Neuro Surgery

Lumbar disc herniation

Impingement of nerve exiting the spinal canal by herniating disc

S/S of radiculopathy in lumbar disc herniation

Pain radiating down LE
Motor weakness
Dermatomal sensory changes
Reflex changes
Nerve root tension signs (straight leg raise)
Tenderness over sciatic notch

Sciatica

Pain along the course of sciatic nerve, usually from nerve root compromise- L1 through L5

Cauda equina syndrome s/s

-Saddle anesthesia
-Urinary retention
-Lower extremity weakness
-Foot drop
-->Go to ER/ immediate referral

Lumbar disc herniation is mostly treated by ______

Conservative tx (85% resolve within 6 weeks)
PT/ exercise, steroid injections, spinal manipulations, NSAIDs/ APAP

Surgical indications for lumbar disc herniation

-Cauda equina syndrome
-Progression of sx despite conservative tx
-Severe radicular pain > 6 weeks

Cauda equina- what is it?
Terminates at....

Nerve roots distal to conus medullaris
Terminates at L1/2

Dermatomal map

Esp look at lower extremities

Disectomy

Removal of disc

Interbody

Between vertebral bodies

Fusion

Encouraging growth between vertebral bodies

Corpectomy

Removal of vertebral body

ALIF
OLIF/ATP
XLIF/LLIF/DLIF
TLIF
PLIF

Anterior lumber interbody fusion
Oblique lateral interbody fusion
Trans-psoas lumbar interbody fusion
Transforaminal lumbar interbdoy fusion
Posterior lumber interobody fusion

ALIF is a spinal fusion procedure usually performed at....
What is it?

L5/S1 or L4/L5
Disectomy performed, interbody spacer introduced and fixed into place with screws/ plates

PLIF procedure

Partial laminectomy to gain access to spinal canal. Theca (and cauda equina) retracted to enable a disectomy. Interbody cage introduced with bone, and screws are placed connecting rods posteriorly

Woman comes in with left sided LE sensory deficits and numbness. Left buttock, posterior left thigh, under left foot for the past 3 weeks. No weakness, no urinary/ bowel problems. Pain 4/10 throbbing and constant, no history of trauma. MRI reveals a disc herniation at L5/S1. What's your approach

First start her on conservative therapy since she doesn't have sx of cauda equina/ alarm sx.

Back pain red flags and presentation of cord compression

History of malignancy
Violent trauma (fall from height, MVA)
Thoracic or radicular pain
Constant, progressive, non-mechanical pain
Systemically unwell
Widespread neuro s/s
Power reduction
Saddle anesthesia
Urinary retention

If you suspect cord compression, what imaging do you order?

MRI

Treatment of cord compression

High dose IV steroids reduces edema
Can be surgical emergency- decompression may be needed to prevent permanent disability
Radiotherapy for malignancy

You don't have as many problems in the thoracic region because...

Joints don't move bc they're stabilized by ribs

Head trauma stats

10% fatal
5-10% suffer serious neurological disorder
20-40% moderate disability

What's more damaging? High velocity or low velocity wounds?

High velocity

Leading cause of TBI

Ground level falls (GLF)

GCS is highly predictive of...

mortality

GCS scale

GCS mild

13-15

GCS moderate

9-12

GCS severe

3-8

GCS below 8 = _____% mortality
GCS above 8 = _____% chance of survival

70%
90%

Secondary head trauma

Herniation syndromes
Cerebral edema
Cerebral ischemia
Vascular injury (can be primary or secondary)

Skull radiography obtained soley for the purpose of...

identifying prescence of skull fracture- no appropriate role in current management of head injured patient

THE screenign tool for imaging acute head trauma

Head CT

CT depicts both ___ and ___ injuries

Bone and soft tissue

NECT

Non-contrast enhanced CT

Head truama patients with acute intracranial lesions on CT have a higher risk for ______ _compared with patients with a CT negative head injury

Cervical spine fractures

_____ of patients with moderate to severe head injury (GCS) also have a spine injury

1/3

Repeat CT should be obtained if there is....

sudden unexplained clinical deterioration, regardless of initial imaging findings

CTA- CT angiography

Noninvasive imaging of vascular system - examines blood vessels and the organs supplied by them

______ is the procedure of choice in the initial evaluation of brain truama

CT without contrast

Who and when to image?

