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Neurosurgery Gray Matter

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Neurosurgery Gray Matter
Based on the Medical Student Curriculum in Neurosurgery
© 2001 Congress of Neurological Surgeons
Neurosurgery Gray Matter
A General Overview
Produced with the Ad-Hoc Committee on Neurological
Surgery, Undergraduate Medical Education Council of State
Neurosurgical Societies
Overview
Neurological Exam
Head Trauma
Cerebrovascular
Spine injury
Degenerative Spine
Disease
Peripheral Nerve
Brain Tumors
Hydrocephalus
Neurological Examination
Cranial Nerve Exam
II
III
IV
V
VI
VII
VIII
IX
X
XI
XII
hold up two fingers, cover one eye,
vice verse
follow fingers
follow fingers, downward and medially
sensory forehead, maxilla, chin
follow fingers, laterally
smile, wrinkle forehead
rub fingers together next to ear
say “ahhhhh” -- palate elevation
swallow
shrug, turn head side-to-side against
resistance
stick out tongue and wiggle side
to side
Sensory and Motor
SENSORY
C3
back of ears
C5
sternal notch
T4
nipples
T10
belly button
L4
medial
malleolus
L5
dorsal foot
S1
lateral foot
MOTOR
C5
C6
C7
C8
L4
L5
S1
Lift arm at
shoulder
Flex at elbow
Extend at
elbow
hand grasp
ankle dorsiflex
great toe
extension
ankle
plantarflex
Motor Strength
Grade
Strength
0
1
2
3
4
5
No contraction
Flicker or trace contraction
Movement with gravity eliminated
Movement against gravity
Movement against resistance
Normal strength
Reflexes
Biceps
Triceps
Knee
Ankle
C5, 6
C6, 7
L2, 3, 4
L5, S1, S2
Biceps m.
Triceps m.
Quadriceps m.
Gastrocnemius m.
Brainstem Exam
Pupils - CN II, III
• unilateral dilated, non-reactive - focal mass lesion/herniation
w/ compression of CN III
• bilateral fixed, dilated - diffusely increased ICP
EOMI - CN III, IV, VI
Corneal - CN V, VII
• positive test means intact pons
Doll’s eyes - CN VI, VIII
Cold Calorics - CN VI, VIII
Gag - CN IX, X
• positive test means functioning upper medulla
Head Injury
Epidemiology
Head injury is common
• 150,000 patients die from traumatic injuries each year
in the United States. Half of these deaths are the
result of head injury.
Head Injury Hurts
• Over 200,000 people in the United States are disabled
due to the effects of head and spinal cord injury.
Classification of Head Injuries
Mild, Moderate or Severe, based upon
post resuscitation GCS score.
Penetrating or Blunt injury
Mass lesion or diffuse axonal injury
Pathophysiology
Primary Injury
• The injury to the brain which occurs as
a result of the initial trauma. This may
be a blunt injury, penetrating injury,
hypoxic or hypotensive injury.
The only treatment is prevention.
Pathophysiology
Secondary Injury:
• Damage to the brain which is ongoing.
This type of injury is potentiated by
hypoxia, hypotension, intracranial
hypertension, and inflammatory cascades
initiated at the time of injury or soon
thereafter.
Secondary injury is treatable.
GLASCOW COMA SCALE (GCS score 3-15
based on best motor, verbal, eye response )
MOTOR Activity
6
obeys commands
5
localizes pain
4
withdraws to pain
3
flexion of arms to pain (Decorticate)
2
extension of arms to pain (Decerebrate)
1
none
EYE Opening
4
spontaneous
3
to command
2
to pain
1
none
VERBAL Activity
5
oriented
4
confused
3
inappropriate
2
incomprehensible
1
none
**note: intubated patients are given the
designation “T” and have a verbal score of 1.
GCS (continued)
Max score = 15
Minimum score = 3
Decorticate - implies destructive lesion of
corticospinal tracts within or near cerebral
hemispheres.
Decerebrate - implies lesion in diencephalon,
midbrain, or pons. Can be mimicked by metabolic
disorders such as hypoxia or hypoglycemia.
