
    progressive, rate variable
  • Recovery usually poor with advanced deficits

83
Myelopathy Surgical Approach
  • Lesion site
  • Extradural
  • Intra-dural, extra-medullary
  • Intramedullary
  • Extradural
  • Anterior pathology anterior approach
  • Posterior pathology posterior approach
    (laminectomy)
  • Intradural-extramedullary posterior
  • Intradural-intramedullary - posterior

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Radiculopathy
  • a general term denoting functional disturbance
    and/or pathological changes in a spinal nerve
    root

90
Radiculopathy
  • Symptoms
  • Pain, paraesthesiae, sensory loss in the
    approximate dermatome of the involved nerve root
  • Axial pain is not a symptom of nerve root
    involvement
  • Weakness in the myotome of the involved nerve
    root pts. frequently cant be specific

91
Radiculopathy
  • Exam findings
  • Lower motor neuron findings in the appropriate
    myotome
  • Sensory findings in the appropriate dermatome

92
Radiculopathy Investigation
  • Lumbar
  • MRI, CT scan
  • Cervical/thoracic
  • MRI

93
Radiculopathy - Conservative Tx
  • Activity modification
  • NSAIDS
  • Analgesics
  • Physiotherapy - active

94
RadiculopathySurgical Indications
  • Intractable radicular (not axial) pain which has
    failed conservative management
  • Progressive or significant neurological deficit

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Spine Pain Red Flags
  • Hx of major trauma or minor trauma in elderly,
    osteoporotic patients
  • Age lt 20 or gt 50
  • Hx of cancer, fever, chills, unexplained wt. loss
  • Hx of recent infection, IV drug abuse,
    immunocompromise
  • Hx of bladder or bowel incontinence, urinary
    retention
  • Hx of major or progressive neurological deficit
  • Hx of pain worsening when supine or severe night
    pain

97
Spine Pain Red Flags
  • Exam major neurological deficit/signs of upper
    motor neuron dysfunction
  • Exam peri-anal anaesthesia
  • Exam loss of anal sphincter tone

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Indications for Surgery (Non-Degenerative Back
Pain)
  • Tumour
  • primary
  • metastatic
  • Infection
  • Discitis/osteomyelitis
  • Epidural Abcess
  • Fracture/subluxation with instability

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Clinical Assessment of Spinal Injuries
  • History
  • Mechanism of injury
  • Spinal pain
  • Paraesthesia or motor weakness
  • Physical examination
  • Log roll, inspect and palpate entire spine
  • Tenderness
  • Malalignment of spinous processes

110
Traps for the Unwary
  • Patient intoxication
  • Altered level of consciousness
  • Distraction from other injuries
  • Cursory examination failure to appreciate
    single root injury

111
Cervical Spine X-rays
  • Lateral to T1
  • AP
  • Open-mouth odontoid
  • CT Scan if one or more of above not available

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X-ray Investigation of the Spine
  • Screening/basic views
  • AP, lateral, open-mouth odontoid, swimmers view
  • Special Investigations
  • Flexion-extension
  • CT
  • MRI
  • Myelogram

114
Treatment of Spine Injuries
  • Immobilize patient
  • Reduce deformity
  • Stabilize/fuse spine

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Back to Basics for Surgery
  • Peripheral Nerve

117
Injury Classification (Seddon)
  • Neurapraxia
  • Axonotmesis
  • Neurotmesis

118
Peripheral Nerve Injury
  • History
  • Usually immediate onset of symptoms/signs from
    time of injury
  • Blunt or penetrating injury
  • Blunt injury frequently associated with fracture
    or dislocation
  • May follow reduction of fracture or dislocation
  • Delayed onset compartment syndrome or vascular
    injury to limb

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Peripheral Nerve Injury
  • Physical Examination
  • Upper vs. lower motor neuron
  • Root vs. peripheral nerve
  • Which root?
  • Which peripheral nerve?

123
Investigations
  • MRI/CT
  • Indirect, helpful if question of upper vs. lower
    motor neuron, root vs. peripheral nerve
  • EMGs/Nerve conduction
  • Former useful, latter not
  • Most sensitive in detecting early recovery
  • Not useful in acute management
  • Extremity X-rays
  • helpful with injury site if fracture or
    dislocation

124
Investigation
  • EMG (all injuries)
  • importance of clinical vs. EMG recovery
  • Root and trunk injuries
  • Metrizamide CT- myelogram
  • MRI

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Overall Treatment Strategy
  • Nerve repair
  • Restore movement
  • Restore sensation
  • Muscle/tendon/joint reconstructive surgery
  • Prosthetics
  • Rehabilitation
  • Educational and vocational advice

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Timing of Surgery
  • Primary repair (penetrating injury)
  • immediate
  • delayed (2 weeks)
  • Secondary repair (blunt injury)
  • 3 - 4 month delay

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Reconstructive Strategies to Achieve Elbow
Flexion
  • Steindler flexoroplasty
  • Latissimus dorsi transfer
  • Pectoralis major transfer
  • Triceps transfer

134
Common Wrist/Hand Tendon Transfers
  • Wrist extension -- pronator teres
  • Thumb extension -- palmaris longus
  • MCP extension -- flexor carpi radialis
  • Finger flexion -- brachioradialis or extensor
    carpi radialis longus to flexor digitorum
    profundus
  • Thumb flexion -- BR or ECRL to FPL

135
Results Etiology
  • Etiology No. of Pts
  • Lacerations 24
  • MVA 22
  • Winter sports 11
  • Falls 8
  • Gunshot wounds 4
  • Others 14
  • Adjacent fractures in 15 patients

136
Individual nerve outcome
  • Nerve Inc. loss
    Exc. loss
  • to f/u
    to f/u
  • Brachial plexus 33
    37.5
  • Axillary 42.9
    75
  • Musculocutaneous 57.1 80
  • Radial 58.3
    87.5
  • Median 75
    85.7
  • Ulnar 66
    100
  • Posterior tibial 50
    60

137
Outcome by Etiology
  • Laceration 87.5
  • MVA 32
  • Winter sports 57.1
  • Falls 50
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