NEUROSURGERY
NEUROSURGERY
Nervous System
Senses changes in environment, interprets them, stimulates response/movement
□ CNS central nervous system: brain and spinal cord
□ PNS peripheral nervous system: everything else
• Afferent nervous system: sensory neurons take info from PNS to CNS
• Efferent nervous system: motor neurons take info from CNS to PNS
▪ Somatic nervous system: skeletal muscle, conscious control
▪ Autonomic nervous system: cardiac m, smooth m, glands; uncons control
– Sympathetic div = increased skeletal blood flow, decreased organ blood flow ; also called fight or flight
– Parasympathetic div = decr skeletal blood flow, incr organ blood flow
– Both are controlled by hypothalmus and medulla oblongata, go to the same effector or target, are antagonistic
–
Spinal cord transmits info to/from brain, integrates reflexes
□ Begins at foramen magnum and extends to 2nd lumbar; 16-18” in length
□ Vertebrae: 7 cervical, 12 thoracic, 5 lumbar; 5 fused [sacrum], 4 fused [coccyx]
□ Intervertebral disks: separate vertebrae, bear/cushion stress on vertebrae
• Outer layer is tough and called the annulus fibrosis
• Inner core is soft and called the nucleus pulposus
□ Meninges : membranes between vertebrae & spinal cord
• Epidural space between vertebra and dura mater
• Dura mater outermost layer extends to S-2
• Subdural space between dura mater and arachnoid
• Arachnoid mater extends to S-2
• Subarachnoid space contains CSF
• Pia mater adheres directly to spinal cord and extends to L-2
□ Spinal nerves -- 31 pairs: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal
• Names and numbers depend on where enter and exit
• Each has a ventral [motor] and dorsal [sensory] root
Brain: weighs approx 3 lb., protected by the cranium or skull
← Brain stem
□ Medulla oblongata: lowest part, 5 of 12 cranial nerves
• Pyramids: crossing of the spinal nerve impulses
• Reflex centers: hiccupping, sneezing, coughing
• Vital reflex centers:
▪ Cardiac center – heart rate
▪ Vasoconstrictor center - BP via blood vessel diameter control
▪ Respiratory center - breathing
□ Pons: above medulla
• Switching point for motor neurons
• Respiratory center
□ Midbrain or mesencephalon: above pons
• Involuntary eye and head movement in response to auditory stimuli
← Diencephalon
□ Thalamus
• Relay center for sensory information
• Interprets stimuli for example pain from changes in temperature (hot stove); recognizes crude touch NOT localized touch
• 1st level of reasoning occurs here
□ Hypothalamus
• Controls large number of subconscious functions
• Controls most of autonomic nervous system
• Is where endocrine and nervous systems interface
• Homeostasis regulation of the body
• Controls: body temp, thirst, hunger, sleep and waking habits, psychosomatic disorders, rage and aggression
← Cerebellum: 2nd largest part of the brain, primarily a motor area
• Controls skeletal muscles, subconsciously
• Receives sensory input from eyes, muscles, joints, and inner ear
• Posture, balance, coordination, equilibrium
• Muscle sense tells body where other parts are
← Cerebrum: largest part of brain, see p 970, fig 24-4
Motor/sensory/association areas, associated with specific lobes
□ Frontal: memory, abstract thinking, ethics, judgement, emotion, expressive speech, motor
□ Parietal: sensory, receptive speech, written word
□ Temporal: auditory, olfactory
□ Occipital: visual cortex, visual association
Limbic system: controls emotion/functions in cerebral cortex and diencephalon
← Meninges: continuous layer with spinal cord, but NO epidural space
← Cerebrospinal fluid (CSF): shock absorber and circulates nutrients
□ About 800ml/day produced by the choroid plexus, a specialized set of capillaries
□ Circulates in subarachnoid space, central canal [spinal cord], ventricles [brain]
□ Reabsorbed in arachnoid villus found in the parietal lobe
← Blood brain barrier
□ Specialized capillaries exclusive to the CNS, least permeable in the body
□ Advantage = keeps out unwanted chemicals
□ Disadvantage = poor diffusion makes it difficult to treat conditions such as encephalitis
← Cranial nerves: direct from brain, do not go thru spinal cord
□ All originate in the brain stem EXCEPT the 1st and 2nd
□ Classified as sensory or mixed (sensory and motor) nerves
□ Identified by Roman numerals and names
• Olfactory - sense of smell
• Optic – sense of sight/vision
• Occulomotor – movement of eyeball[medial, inferior, superior rectus, inferior oblique], eyelid, pupil, lens [ciliary m]; muscle sense for eyeball
• Trochlear – eyeball movement (superior oblique); muscle sense for eyeball
• Trigeminal
▪ Motor: masseter muscle control
▪ Sensory (convey touch, pain, temp changes)
– ophthalmic (forehead to corner of eye),
– maxillary (corner of eye to upper lip/teeth)
– mandibular (lower lip/teeth/tongue)
• Abducens - eyeball movement (lateral rectus); eyeball muscle sense
FYI: EOM formula LR6(SO4)3
• Facial- facial muscles; lacrimal, salivary glands; anterior 2/3 of tongue (taste)
• Vestibulocochlear - vestibular [balance]; cochlear [hearing]
• Glossopharyngeal -salivary gland secretion and posterior 1/3 of tongue
• Vagus – internal organ control motor and sensory; originates in medulla and goes down through neck into chest and abdomen
• Accessory – head and neck movement, speech, and muscle sense for the head
• Hypoglossal – tongue muscles: swallowing, speech, muscle sense for tongue
Neuropathology
← Cervical spine: can have severe consequences due to all spinal nerves pass thru it. Treatment is conservative, with minimal surgical intervention.
