Common Neurosurgical Hospital Consult Diagnoses

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Common Neurosurgical HospitalConsult Diagnoses

• Jeff Crecelius
• Neurosurgeon
• Goodman Campbell Brain and Spine

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Disclosures

• None really
• Will use word Kyphoplasty which is commercial but
  in widespread use
• No financial interest in Kyphon, but did first
  case in Lafayette, and received free barbecue at
  training course in Memphis many years ago

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Brain Bleeds

• Sounds dramatic, and sometimes it is but often
  not.
• Epidural
• Subdural
• Subarachnoid
• Intracerebral

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Epidural Hematoma

• Relatively uncommon-only1-2 of TBI
• Good prognosis if pure i.e. isolated
• Lucid interval is classic, but uncommon (20)
• Prompt surgery is important
• Usually in younger patient with relatively low
  energy trauma

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Subdural Hematoma

• Acute in high energy injury associated with other
  brain involvement
• Acute in low energy may be tolerated if in
  elderly with atrophy and room to spare
• Subacute (from clot to red liquid) may be treated
  with just burr hole
• Chronic (crankcase fluid) commonly recognized in
  elderly weeks after minor injury

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Subarachnoid Hemorrhage

• Traumatic usually from high energy injury
• Spontaneous from many sources
• Aneurismal cause in about 75
• Others causes include AVM, tumor, vasculitis
• Cause usually apparent from CT pattern and
  historyif likely from aneurysm, we transfer to
  Indianapolis for evaluation

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Intracerebral

• Hypertensive
• Ischemic
• Vascular Malformations (AVM, Cavernous)
• Amyloid Angiopathy
• Trauma (DTICH)
• Tumor
• THIN Blood (growing incidence of
  iatrogenic)another day for that!

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Normal Pressure Hydrocephalus

• Misnomer and really a spectrum of disease
• Triad of symptoms
• Gait DisturbanceStuck, but not unique
• Incontinence (which is common with immobility)
• Dementia
• Difficult diagnosis (especially in hospital
  otherwise ill with co morbidity)
• Clinical
• Imaging (CT, MR, Isotope Cisternogram)
• Tap Test vs. Ambulatory Lumbar Drainage

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Radiculopathy

• Common especially C6C7, L5S1
• Red Flags
• Agelt20,gt50 Weight loss Fever Worse at rest
• Cauda Equina Syndrome
• Rare but increasingly reported
• Insurance restriction of MRgtPCP staff
  overwhelmedgtStreet knowledge of incontinence as
  the key to cut the red tape.
• Uncommon to have normal reflexes and exam though

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No Red Flag Radiculopathy

• Brief rest (2-3days)
• Walk
• PT if gentle (but conditioned to be Aggressive)
• Analgesic
• Muscle relaxants
• Education/reassurance
• SMT
• Steroids? (IV, oral, ESI)

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Osteoporotic Thoracolumbar Compression Fractures

• Risk Factors
• Low Weight
• Cigarettes
• Family History
• Female (especially postmenopausal)
• Alcohol
• Steroids
• Inactivity

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Evaluation of Fracture

• X-ray
• Compare if available
• MRI
• Acuity?
• CT and Bone Scan
• If MR contraindicated (ex. Implants like
  pacemaker)

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Treatment of Fracture

• Non-invasive
• Rest with DVT prophylaxis
• Analgesics
• PT
• Brace
• Typical time course about 6 weeks
• Follow up x-rays about 2 week intervals
• Assess progression

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Treatment of Fracture

• Invasive (augmentation)
• Vertebroplasty
• Kyphoplasty
• Multilevel Stabilization
• Rare

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Indications for Augmentation

• At least 5 height loss
• Intractable Pain
• Activity related and at fracture site
• Acute or Subacute on MR or Bone Scan
• Also may be used for hemangiomas, myeloma, or
  metastases (off label)

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Contraindications to Augmentation

• Healed (cold on bone scan/old on MR)
• Coagulopathy
• Evolving leniency by IR re anti-platelet agents
• Retropulsion
• Planum

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Questions

• Thanks