Preventing Secondary Injury
How do we avoid secondary injury?
•
•
•
•
Avoid hypotension
Avoid hypoxia
Identify and treat intracranial mass lesions
Identify and treat patients with intracranial
hypertension.
The Role of Hypotension
How bad is hypotension in patients with
severe head injury?
REALLY REALLY REALLY BAD!
• TCDB: 717 patients
• A SINGLE observation of SBP<90 mm Hg
DOUBLED mortality, increased in hospital
morbidity, and significantly influenced final
outcome.
Hypoxia: Another Bad Thing
Also bad for head injured
patients
Effects not as profound as
hypotension
Defined as apnea or
cyanosis in the field or a
PaO2 of < 60 mm Hg by
ABG
Intracranial Hypertension
Two Causes:
• Mass Lesion
• Cerebral edema
Must make diagnosis
because treatment is
radically different.
Both may lead to same
effects:
Posterior fossa hemorrhage
• Herniation syndromes
• Decreased CBF
Gun shot wound
Intracranial Hypertension
Mass Lesions:
•
•
•
•
Evolve quickly
Lateralizing Signs
Pupillary Changes
Early herniation possible
Intracranial Hypertension
Diffuse Axonal Injury
• Depressed level of consciousness
• No localizing signs
• Herniation syndromes and peak ICP delayed
Herniation Syndromes
Subfalcine:
• “Midline Shift,” or
movement of medial
frontal/parietal lobes
underneath falx cerebri.
• No direct injury
attributed to herniation
itself, a sign of mass
effect.
Herniation Syndromes
Transtentorial/Uncal
• Movement of medial
temporal lobe over
tentorial edge,
compressing brainstem.
• Usually the result of a
lateral or anterior
temporal lesion.
• Uncus becomes
impacted over edge and
produces medically
irreversible brainstem
compression.
Intracranial Hypertension
Effects on CBF:
• The brain usually tightly controls CBF
through regulation of the tone of
smooth muscle in intracranial vessels.
This process is called autoregulation.
• Autoregulation may be chemical or
pressure dependent.
• Following TBI, autoregulation may be
impaired or lost completely.
Intracranial Hypertension
Normally, CBF is maintained in a
normal range even with wide swings in
SBP.
If autoregulation is lost, perfusion
becomes completely pressure
dependent.
As CPP = SBP - ICP, increased ICP will
lower CPP.
The Vicious Cycle
Increased ICP
Decreased CBF
Increased edema
Ongoing ischemia
Breaking the Cycle
Support Blood Pressure and
Oxygenation
Treat Intracranial
Hypertension
•
•
•
•
•
Remove Mass Lesions
Medical Management
The role of hyperventilation
The role of steroids
New frontiers (Tirilizad,
Hypothermia, THAM,
SC58125)
Initial Evaluation and Management
ABC’s: Patients with head injuries are
trauma victims. Adhere to ATLS
guidelines.
• Hypotension = Hypovolemia until proven
otherwise.
ABCD: After ABC’s, assess disability.
• GCS score, pupillary examination, motor
asymmetry, cervical spine precautions
Initial Evaluation and Management:
Blunt Head Injury
GCS 3-8
• Severe head injury, requires STAT
neurosurgical consult and subsequent CT.
GCS 9-12
• Moderate head injury, requires urgent CT
and neurosurgical consultation based on
CT findings and early clinical course.
Clinical observation is critical (utility of
sedation).
Initial Evaluation and Management
GCS 12-15
• Mild head injury. Patient’s other injuries
may take precedence. CT scan essential
for patients who are not normal. In the fully
awake patient, CT may not be necessary
provided that the patient can be observed,
there are no focal deficits, and there are no
complicating factors.
Initial Evaluation and Management
Pupillary examination
• Anisocoria
• Size and shape
• Reactivity
“Pupillary asymmetry, dilation, or loss of light
reflex in the unconscious patient usually
reflects herniation caused by ipsilateral mass
effect.”
