Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection...
Transcript of Neuro/Spine - ashnha.com€¦ · Neuro/Spine April 27, 2012. Anatomy Review Skull Bones Protection...
Neuro/SpineApril 27, 2012
Anatomy Review Skull Bones Protection for the brain Sutures – bony seams 8 Cranial cavity bones Frontal, occipital,
ethmoid, sphenoid, temporal, parietal
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 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 and spinal
cord Cushion for brain Aids in keeping ICP
constant Increase volume if brain
atrophies, decreases volume to compensate for brain swelling
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
Cranial Nerves
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 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
Intervertebral Disks Cushion, shock absorbers Annulus Fibrosus Nucleus pulposus
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
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
Spinal Nerves
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 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,
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
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
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
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
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)
Herniated Disc
Compression Fractures
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
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
Lumbar Fusion
Kyphoplasty
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
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
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
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
Mayfield Skull Pins & Horseshoe
Sitting Position with Pins
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)
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
OSI Jackson Frame
OSI Jackson Frame
OSI Bed with Flat Top
Wilson Frame
Cloward Saddle
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
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
Physical Hemostatic Agents
Electosurgery: monopolar, bipolarBone waxSpongesCottonoidsHemaclips
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
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
Bone Autograph Patient’s own bone ICBG Bone Mill “coffee grinder”
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
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
Basic Neuro Instruments Rongeurs Pituitary Kerrisons Currettes Frazier suctions Raney clips Perforators Hibbs Myerding Clowards retractor Laminar Spreader Nerve Hooks
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
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