Back to Basics for Surgery Neurosurgery

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Back to Basics for SurgeryNeurosurgery

• R. Moulton

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Principles of Neurological Diagnosis
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Questions

• What is the lesion
• Where is the lesion

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• History
• Physical (Neurological) Examination
• Special Tests

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Presentation of Neurosurgical Illness

• Raised ICP
• Headache, vomiting
• papilloedema
• Neurological Dysfunction
• General level of consciousness
• Focal sensory or motor loss
• Seizures
• Pain

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• What is the lesion history
• Where is the lesion neurological exam

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History (What is the lesion?)

• Symptoms
• Mode of onset
• Speed of onset
• Prior relevant illness
• Progression/regression of symptoms

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Neurological Examination (Where is the Lesion?)

• Level of Consciousness GCS
• Mental status orientation, memory,
  concentration, abstraction, calculation
• Cranial Nerves
• Motor examination
• Upper vs. lower motor neuron
• Cerebellar function
• Gait
• Sensory examination
• light touch, pain temp, joint position sense
• Cortical sensory modalities

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Cranial Nerves

• I Olfactory
• II Optic
• III Oculomotor
• IV Trochlear
• V Trigeminal
• VI Abducens
• VII Facial
• VIII Acoustic
• IX Glossopharyngeal
• X Vagus
• XI Accessory
• XII Hypoglossal

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Motor Examination

• Upper Motor Neuron
• Weakness (distal gt proximal) antigravity muscles
  preserved
• Increased reflexes and tone (spasticity)
• Disuse atrophy
• Loss of coordination (ataxia)
• Apraxia
• Upgoing plantar response

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• Lower Motor Neuron
• Weakness
• Decreased tone
• Decreased reflexes
• Denervation atrophy
• Coordination usually intact

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Sensory Examination

• Special senses cranial nerves
• Basic Modalities
• Light touch, pain temp, vibration
  proprioception
• Dermatomes, peripheral nerve distribution
• Cortical Modalities
• Graphaesthesia, stereognosis, simultaneous
  appreciation of tactile stimuli,
  somatotopognosis, agnosagnosia, neglect

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Special Tests

• Biochemical, hematological, microbiology
• Blood
• CSF
• Imaging
• Plain x-rays
• CT
• MRI
• Angiography
• Electrophysiology
• EMG, nerve conduction, EEG etc.

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Neurological Examination of the Comatose Patient

• Level of Consciousness
• Glasgow Coma Score
• Brainstem Integrity
• Pupillary Reaction
• Ocular Movement
• Corneal reflexes
• Gag/breathing

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• Eye Opening
• spontaneous 4
• to voice 3
• to pain 2
• none 1
• Verbal Response
• oriented 5
• confused - sentences 4
• words only 3
• sounds 2
• none 1
• Movement
• obeys 6
• localises 5
• flexion withdrawal 4
• abnormal flexion 3
• extension 2
• none 1

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Rostral-Caudal Deterioration

• Midbrain
• Bilateral pupillary abnormalities
• Oculomotor abnormalities
• Pons
• Loss of corneal reflexes
• Medulla
• Loss of gag reflexes
• Respiratory and vasomotor collapse

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Brain Tumour Classification

• Intra-axial (frequently malignant)
• Primary
• Glial
• Choroid plexus
• Neuronal or mixed glial-neuronal
• PNET/medulloblastoma
• CNS lymphoma
• Pineal region
• hemangioblastoma
• Metastatic

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Brain Tumour Classification

• Extra-axial (usually benign)
• Meninges
• Cranial nerves (Schwannoma)
• Pituitary
• skull

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Glial Tumours

• Astrocytoma (gliobastoma multiforme)
• Oligodendroglioma
• Ependymoma
• Mixed tumours
• Gr. I - IV

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Treatment

• Supportive
• Specific
• Corticosteroids (dexamethasone)
• Surgical
• Biopsy
• Excision
• Internal decompression

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Treatment contd.

• Radiotherapy
• Conventional
• Stereotactic focused
• Chemotherapy
• Temazolamide (malignant glial tumours)
• Lymphoma protocols
• Specific to tissue of origin for metastases
• Observation

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No Contrast
With Contrast
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Stroke Classification and Management
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Stroke Definition

• Sudden onset of a neurological deficit due to
  disease or injury of the blood supply of the
  brain.