GCS of 3-8 (severe) or 9-12 (moderate)- obtain NECT

CT indicated if GCS = 15 plus any of the following...

HA
Vomiting
Patient > 60 yrs old
Intoxication (drugs/ alcohol)
Short term memory deficits (antegrade amnesia)
Visible trauma above clavicles
Seizure

Canadian had CT rule for minor head injury: CT if GCS = 13-15 and....

witnessed LOC, amnesia, or confusion

High risk for neurological intervention (Canadian head CT)

GCS < 15 hours at 2 hours
Suspected open/ depressed skull fx
-Clinical sign of skull base fracture
->2 vomiting episodes
Age >65

Medium risk for brain injury detected by head CT (Canadian head CT rule)

Antegrade amnesia >30 minutes
"Dangerous mechanism" (auto-pedestrian, ejection from vehicle

NECT is first line in patient with...

sudden onset of unexplained neurological deficit

Emergent NECT imaging is also often obtained in patients with ______ to screen for suspected SAH, hydrocephlus, intracranial mass, etc

Headache

_____ is indicated in patients with sudden clinical deterioration and mixed-density hematoma (indicating rapid bleeding or coagulopathy)

CTA

______ in spontaneous intracranial hemorrhage predicts hematoma expansion and poor clinical outcome

Contrast extravasation

_______ is the most common underlying etiology in younger age groups

Vascular malformations

In elderly patients, ______ and ______ are the two most common etiologies of unexplained sICH (spontaneous ICH)- vascular

Hypertensive hemorrhage and amyloid angiopathy

Intracranial hemorrhages can either be...

intra-axial (intracerebral) or extra-axial (epidural/subdural/subarachnoid)

Epidural, subdural, suabrachnoid, intraventricular hemorrhages are examples of...

Extra-axial hemorrhages

MC type of stroke

Ischemic
2nd is hemorrhagic

Intracerebral hemorrahge facts
Onset?

Most deadly
Unlike ischemic, onset is progressive over minutes to hours

Intracerebral hemorrhage presentation

Severe HA, vomiting, altered level of consciousness
At least 1/3 enlarge over first 3 hours

Risk factors for intracerebral hemorrhage

Age- increases w/ age (esp after 55 and doubles each decade therafter)
Male> female
Greater in blacks
hx of stroke
Alcohol
Street drugs
Liver dysfunction

In an intracerebral hemorrhage, ____ of hematoma correlates with morbidity/ mortality

Volume

Management of intracerebral hemorrhage

ICU
Tight blood pressure control
Euglycemia/ normothermia
Anticonvulsants
Correct coagulopathies

MC cause of subarachnoid hemorrhage

Trauma

Most spontaneous SAH are due to..

aneurysmal rupture

Peak age for aneurysmal rupture

55-60

Sentinal HA for 2-8 weeks prior to SAH in 10-50% of patients

True

SAH presentation

Sudden onset severe HA (thundreclap)

_____ will detect 95% of SAH
If you're suspicious and CT is negative....

-NECT
-Get Lumbar puncture

Risk factors of SAH

HTN
SMoking
Alcohol abuse
Symptothomimetic drugs
Women> men
Hx / family hx of aneurysms
Pregnancy

Managment of SAH

ICU
Q1 neuro checks
Consider anticonvulsants
Oral nimodipine (Ca channel blocker)
Euvolemia
Prevent hydrocephalus

Epidural hemorrhage etiology

Almost always traumatic
Arise from lacerated meningeal arteries, fractures, or torn dural venous sinuses

Most spontaneous epidural bleeds are found in the ______ epidural space and are emergenct

Spinal (not cranial)

Classic presentation of epidural hemorrhage (only about 40%)