□ Spondylosis: is osteophyte or bone spur formation in the spinal canal
□ Cervical disk extrusion: acute or chronic
← Thoracic spine
□ Spondylosis
□ Extrusion of disk
← Lumbar spine
□ Spondylosis
□ Stenosis
□ Spondylolithesis
□ Disk extrusion
← Neoplasms/Tumors
□ Primary originate in nervous tissue or meninges
□ Secondary are metastasized from other parts of the body
□ Benign tumors: craniopharyngiomas, epidermoids, hemangiomas, menigiomas, acoustic neuromas, pituitary microadenomas; usually excisable via craniotomy
□ Malignant tumors: astrocytes or gliomas; usually cannot be completely removed but efforts are made to remove most
← Head Trauma
□ Scalp lacerations, fractures, hematomas (epidural or subdural), and brain injuries
← Spinal Cord Trauma
□ Vertebral fracture
□ Vertebral dislocation
□ Herniated disk into spinal canal
□ Laceration from GSW or MVA
← Cerebrovascular disease (#3 cause of death in US); symptoms reflect ischemia (TIAs) or hemorrhage
□ Intracranial aneurysm
□ Arteriovenous malformations
□ Brain hemorrhage
□ Stroke or cerebrovascular accident (CVA)
← Congenital Pathology
□ Craniosynotosis: premature closure of the cranial sutures
□ Hydrocephalus: result of obstructed CSF flow
□ Spina bifida
← Infection
□ Abscess
□ Subdural empyema
□ Post-op infection
← Spinal Cord Tumors
□ Intramedullary in the spinal cord
□ Intradural in dura, outside spinal cord
□ Extradural outside spinal cord
← Peripheral nerve pathology
□ Carpal tunnel syndrome - compression of the median nerve
□ Ulnar nerve compression – compression of ulnar nerve by the ligament of Osborne
← Diagnosis
□ History and physical Myelogram
□ Symptoms usually specific to area of pathology CAT Scan
□ Electroencephalogram (EEG) X-ray
□ MRI Cerebral arteriograms
← Medications
□ Lidocaine 1% with epinephrine
□ Topical hemostatic agents: gelfoam, avitene, surgicel, bone wax
□ Antibiotic irrigants
□ Topical papaverine for prevention of spasm during intracranial artery surgery
□ Methyl methacrylate with cranioplasty
□ Heparin saline irrigation again with intracranial artery surgery
□ Contrast solutions with cerebral arteriography
□ Gliadel wafers (tumor bed of glioblastoma)
← Anesthesia : general or could be local with MAC for minor laceration suturing
← Positioning
□ Cranial surgery: supine primarily, with a specialty headrest and or fixation devices, but varies w/ need for access, can be lateral or semi-lateral, sitting, prone
□ Spinal surgery: supine for anterior procedure, prone for posterior
□ Specialty equip: Mayfield headrest, Gardner-Wells tongs
← Preps will require shave esp. on head; surg pref; do not get in eyes/facial orifices
← Draping: towels; adhesive drape; laparotomy, thyroid, craniotomy, lumbar; stockinette for peripheral proc.
← Supplies:
□ Marking pen Hemostatic clips
□ Disposable bi-polar cord Shunt catheters, tubing, connectors
□ Monopolar pencil/bovie Cotton balls
□ Cottonoids/patties Hemovac drain
□ Raney clips Nerve stimulator
□ Telfa Microscope drape
□ C-Arm drape Ultrasound wand drape
← Instruments see p 987-990
□ Minor tray if laminectomy / craniotomy trays do not incl basic instrumentation
□ Laminectomy tray
□ Craniotomy tray
□ Basic ortho tray
□ Plates and screws
□ Specialty self-retaining retractor trays: Greenburg
□ Miscellaneous Instrumentation
← Equipment
□ Operative Ultrasound machine Video tower
□ CUSA Cavitron ultrasonic aspirator Microscope
□ Bipolar and monopolar ECU Stereotaxis system
□ Nitrogen source for power equipment (saws/drills) YAG or CO2 laser
□ Headlight and light source C-Arm and monitor
□ Fluid warming and temperature regulating equipment Cell saver
□ Mayfield overbed table
← Dressings/Drains: surgeon preference
← Post-op care: keep field sterile until patient has left the OR; careful with moving patient to avoid patient injury and hemorrhage
← Post-operative Complications
□ Infection Hemorrhage
□ Nerve damage CSF leakage
□ Meningitis Neurological deficits
← Procedures begin on page 992-1021 in Price
□ Carpal Tunnel Release Craniotomy
□ Hematoma Aneurysm repair
□ Tumor excision Cervical Discectomy
□ Lumbar Discectomy Ventroperitoneal Shunt
(VP Shunt)
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