Neuro/Spine. April 27, 2012

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Elwin Todd
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1 Neuro/Spine April 27, 2012

2 Anatomy Review Skull Bones Protection for the brain Sutures bony seams 8 Cranial cavity bones Frontal, occipital, ethmoid, sphenoid, temporal, parietal

3 Meninges Fibrous membranes support and protect brain and spinal cord Dura mater Arachnoid mater Pia mater

Brain Divisions Cerebrum 2 hemispheres connected centrally by corpus callosum Controls motor and sensory for contralateral side Frontal lobe higher function of

controls fluid/electrolyte balance, appetite, reproduction, thermoregulation, immune response, emotional response Pituitary multiple hormones (TSH,GH) Brain Stem

4 Brain Divisions Cerebrum 2 hemispheres connected centrally by corpus callosum Controls motor and sensory for contralateral side Frontal lobe higher function of intellect, movement, language & personality Parietal senses pain and touch Occipital visual Temporal- memory, speech, smell Thalamus sensory station Hypothalamus controls fluid/electrolyte balance, appetite, reproduction, thermoregulation, immune response, emotional response Pituitary multiple hormones (TSH,GH) Brain Stem Midbrain eye movements Pons horozontal eye movement, face movement medula oblongata vital cardiovascular and respiratory regulatory functions Cerebellum balance & coordination of movement

Ventricular System & CSF 4 ventricles Communicating cavities within the brain Produce and serve as reservoir for CSF Spinal fluid Bathes brain

5 Ventricular System & CSF 4 ventricles Communicating cavities within the brain Produce and serve as reservoir for CSF Spinal fluid Bathes brain and spinal cord Cushion for brain Aids in keeping ICP constant Increase volume if brain atrophies, decreases volume to compensate for brain swelling

6 Cerebral Blood Supply Main arteries to the brain 2 internal carotid arteries 2 vertebral arteries Circle of Willis Base of brain Ensure continuity of circulation if any main artery is interrupted

7 Cranial Nerves

8 Vertebral Column 33 vertebra: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal Function: maintain stability, protect neural elements, and range of motion Atlas and axis shaped differently to support the skull and allow for more rotational movement

Vertebrae Anatomy Vertebral body oval block of bone Pedicles connect body to arch Lamina 2 broad plates Articular facets project from the pedicles form joints with the

9 Vertebrae Anatomy Vertebral body oval block of bone Pedicles connect body to arch Lamina 2 broad plates Articular facets project from the pedicles form joints with the facets of the vertebra above and below Transverse processes extend laterally, muscles and ligaments attach Spinous processes extend posteriorly and can be felt in most people

10 Intervertebral Disks Cushion, shock absorbers Annulus Fibrosus Nucleus pulposus

11 Spinal Cord Downward prolongation of the brain Carries impulses from the brain to motor neurons of PNS Protected by the vertebra of spinal column Spinal canal formed by vertebral bodies, pedicles & laminae

12 Spinal Nerves Spinal nerves Part of the PNS 31 pairs of nerve roots branch off from the spinal cord and control functions of the body Each have an anterior (motor) and posterior (sensory) nerve root Carry motor and sensory impulses from CNS and PNS

13 Spinal Nerves

14 Dermatomes An area of skin that is innervated by a sensory root of a spinal nerve Symptoms that follow a dermatome (pain,rash) may indicate pathology of nerve root Pinched nerve roots causing radiculopathy Herpes zoster (shingles)

Hematoma Blood clot causing increase ICP and compression of brain Epidural Hematoma Between skull and dura Sx: unconsciousness, fixed dilated pupil, extremity weakness, abnormal posturing Subdural

15 Hematoma Blood clot causing increase ICP and compression of brain Epidural Hematoma Between skull and dura Sx: unconsciousness, fixed dilated pupil, extremity weakness, abnormal posturing Subdural Hematoma Acute, subacute or chronic Between dura and arachnoid Sx: loss of consciousness, gradual increase headache, dizziness, confusion, nausea, vomiting, seizures Intracerebral hematoma Tears in brain substance commonly in ant. temporal and frontal lobes Sx: severe headache, confusion, drowsiness, paralysis of opposite side, speech changes Burr Holes or Craniotomy or Craniectomy to decompress brain and remove/drain blood clots

Tumors Intracranial tumors: tumors within the brain or its membranes Metastatic tumors more common than primary Over 120 types of primary CNS tumors Classified by histologic type: glioblastoma,