Initial Evaluation and Management
Motor Examination
• The best motor response is used for GCS
• Motor asymmetry should be noted
• Tentorial herniation usually causes
contralateral hemiparesis, but can cause
ipsilateral hemiparesis (Kernohan’s Crus
Syndrome). Pupillary changes are a better
localizer.
Radiographic Examination
This image cannot currently be displayed.
Skull films:
• Don’t bother
C-Spine films
• Don’t Forget
CT Head
• Get one!
Cerebral contusion
Radiographic Examination
CT Findings in Severe Head Injury:
Mass Lesions: blood clots in various
locations
• Epidural Hematoma (lentiform shape)
• Subdural Hematoma (crescent shaped)
• Intraparenchymal Hematoma (within brain)
Head-Injured Patient (continued)
Treatments for increased ICP:
Elevate HOB to 30°
Mannitol
Hyperventilate
Sedation
CSF drainage
Pressors
**Note: for increased ICP, keep patient sedated, paralyzed if
necessary, and CPP above 70mm Hg.
Head-Injured Patient (continued)
For increased ICP:
The goal is Cerebral Perfusion Pressure >
70mm Hg.
• Normal ICP is around 12mm Hg. Use above
meds to maintain ICP under 20mm Hg in trauma
patient. May need to use pressors to increase
MAP and maintain CPP > 70mm Hg if unable to
adequately control ICP with above interventions.
• In pts. with severe injury, CPP > 60mm Hg may be
adequate
• REMEMBER -- each patient is UNIQUE!
Skull Fractures
Open vs. Closed -- depends on overlying
skin
Linear, Stellate or Comminuted fracture
line(s)
Depressed vs. Nondepressed
Simple fractures:
• Also known as nondepressed
fractures
• Requires no treatment as long as
there is no associated intracranial
bleeding (seen when fracture line
crosses major vascular channel).
• Considered open if fracture crosses
nasal sinuses or mastoid air cells.
Epidural/Subdural Hematomas
CT is Key!
• Scan all head trauma patients -- scan quickly if there is a
change in baseline mental status!
• Scan children and elderly with mental status changes.
• Scan if you have the slightest suspicion of intracranial
bleeding.
• And, don’t forget, SCAN! It can save the patient’s life!
Treatment: expectant if small, craniotomy if there is
mass effect or change in mental status.
Epidural Hematomas
Between inner table of skull and dura mater
Classic lenticular shape
Usually arise from tear of middle meningeal
art.
Classic presentation
• follows a blow to the head and
unconsciousness
• may be a lucid interval of several
hours
• as hematoma enlarges, medial
temporal lobe is forced over the
tentorium affecting the oculomotor
nerve --result is a dilated ipsilateral
pupil.
Often fatal, but curable if lesion is found
quickly.
Subdural Hematoma
Usually result from tear of
bridging veins between cortex and
dura., disruption of cortical
arteries and cortex laceration.
Follows contour of brain.
Associated with severe head
injury, so neurologic deficit often
remains after clot evacuated.
May progress over several days:
• increasing lethargy,
confusion, hemiparesis
• may see profound
improvement with removal of
clot.
Subdural Hematomas (cont)
Acute
• associated with severe trauma
Subacute
Acute Subdural
• progress over several days
Chronic
• gradually enlarge, seen most
often in children and elderly
Chronic Subdural
Subarachnoid
Hemorrhages and
Cerebral Aneurysms
Subarachnoid Hemorrhage (SAH)
Etiologies
• Trauma – most common
• Intracranial aneurysms
• Arteriovenous
malformations
Spontaneous Aneurysmal SAH
Estimated annual rate 1028/100,000 persons
About 30,000 ruptures
per year
• 1/3 die before
reaching hospital
• 1/3 with serious
morbidity
• 1/3 do well
Subarachnoid Hemorrhage
Hunt-Hess Classification of aneurysmal SAH:
Class
Symptom
Mortality
I
II
III
IV
V
none
H/A, nuchal rigidity
confusion/lethargy
stuporous
comatose
5%
10%
15%
60%
almost 100%
Clinical Presentation of SAH
Thunderclap headaches –
“worse headache”
Meningismus
Ocular hemorrhage
• Preretinal hemorrhage seen
with fundoscopic exam
Principles of Acute Diagnosis
Admission procedures
• ABC’s
 protect airway, stabilize vital signs
• Review Past Medical History
 identify risk factors
• Physical Examination
 Blood pressure, pulse rate and
rhythm, cardiac examination,
check for cervical, supraclavicular,
ocular or cranial bruits,
fundoscopic examination
Evaluation of SAH
Non-contrast head CT
If CT negative, then
lumbar puncture
• Finding – RBC count
usually > 100,000
• Check first and last tubes
If any of above positive
proceed with cerebral
angiogram and
neurosurgical consultation
Carotid Artery Disease
Carotid Artery Disease
Carotid Endarterectomy
• Multiple large randomized controlled studies have
evaluated CEA.
