Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection...

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Neuro/Spine April 27, 2012

Transcript of Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection...

Page 1: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Neuro/SpineApril 27, 2012

Page 2: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

ethmoid, sphenoid, temporal, parietal

Page 3: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Meninges Fibrous membranes support

and protect brain and spinal cord Dura mater Arachnoid mater Pia mater

Page 4: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 5: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 6: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

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Cranial Nerves

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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

Page 9: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 10: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Intervertebral Disks Cushion, shock absorbers Annulus Fibrosus Nucleus pulposus

Page 11: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 12: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 13: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Spinal Nerves

Page 14: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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)

Page 15: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 16: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 17: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 18: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,
Page 19: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 20: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 21: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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)

Page 22: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Herniated Disc

Page 23: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Compression Fractures

Page 24: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 25: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,
Page 26: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 27: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Lumbar Fusion

Page 28: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Kyphoplasty

Page 29: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Preparation for Surgery: What is the Plan?

Age, weight, allergies, NPO statusDiagnosis and procedure, approachLOC – able to sign consent? Family availableStability of spine and other injuriesCommunication barriersSurgical site marked and matches consent: side of head,

level of spine, approach site

Page 30: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 31: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 32: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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 90-180 degrees At least 1 arm tucked Placement of microscope, headlight

Page 33: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Mayfield Skull Pins & Horseshoe

Page 34: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Sitting Position with Pins

Page 35: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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)

Page 36: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 37: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

OSI Jackson Frame

Page 38: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

OSI Jackson Frame

Page 39: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

OSI Bed with Flat Top

Page 40: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Wilson Frame

Cloward Saddle

Page 41: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Lateral Approach to Spine XLIF (eXtreme

lumbar interbodyfusion) Incision on

patient’s side Lateral decubitus

position (90º) Secure body so no

moving Iliac crest at break

in bed

Page 42: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 43: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Physical Hemostatic Agents

Electosurgery: monopolar, bipolarBone waxSpongesCottonoidsHemaclips

Page 44: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 45: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 46: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

Bone Autograph Patient’s own bone ICBG Bone Mill “coffee grinder”

Page 47: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 48: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 49: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 50: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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

Page 51: Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,

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