16 Tumors Intracranial tumors: tumors within the brain or its membranes Metastatic tumors more common than primary Over 120 types of primary CNS tumors Classified by histologic type: glioblastoma, menegioma Symptoms Progressive neurologic deficit usually motor weakness Headaches and seizures Diffuse increase in ICP Depends on location Large left or bifrontal lobe tumors personality changes Left frontotemporal region aphasia Diagnosed by history, neurologic exam, CT/MRI &/or biopsy Treatment can include steroids, antiepileptic meds, management of hydrocephalus, surgery, radiation, chemotherapy

17 Hydrocephalus Excessive accumulation of CSF in ventricles resulting in increased ICP Due to obstruction, poor absorption, or overproduction of CSF Reasons include congenital abnormalities, aqueductal stenosis, tumor, subarachnoid hemorrhage, meningitis Common among young children and older adults Acute or Chronic Symptoms vary depending on age Infants: enlarged head, seizures, vomitting, sleepy Adults impaired balance, memory loss, poor coordination, headache External ventriculostomy catheter placement Temporary shunting for acute symptoms Catheter placed in ventricle through bur hole and connected to external drainage system Internalized ventriculoperitoneal (VP) shunt One way valve system drains CSF away from ventricle into the peritoneum

aneurism, tumor Craniectomy permanent removal of section of skull Severe head injury, tumor,

19 Brain Approaches Bur Holes Small hole for minimum exposure to brain Hematoma, VP shunt Craniotomy Remove bone flap and is replaced at end of case with plates/screws Hematoma, aneurism, tumor Craniectomy permanent removal of section of skull Severe head injury, tumor, infected bone Transsphenoidal Approach used to remove pituitary tumors Can use stereotatic navigation

20 Spine Pathologies Tumors Most common are metastatic cord compression causing pain and weakness Treatment goals: pain releif, preservation/restoration of neurologic function Treatment may include surgery or radiation or combo Trauma Most common type of injuries: fractures, subluxation, disk herniation Cervical spine most vulnerable to injury Need early stabilization to minimize cord trauma Spinal cord injury Complete: lacks sensation, position sense, & voluntary motor function below level of injury Incomplete: still has some sensory, position sense & motor impulses present

21 Spine Pathologies Degenerative diseases - arthritis, osteoperosis Most common cause for neck pain and back pain Herniated disks or bulging disk commonly occur at L4-5, L5-S1 Spinal stenosis narrowing of spinal canal Common in cervical & lumbar regions Radiculopathy compression of nerve roots causing pain & weakness Treatments include rest, physical therapy, steriod injections, surgery (laminectomy, laminotomy, diskectomy, fusion)

22 Herniated Disc

23 Compression Fractures

24 Spine Surgery Laminectomy Removal of one or more vertebral lamina from to expose spinal canal to treat compression fracture, degenerative changes, dislocation, herniated disk, tumor causing pressure on spinal cord Diskectomy Herniated or ruptured disk most common injury seen by neurosurgeons Most occur in lower lumbar region Removal of ruptured annulus fibrosus or herniated nucleus pulposus

26 Spine Surgery Fusion Stabilization of spine using plates/screws or rods May be indicated following injury or excision of bone Cervical, thoracic, lumbar Vertebroplasty and Kyphoplasty Treats vertebral compression fractures from osteoporosis or pathologic condition Bone cement injected into vertebral body to decrease pain and prevent body height loss

27 Lumbar Fusion

28 Kyphoplasty

29 Preparation for Surgery: What is the Plan? Age, weight, allergies, NPO status Diagnosis and procedure, approach LOC able to sign consent? Family available Stability of spine and other injuries Communication barriers Surgical site marked and matches consent: side of head, level of spine, approach site

30 What is the Plan? Continued Diagnostic studies (xrays, CT, labs, MRI, etc): have available Surgical approach, position needed, need to communicate with anesthsia Equipment, instruments, supplies: neuromonitoring, microscope, midas, positioning equipment, stereotactic navigation, ICP monitor Implants, bone grafts Blood products Medications Preliminary procedures: placement of lines, foley etc Radiology

31 Assessment LOC, mental status, orientation, follow commands GCS: eye opening, verbal, and motor response ROM: neck, arms, legs Skin assessment Other injuries from trauma Pain, location, which side for spine Anxiety

32 Positioning Cranial Surgery Supine Approach most commonly for frontal, parietal and temporal lobes Mayfield pins or horseshoe or head on gel doughnut Prone Approach for occipital lobe Head in mayfield pins Semi fowlers or sitting position Head in mayfield pins For occipital approach Mayfield pins Bacitracin ointment for pins Surgeon will place pins and have control of head while transferring patient Do not move the patient after pins placed and head locked in place, could break neck May turn the bed degrees At least 1 arm tucked Placement of microscope, headlight