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Stroke Classification

• Ischemic
• Bland
• Hemorrhagic transformation
• Hemorrhagic (hemorrhage is 10 event)
• Hypertension
• Amyloid angiopathy
• Aneurysmal
• AVM
• Other

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Ischemic Stroke (Infarction)

• Thrombotic (local vessel disease)
• Embolic
• Artery to artery (usually carotid)
• Heart to artery (atrial fibrillation)
• Paradoxical (vein to artery)
• Other (air, foreign body, iatrogenic)

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Intracerebral Hemorrhage

• Hypertensive
• Occurs in long narrow perforating arteries (basal
  ganglia, thalamus, pons, cerebellar nuclei)
• Charcot-Bouchard aneurysms
• Related primarily to duration of hypertension

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Intracerebral Hemorrhage

• Amyloid angiopathy
• Age related change in cerebral vessels
• Lobar hemorrhage
• Most commonly in posterior part of cerebral
  hemispheres

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Intracerebral Hemorrhage

• AVM
• Berry aneurysm
• Subarachnoid hemorrhage
• Usually exclusively subarachnoid
• May have intracerebral component
• Occasionally exclusively intracerebral

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Management

• Diagnosis
• History
• Physical Examination
• Special tests (imaging)
• Treatment

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Stroke Diagnosis

• History
• Rapid onset fixed deficit ischemic
• Rapid onset progressive deficit hemorrhage
• Sudden severe headache, nausea/vomiting/photophobi
  a /- neurological deficit - SAH

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Stroke Physical Examination

• Focal deficits
• Most often ischemic stroke or ICH
• Much less common in SAH
• Alteration in level of consciousness
• SAH
• ICH
• Delayed swelling from large infarcts

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Stroke Investigation

• CT scan
• First line imaging to distinguish infarct from
  hemorrhage
• 1st choice for confirming SAH, LP if negative
• Other
• Cerebral angiography, doppler for carotids
• MRI in special circumstances

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Acute Stroke Treatment

• Supportive
• Airway
• Blood pressure
• Definitive
• Thrombolysis
• Hematoma evacuation (limited circumstances)

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Stroke Treatment

• Prevention
• Risk factor modification
• Hypertension, smoking, diabetes,
  lipids/cholesterol
• Antiplatelet agents (artery-artery embolism,
  local occlusive disease)
• Anticoagulation (heart to artery emboli)
• Surgical prevention
• Carotid endarterectomy, stenting
• Aneurysm obliteration
• AVM excision

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Skull Fracture
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Primary Impact Injury

• Shear (diffuse) injury of axons
• Laceration/contusion of cortical surface

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Blumbergs, Head Injury, 199745
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Cerebral Contusions
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Secondary Insults

• Hypoxia
• Ischaemia
• Intracranial hematomas
• Raised intracranial pressure
• Seizures
• Infection
• Fluid and electrolyte disturbance

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Respiratory Changes in Head Injury

• Depression/abolition of gag and cough reflexes
• Hypercarbia 2o to respiratory centre depression
• Hypoxemia -- systemic causes
• inadequate airway management
• chest trauma
• aspiration

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Recommendations for Treatment
Resuscitate aggressively with appropriate fluids
Brain oedema is not a concern
Manage source of bleeding in unstable patients
prior to transfer
Do not use mannitol in presence of
hypotension or you will further destabilise the
patient
Consider transient use of vasopressor drugs
while restoring volume and controlling
haemorrhage
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Trauma Craniotomy Incision
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Pressure Volume Curve
Pressure
Vskull Vbrain Vblood VCSF Vmass
Volume
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Trans-Tentorial Herniation
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Use of Mannitol

• .5 - 1 gm./kg of 20 solution
• give as a bolus
• urinary catheter
• Contraindications
• Shock
• Anuria

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Other ICP Therapies

• CPP therapy
• Barbiturate Coma
• Decompressive Craniectomy

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Back to Basics For Surgery

• Spine

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Pain Generators

• Myofascial
• Disc
• Facet Joint
• Nerve
• Visceral
• Vascular

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Physical Examination The Spine

• Inspect deformity
• Palpate deformity, local tenderness
• Range of motion (limitation, pain)