• Significant benefit (vs. best medical therapy) for
symptomatic lesions with stenosis >50%.
• Moderate benefit for asymptomatic lesions with
stenosis >60%.
• Benefit dependent on low surgical
morbidity/mortality
Carotid Artery Disease
Epidemiology
• Atherosclerotic plaques
begin to form at 20 yrs. of
age.
• Risk of stroke correlates
with degree of stenosis
Presentation
• Stroke, TIA, amaurosis
fugax
Carotid Endarterectomy and
Removed Plague
Spinal Cord Injury
Spinal Cord Injury
Epidemiology
• 10,000 per year in US
 Traumatic para- and
tetraplegia range from
10-50 new patients per
million individuals
 Mostly young healthy
individuals
Primary and Secondary SCI
Deficits caused by SCI are caused by
damage incurred at the time of injury, as
well as progressive damage that occurs
hours to days following injury.
The initial injury is termed “primary”
injury, ongoing processes are termed
“secondary” injury
Secondary Spinal Cord Injury
Trauma to the spinal cord triggers a
series of biochemical events which play
out over a period of hours to weeks
following injury.
These events cause local and systemic
effects, some of which are amplified by
positive feedback cycles.
Secondary Injury After SCI
Leading to Cell Death
Preventing Further Spinal Cord
Injury
ABC’s:
• Oxygenate, avoid hypotension
Immobilization:
• Prevent further mechanical damage to
spinal cord
Methylprednisolone:
• May ameliorate some effects of secondary
injury cascades
Treatment of Spinal Cord Injury
Decompression
• Alleviate effects of
compression on local
blood flow
Stabilization
• Prevent further damage
due to pathological
movement of spine
Mobilization
• Preserve and improve
residual function through
aggressive rehabilitation
Degenerative Spine
Disease
Degenerative Disc Disease
Clinical Presentation
Myelopathy
VS
• Spinal cord
compression
• Upper motor neuron
findings
 Brisk reflexes
 Spastic gait
Radiculopathy
• Nerve root
compression
• Lower motor neuron
findings
 Diminished reflexes
 Dermatomal findings
 Isolated muscle
weakness
Low Back Pain (LBP) and
Radiculopathy
LBP is extremely common
•
•
•
•
Lifetime prevalence 60-90%
Annual incidence 5%
85% no specific diagnosis
90% with LBP improve within 1
month with or without treatment
• Only 1% have radicular
symptoms
Nerve Root Syndromes
(radiculopathy)
Different nerve roots have different motor
and sensory functions, and these
functions are relatively stereotypical.
The history and physical examination of a
patient are usually adequate to
diagnose a nerve root compression
syndrome.