Brief posttraumatic LOC from initial impact followed by a "Lucid" interval for several hours
Then obtunded, contralateral hemiparesis, ipsilateral pupillary dilation
Deterioration may take hours to weeks
May have HA, vomiting, seizure, hemi-hyperreflexia, unilateral Babinski, elevated CSF

CT findings for epidural hemorrhage

Biconvex (lens shaped) density

Management of epidural hemorrhage

Craniotomy
May medically manage if small, no midline shift, GCS > 8 and no focal neuro deficit

_____ causes most of subdural hemorrhages
More or less lethal than epidural?

Trauma
More lethal

Subdural hemorrahges may result from torn _______

surface or bridging vessels

Nontraumatic subdural hemorrhages reported in association with a number of other conditions including...

hyponatremic dehydration
Inherited or acquired coagulation disorders
Dural venous sinus thrombosis
Meningitis

Burr holes are created for..

evacuation of extracerebral clots or in prep for a craniotomy

AV malformations

Dilated arteries and veins with dysplastic vessels- arterial blood flows directly from arteries and veins with no capillary bed or parenchyma

MC site of AV malformation

Intraparenchymal

Hemorrhage of AV malformations are related to...

Size (smaller are more lethal dt higher pressure)

Treatment of choice for AV malformations

Surgery

Coil embolization

Catheter-based procedure that allows precise occlusion of abnormal blood flow in a blood vessel

Normal flow of CSF

Made in choroid plexus of lateral ventricles --> foramen of monro --> 3rd ventricle --> cerebral aqueduct --> 4th ventricle --> cisterna magna, reabsorbed into arachnoid granulations

Types of congenital hydrocephalus

Chiari Type 1 malformation: 4th ventricle outlet obstruction
Chiari type 2
Dandy walker: Atresia of foramina of 4th ventricle

Most common etiology of hydrocephalus

Infectious (Post meningitis, TB, crytpococcus

S/S of hydrocephalus in children

Abnormal head circumference
Irritability, poor head control, N/V
Fontanels full an dbulging
"Setting sun sign"
Blindness

VP shunt

Ventriculoperitoneal shunt:
Used to treat swelling of the brain due to excess buildup of cerebrospinal fluid by draining fluid into the peritoneal cavity.

Cerebral blood flow depens on ______ which is related to ICP
If ICP goes up, CCP goes ______ which means....

CPP- cerebral perfusion pressure
If ICP goes up, CPP goes down, which means less blood flow to the brain

Normal ICP pressures
-Adults and older children:
-Young children
-Term infants

-

Types of ICP measuring monitors

Ventriculostomy
Intraparenchymal fibreoptic catheter
Epidural transducer
Subdural catheter
Subdral bolt

Epidural abscesses are most often in _____ spine and ____ to the spinal cord

Thoracic
Posterior

Presentation and risk factors of epidural abscesses

-Back pain, fever, spine tenderness
-IV drug use, alcoholism, DM, CRF, skin infection (furuncle)

Study of choice to test for epidural abscess

MRI

Surgical approach to epidural abscess

Laminectomy + antibiotics

MC oganism causing epidural abscess

S. aureus

What antibiotics would you prescribe for an epidural abscess caused by an unknown organism?

Ceftriaxone + Mentronidazole + Vancomycin until organism is ID'd

Risk factors for spinal osteomyelitis (infection of vertebrae)

Similar to epidural abscess
IV drug use
Alcoholism
Immunocompromised
DM
Hemodialysis
Post spinal surgery

Diagnosis of spinal osteomyelitis

Percutaneous bone biopsy

Treatment of spinal osteomyelitis

Antibiotics (MC organism is S. aureus)
Surgery if instability in vertebrae
Pain meds
TLSO brace

Presentation of discitis (which is what?)

Infection of nucleus pulposis
Back pain with any movement of spine
Fever/ chills
Radicular sx
Radiation to abdomen

Diagnosis of discitis

MRI
WBC, cultures, ESR, CRP, percutaneous biopsy

Treatment of discitis

Antibiotics 4-6 weeks until ESR normalized
Possible surgery