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Myelopathy

• a general term denoting functional disturbance
  and/or pathological changes in the spinal cord

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Myelopathy Important Questions

• Level of lesion
• Nature of lesion
• Surgical (spondylotic, neoplastic, infectious,
  hematoma, traumatic)
• Treatment frequently curative
• Non-surgical (degenerative, inflammatory)
• Degree of patient disability
• Rate of progression
• History, physical examination, special
  investigations

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Myelopathy History

• Patient Complaints
• Numbness (loss of sensation, alteration of
  sensation paraesthesia, awkwardness)
• Ataxia (awkwardness, clumsiness)
• Usually
• Gait (imbalance, unsteadiness, unable to move
  quickly)
• Fine movements of hands (doing up buttons,
  handwriting)
• Weakness usually a late finding

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Myelopathy History

• Patient Complaints
• Numbness (loss of sensation, alteration of
  sensation paraesthesia, awkwardness)
• Ataxia (awkwardness, clumsiness)
• Usually
• Gait (imbalance, unsteadiness, unable to move
  quickly)
• Fine movements of hands (doing up buttons,
  handwriting)
• Weakness usually a late finding

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Myelopathy History

• Limbs involved lower (may be thoracic or
  cervical), upper and lower (always cervical)
• Onset gradual, rapid or sudden
• Associated pain
• Activity related spondylotic
• Nocturnal neoplastic
• Associated radicular pain
• Previous or concurrent neurological
  symptoms/illness

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Myelopathy Physical Examination

• Motor
• Strength weakness is usually late finding in
  slowly evolving surgical conditions, occurs in
  corticospinal distribution
• Reflexes (change occurs early) hyperactive
  distal to lesion in gradually evolving lesions
• In disc disease may be hypoactive at level of
  lesion

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Myelopathy Physical Examination

• Tone (early) increased distal to lesion
• Coordination (early) impaired distal to lesion
• Plantar responses up-going (reliability?)
• Sensation
• Proprioception frequently impaired in lower
  limbs impossible to establish precise level
• Pinprick extremely useful in thoracic lesions

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Special Investigations

• Plain x-rays (bone destruction, fracture,
  subluxation, spondylotic changes), n.b. no
  visualization of nervous tissue
• CT scan (same indications/contraindications as
  x-ray)
• MRI usually the definitive investigation
• CT-myelography (most useful for looking at bone
  and disc relation to spinal cord/nerve roots)

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Myelopathy Surgical Decision-Making

• Nature of the lesion
• Natural history of the lesion
• Trauma static/improving unless spine unstable
• Neoplastic progressive, rate variable depending
  on histology
• Infectious usually rapidly progressive
• Spondylotic myelopathy, usually gradually
  progressive, rate variable
• Recovery usually poor with advanced deficits

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Myelopathy Surgical Approach

• Lesion site
• Extradural
• Intra-dural, extra-medullary
• Intramedullary
• Extradural
• Anterior pathology anterior approach
• Posterior pathology posterior approach
  (laminectomy)
• Intradural-extramedullary posterior
• Intradural-intramedullary - posterior

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Radiculopathy

• a general term denoting functional disturbance
  and/or pathological changes in a spinal nerve
  root

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Radiculopathy

• Symptoms
• Pain, paraesthesiae, sensory loss in the
  approximate dermatome of the involved nerve root
• Axial pain is not a symptom of nerve root
  involvement
• Weakness in the myotome of the involved nerve
  root pts. frequently cant be specific

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Radiculopathy

• Exam findings
• Lower motor neuron findings in the appropriate
  myotome
• Sensory findings in the appropriate dermatome

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Radiculopathy Investigation

• Lumbar
• MRI, CT scan
• Cervical/thoracic
• MRI

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Radiculopathy - Conservative Tx

• Activity modification
• NSAIDS
• Analgesics
• Physiotherapy - active

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RadiculopathySurgical Indications

• Intractable radicular (not axial) pain which has
  failed conservative management
• Progressive or significant neurological deficit