Spinal Anatomy:
Lumbar Radiculopathy from
Herniated Disc
Presentation
• Positive straight leg raise
• Radicular symptoms
 L45 HNP
– L5 dermatome
– Weakness EHL
 L5S1 HNP
– S1 dermatome
– Gastroc. Weakness
– Absent ankle jerk
Lumbar Radicular Syndromes:
L5 Radiculopathy (40-50%):
L3 Radiculopathy (Rare):
•Pain lateral thigh/leg into top of foot
• Pain anterior or anterolateral thigh
•stereotypical sensory loss in first
• quadriceps weakness
webspace
• diminished patellar reflex
•EHL weakness and tibialis anterior
(foot drop)
•medial hamstring reflex diminished
L4 Radiculopathy (3-10%):
•
Pain across knee, to medial
malleolus
•
quadriceps weakness, maybe
foot dorsiflexor weakness
•
diminished patellar reflex
S1 Radiculopathy (40-50%):
•Pain and sensory loss extend down
posterior leg into lateral aspect of
foot, lateral malleolus
•Weak plantar flexors of foot
•Achilles reflex diminished
Cervical Herniated Disc
Presentation
• Cervical radiculopathy
• Neck pain
• Myelopathy
Cervical Radicular Syndromes:
C6 Radiculopathy (19%):
Sharp
stabbing pain in lateral
forearm, thumb and index finger
(six shooter).
•Biceps weakness
•Loss of biceps reflex
•Dermatomal sensory loss
C7 Radiculopathy (69%):
• Pain into 2nd and 3rd fingers
• Forearm extensors or triceps
weak
• Loss of triceps reflex
• All fingertips may be involved in
paresthesias
C8 Radiculopathy (10%):
• Hand intrinsic weakness
• Medial hand pain (4th and 5th
finger) and sensory changes
Cauda or Conus Syndromes
Caused by large mass in canal which
compresses the conus or cauda equina
Slightly different presentations
Slightly different prognosis
Many similarities: Bilateral leg
symptoms, bowel and bladder
dysfunction, “saddle” sensory loss.
Both are neurosurgical emergencies.
Lumbar Spinal Stenosis
Presents with “Neurogenic Claudication”
Often occurs in patients with congenital stenosis
Usually a disease of the elderly
Responds well to surgery
May be difficult to distinguish from vascular
claudication
Claudication
Neurogenic claudication
VS Vascular claudication
• Sensory loss
• Sensory loss
dermatomal
stocking/glove
• More variable pain onset
• Usually very reproducible
pain onset
• Standing to rest not
• Standing to rest is OK
sufficient
• No pallor on foot
• Pallor with foot elevation,
elevation, pulses OK
diminished pulses
• “Anthropoid” posture
• Normal Posture
• Improves/stable with
• Made worse by
stationary bike test
stationary bike test
(Stretch ligament in
flexion opens canal)
Cervical Stenosis
Presents with neck pain
and myelopathy
• Gait disturbances
• Hand dysfunction
• Bowel and bladder
problems
• Hyper-reflexes
Who to Image:
Plain films are a cheap and easy
screening tool
Plain films lack specificity and sensitivity
Plain films deliver 1000X the dose of
radiation to the genitals as does a CXR.
• Need to justify use: AHCRP
Who to Image:
In the absence of “Red Flags,” no one
requires plain films during the first 6
weeks of pain.
If imaging is required due to presence of
“Red Flag,” or prolonged symptoms,
consider MRI.
Imaging “Red Flags”
Trauma
• Major Trauma
• Minor Trauma in older
or osteoporotic patients
• Steroid use
• Osteoporosis
• Age >70
Infection
•Fever, chills weight loss
•Risk factors for spinal infection
(IVDA, UTI, immunosuppression)
•Pain worse when supine or at night
Tumor
• Age >50 or <20
• History of CA
• Unexplained weight loss
Other*
•Progressive neurological
deficit
•Cauda equina syndrome
Indications for MRI or Surgical
Referral
Neurological Deficit
Pain lasts beyond 6-12 weeks
“Red Flag”
Recurrent pain
Findings on imaging studies
Peripheral Nerve Disease
Peripheral Nerve Entrapment
Neuropathies
Compression of peripheral nerve from
external forces or nearby anatomical
structures
Pain is the most common symptom
• Frequently worse at night
• Often retrograde radiation from point of
entrapment
• Tenderness at point of entrapment
Entrapment Neuropathies
Carpal tunnel
• Compression of
median nerve at
wrist
• Tinel’s sign
• Phalen’s test
• Symptoms palmar
thumb, index, middle
finger
• Hand weakness
Tardy ulnar palsy
• Compression at
elbow
• Pain, numbness little
finger (ulnar
distribution)
• Froment’s sign
• Claw deformity
• Atrophy interossei
muscles
Brain Tumors
Brain Tumors
Two types – primary and metastatic
Presentation
•
•
•
•
Head aches
Nausea and vomiting
Seizure
Focal neurological deficit
Primary Brain Tumors
Epidemiology
• 5 per 100,000 individuals per
year
• 10,000 new cases per year in
US
• Rarely metastasis outside brain
• Very poor prognosis for
malignant tumors
Metastatic Brain Tumors
Epidemiology
• 60,000 – 70,000
new cases per
year
• Increase
incidence in
smokers
Brain Tumors in Children
22 new cases per million
each year
Second leading cause of
cancer death in children
More often in posterior
fossa
Present with sign of
increased intracranial
pressure
•
•
•
•
Hydrocephalus
Papilledema
Head ache
Nausea vomiting
Hydrocephalus
Hydrocephalus
DEFINITION:
Diverse group of conditions which
result from impaired circulation and
resorption of CSF.