33 Mayfield Skull Pins & Horseshoe

34 Sitting Position with Pins

35 Positioning Anterior Spine Surgery Anterior Cervical Spine Supine with mayfield pins or horseshoe on radiolucent table or regular bed May need cervical traction Arms tucked to side Anterior Lumbar/Thoracic Supine Radiolucent table Rails clear for retractor (bookwalter, omni)

36 Positioning Posterior Spine Surgery Posterior cervical Prone with head in mayfield pins or face on foam pillow Gel chest rolls, wilson, or jackson frame Arms tucked down to side Radiolucent table Posterior lumbar/thoracic Prone on gel chest rolls, Jackson, Wilson frame, or Cloward Arms overhead not extended greater than 90 degrees Radiolucent table Make sure there is enough people to safely transfer

37 OSI Jackson Frame

38 OSI Jackson Frame

39 OSI Bed with Flat Top

40 Wilson Frame Cloward Saddle

41 Lateral Approach to Spine XLIF (extreme lumbar interbody fusion) Incision on patient s side Lateral decubitus position (90º) Secure body so no moving Iliac crest at break in bed

42 Skin Preparation Hair Removal Do as close to surgery time as possible Use clippers Save hair for patient Hold hair back: Ointment, rubberbands Skin Prep Have appropriate solution: surgeon preference, allergies Prep area: incision site, VP shunt placement, ICBG site

43 Physical Hemostatic Agents Electosurgery: monopolar, bipolar Bone wax Sponges Cottonoids Hemaclips

Floseal/Surgiflo Gelatin matrix is mixed with thrombin Topical gel that clots

44 Pharmacological Hemostatic Agents Thrombin Catalyzes conversion of fibrinogen to fibrin Soak cotton patties or gelfoam in thrombin and then apply topically Floseal/Surgiflo Gelatin matrix is mixed with thrombin Topical gel that clots bleeding site Gelfoam Absorbable gelatin sponge placed topically over bleeders, often soaked in thrombin

platelets to the area Surgicel Oxidized regenerated cellulose pad, placed

45 Pharmacological Hemostatic Agents Avitene Collagen hemostat, usually a loose fibrous form that is placed topically with bleeding surface, attracts platelets to the area Surgicel Oxidized regenerated cellulose pad, placed topically & forms clot, as absorbs it becomes gel Local Anesthetic with epinephrine

46 Bone Autograph Patient s own bone ICBG Bone Mill coffee grinder

Bone Allograft Products Cancellous bone chips DBX bone putty

as bone grows and takes up the space BMP Bone Morphogenetic Protein

BMP stimulates bone growth and the sponge gets absorbed Osteocel

47 Bone Allograft Products Cancellous bone chips DBX bone putty Demineralized Bone Matrix used to fill gaps or voids in bone Absorbs as bone grows and takes up the space BMP Bone Morphogenetic Protein (synthetic) is reconstituted then absorbed into a collagen sponge The BMP stimulates bone growth and the sponge gets absorbed Osteocel Contains stem cells so acts like autographs because biologically active Kept in freezer

Frame Cloward OSI Jackson frame OSI Flat Top

48 Basic Neuro Equipment Midas Microscope Cusa Bone Mill ICP monitor Stereotatic Navigation Wilson Frame Cloward OSI Jackson frame OSI Flat Top Mayfield: skull pins, horseshoe Radiology: C-arm, flat plates

49 Basic Neuro Instruments Rongeurs Pituitary Kerrisons Currettes Frazier suctions Raney clips Perforators Hibbs Myerding Clowards retractor Laminar Spreader Nerve Hooks

50 Room Set Up *Think Meds, Beds, Equipment, & Implants* Meds: Local, hemostatic agents, etc. Beds: positioning equipment for the bed Wilson frame, Jackson, Mayfield, etc. Equipment: microscope, midas, c-arm, etc. Available and working Implants: fusion, crani plates, bone graft

51 Documentation Remember to document! Pre-existing skin lesions, lack of motor strength or difficulty with movement Other injuries Specifics of positioning If it is not documented, it was not done. Implant Documentation is critical

Pathologies, Procedures and Room Set-Up

Pathologies, Procedures and Room Set-Up Degenerative diseases - arthritis, osteoperosis Most common cause for neck pain and back pain Herniated disks or bulging disk Commonly occur at L4-5, L5-S1 Spinal