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Spine Pain Red Flags

• Hx of major trauma or minor trauma in elderly,
  osteoporotic patients
• Age lt 20 or gt 50
• Hx of cancer, fever, chills, unexplained wt. loss
• Hx of recent infection, IV drug abuse,
  immunocompromise
• Hx of bladder or bowel incontinence, urinary
  retention
• Hx of major or progressive neurological deficit
• Hx of pain worsening when supine or severe night
  pain

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Spine Pain Red Flags

• Exam major neurological deficit/signs of upper
  motor neuron dysfunction
• Exam peri-anal anaesthesia
• Exam loss of anal sphincter tone

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Indications for Surgery (Non-Degenerative Back
Pain)

• Tumour
• primary
• metastatic
• Infection
• Discitis/osteomyelitis
• Epidural Abcess
• Fracture/subluxation with instability

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Clinical Assessment of Spinal Injuries

• History
• Mechanism of injury
• Spinal pain
• Paraesthesia or motor weakness
• Physical examination
• Log roll, inspect and palpate entire spine
• Tenderness
• Malalignment of spinous processes

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Traps for the Unwary

• Patient intoxication
• Altered level of consciousness
• Distraction from other injuries
• Cursory examination failure to appreciate
  single root injury

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Cervical Spine X-rays

• Lateral to T1
• AP
• Open-mouth odontoid
• CT Scan if one or more of above not available

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X-ray Investigation of the Spine

• Screening/basic views
• AP, lateral, open-mouth odontoid, swimmers view
• Special Investigations
• Flexion-extension
• CT
• MRI
• Myelogram

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Treatment of Spine Injuries

• Immobilize patient
• Reduce deformity
• Stabilize/fuse spine

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Back to Basics for Surgery

• Peripheral Nerve

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Injury Classification (Seddon)

• Neurapraxia
• Axonotmesis
• Neurotmesis

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Peripheral Nerve Injury

• History
• Usually immediate onset of symptoms/signs from
  time of injury
• Blunt or penetrating injury
• Blunt injury frequently associated with fracture
  or dislocation
• May follow reduction of fracture or dislocation
• Delayed onset compartment syndrome or vascular
  injury to limb

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Peripheral Nerve Injury

• Physical Examination
• Upper vs. lower motor neuron
• Root vs. peripheral nerve
• Which root?
• Which peripheral nerve?

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Investigations

• MRI/CT
• Indirect, helpful if question of upper vs. lower
  motor neuron, root vs. peripheral nerve
• EMGs/Nerve conduction
• Former useful, latter not
• Most sensitive in detecting early recovery
• Not useful in acute management
• Extremity X-rays
• helpful with injury site if fracture or
  dislocation

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Investigation

• EMG (all injuries)
• importance of clinical vs. EMG recovery
• Root and trunk injuries
• Metrizamide CT- myelogram
• MRI

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Overall Treatment Strategy

• Nerve repair
• Restore movement
• Restore sensation
• Muscle/tendon/joint reconstructive surgery
• Prosthetics
• Rehabilitation
• Educational and vocational advice

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Timing of Surgery

• Primary repair (penetrating injury)
• immediate
• delayed (2 weeks)
• Secondary repair (blunt injury)
• 3 - 4 month delay

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Reconstructive Strategies to Achieve Elbow
Flexion

• Steindler flexoroplasty
• Latissimus dorsi transfer
• Pectoralis major transfer
• Triceps transfer

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Common Wrist/Hand Tendon Transfers

• Wrist extension -- pronator teres
• Thumb extension -- palmaris longus
• MCP extension -- flexor carpi radialis
• Finger flexion -- brachioradialis or extensor
  carpi radialis longus to flexor digitorum
  profundus
• Thumb flexion -- BR or ECRL to FPL

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Results Etiology

• Etiology No. of Pts
• Lacerations 24
• MVA 22
• Winter sports 11
• Falls 8
• Gunshot wounds 4
• Others 14
• Adjacent fractures in 15 patients

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Individual nerve outcome

• Nerve Inc. loss
  Exc. loss
• to f/u
  to f/u
• Brachial plexus 33
  37.5
• Axillary 42.9
  75
• Musculocutaneous 57.1 80
• Radial 58.3
  87.5
• Median 75
  85.7
• Ulnar 66
  100
• Posterior tibial 50
  60

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Outcome by Etiology

• Laceration 87.5
• MVA 32
• Winter sports 57.1
• Falls 50