CSF Formation
CSF IS PRIMARILY FORMED
BY THE CHOROID PLEXUS.
NORMAL CSF PRODUCTION:
20 ml/h., about 500 ml/day,
total volume 150 ml.
Therefore must circulate 3
times per day.
Types of Hydrocephalus
OBSTRUCTIVE OR NONCOMMUNICATING
(OBSTRUCTION WITHIN THE
VENTRICULAR SYSTEM)
NON OBSTRUCTIVE OR
COMMUNICATING
(MALFUNCTION OF ARACHNOID
VILLI)
Clinical Manifestations
SYMPTOMS:
•
•
•
•
•
IRRITABILITY
POOR APPETITE, DECREASED FEEDING
LETHARGY
VOMITING
IN OLDER PATIENTS:
 HEADACHE
 CHANGES IN PERSONALITY
 ACADEMIC DETERIORATION
Clinical Manifestations
SIGNS:
• Anterior fontanelle wide open and bulging,
increased head circ.
• Dilated scalp veins
• Setting sun sign
• Brisk tendon reflexes, spasticity
• Possibly clonus
Shunts
Shunts: the main form of
therapy for
hydrocephalus
Types: peritoneal; atrial;
pleural; ureteral;
gallbladder;
subarachnoid
Disadvantages:
mechanical and
infectious complications
What’s a Shunt?
Ventricular catheter
Reservoir
One-way valve
Peritoneal, pleural, or atrial catheter
Diagnosis of Shunt Failure
Guidelines
Symptoms: Headache,
nausea, vomiting, lethargy,
increased head circumference,
fontanelle, wound drainage,
MOTHER KNOWS BEST!
What about fever?
Studies: Head CT, shunt
series, shunt tap, abdominal
ultrasound, nuclear medicine
scan, ICP monitoring
Eval. of Shunt Malfunction
H&P
• reason for initial insertion
• date of last revision and reason for revision
• fontanelle tension if < 1 year old
? SYMPTOMs of Acute ↑ ICP
• headache, N/V, diplopia, lethargy, ataxia, seizures
? SIGNs of Acute ↑ ICP
• papilledema, upward gaze palsy, visual field
deficits
• Infants: bulging fontanelle,
prominent scalp veins
Shunt Malfunction
Radiographic studies:
• Shunt series
 A/P and Lateral skull
 low CXR or
Abdominal CXR
• Head CT without contrast
• COMPARE to old CT for
evidence of increased
ventricular size.
Treatment: shunt revision
may be necessary up to
several times per year.
Head CT Prior to Shunt
Head CT Post Shunt Placement
Questions?
Ad Hoc Committee on Neurosurgical Education of the Council of State
Neurosurgical Societies and Contributors
Mick Perez-Cruet, Chairman
William Bingaman
Gary Bloomgarden
Fernando Diaz
Stewart Dunsker
Domenic Esposito
David Jimenez
Satish Krishnamurthy
Ralph Lehman
Lyal Leibrock
Cheryl Muszynski
Scott Purvines
Daniel Resnick
Randall Smith
Christopher Wolfla
Edie Zusman
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