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NEURO SURGERIES
Mr. Hariraja M
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Lecture Outline

This lecture deals about the approaches, indications,
monitoring, assessment, complication and management of
neuro surgeries.

It also deals about clinical features, types, and management
of hydrocephalus and spina bifida
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Lecture objectives

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At the end of This lecture student will be able to

Enumerate indications for Neuro surgery

Explain different approaches of Neuro surgeries

Explain Complications of Neuro surgeries

Assessment and Management of complications of Neuro
surgeries, hydrocephalus and Spina Bifida
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Purposes For Neurosurgery
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
Diagnosis - e.g. biopsy, lumbar puncture

Evacuation e.g. haemorrhage, pus

Excision e.g. mass lesion, eliptogenic focus

Decompression e.g. tumour, abscess

Relief of Increased ICP – e.g. bilateral frontal craniectomy

Repair e.g. aneurysm, artery, Dural tear, elevation of depressed skull fracture

Drainage of CSF – shunt, lumbar puncture

Other purposes

Implant e.g. nerve stimulators, radioactive seeds (tumour treatment from within - brachytherapy)

Transplant e.g. human foetal tissue (PD), stem cells

Spinal surgery (e.g. following trauma, tumours etc.)
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Indications for Neuro surgeries
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1. BRAIN
a. BRAIN TUMOURS

Benign or malignant tumors associated with midline shift

Meningioma

Skull base tumors

Pituitary tumors
b. TRAUMATIC BRAIN INJURIES ( Hemorrhage & Hematoma)
c. VASCULAR DISORDERS

Aneurysms

Arteriovenous malformations (AVMs)

Other miscellaneous vascular conditions
d. HYDROCEPHALUS
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Indications for Neuro surgeries
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2. NECK:
a)
Neck pain secondary to malignant disease
b)
Neck pain secondary to infection
c)
Neck pain associated with neurological deficit
d)
Cervical myelopathy
e)
Mechanical neck pain without arm pain
f)
Neck pain associated with referred pain to the upper arm without
neurological deficit
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Indications for Neuro surgeries
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3. BACK:
a)
Back pain with neurological and bladder Involvement (cauda equina
syndrome)
b)
Back pain secondary to neoplastic disease or infection
c)
Back pain and sciatica with neurological deficit
d)
Mechanical lower back pain without lower limb pain
e)
Back pain and sciatica without neurological deficit
f)
Spinal stenosis with limitation of walking distance
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Indications for Neuro surgeries
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4. PERIPHERAL NERVES:
a)
Carpal tunnel syndrome
b)
Ulnar nerve compression
c)
Occipital neuralgia
d)
Clinical guidelines for the management of acute
e)
low back pain
f)
Key patient information points for acute low
g)
back pain
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Neurosurgery Approaches
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Stereotaxy –placement of burr hole / bone flap and safest
approach for destruction of deep brain tissue located by using 3-D
coordinates (CT / MRI)


Burr hole – hole drilled into the cranium

Craniotomy – opening into skull (via hole or flap)

Craniectomy – excision of part of the skull (bone is left out)

Cranioplasty – plastic surgery of the skull e.g. bone or plate
replacement
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Stereotactic and Burr hole surgery:
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Example of stereotactic system with CT/MRI
guidance e.g. for biopsy
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Example of biopsy procedure:
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Example of operative approaches:
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Craniotomy to remove EDH:
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Example of evacuation of SDH:
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Neurosurgery Techniques
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
Lumbar puncture – insert lumbar puncture needle to collect CSF
usually at the L3/4 space (below L1 where spinal cord ends) –
contraindicated if ICP is increased since it may cause tentorial
herniation (pressure gradient)

Shunt techniques for Hydrocephalus

Surgical resection (remove parts of the brain – for epilepsy,
tumour etc.)

Drainage – of abscess, CSF shunt
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Example of lumbar puncture:
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Examples of shunt techniques:
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SAH - Aneurysm repair
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
Clipping – dissection of arachnoid tissue around neck of
aneurysm allows a clip to be positioned to prevent further
rupture

Wrapping – muslin gauze or fascia lata is wrapped around
fundus (rebleeding may occur)

Trapping – clip proximal and distal vessels and bypass
anastomosis ( risk of infarction)

Common carotid ligation (collateral circulation through circle of
Willis and reverse flow from external carotid may prevent
ischemia)
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Example of Trapping and Clipping technique
for aneurysm
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Aneurysm repair
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
Balloon embolisation –balloon inserted via an angiographic
catheter is inflated in aneurysm sac - not optimal (risk rupture of
aneurysm, embolic CVA, rebleed)

Helical platinum coil embolisation – tracker catheter guided
through aneurysm neck introduces a coil on a delivery wire /
electrical current releases coil from delivery wire
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ASSESSMENT AND MONITORING IN THE 23
INTENSIVE CARE UNIT
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POSTOPERATIVE MONITORING

Systemic and neuro monitoring are essential after neurosurgery to help identify patients
who may deteriorate.

The most important monitor after elective neurosurgical procedures is the repeated
clinical examination.
1. Neurological evaluation

Postoperative neurological evaluation is focused on two characteristics - consciousness
and focal neurologic findings.

The procedure may determine the specific focal finding to concentrate upon. Common
instruments include: the Glasgow Coma Score, Full Outline of UnResponsiveness (FOUR
score), Reaction Level Score, and NIH Stroke Scale.
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Cont.
3. Systemic monitoring

Hypoxia and hypotension are the two most important systemic secondary insults in
TBI patients, and it is reasonable to presume this also is true for postoperative
neurosurgical patients.

Therefore, oxygen saturation by pulse oximetry and blood pressure should be
continuously monitored. Continuous EKG also should be considered (e.g. severe
arrhythmias may occur after SAH).

Other cardiovascular monitors (e.g. pulmonary artery catheters, invasive pulse
pressure contour monitors, non-invasive impedance cardiography ) may be necessary
for patients with pre-existing cardiac disease
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Cont.
3. Intracranial Pressure Monitor

An ICP monitor should be considered in the following circumstances:
Large vascular tumors, severe edema, trauma surgery, deeply sedated
patients where an exam cannot be obtained (or a patient fails to wake up), known
operative complications (e.g. aneurysm rupture, known vessel occlusion), and large fluid
shifts are expected.
4. Other monitors

For most patients the extent of specialized neuro monitoring should be based on the
clinical presentation and the experience of the responsible physician. This includes
1) bedside CBF assessment (e.g. jugular bulb oximetry, Transcranial Doppler
sonography [TCD] Thermal diffusion flow metry, Near infrared spectroscopy [NIRS])
2) Microdialysis and brain tissue oxygen tension (PbtO2) and
3) Electroencephalography
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Cont.
5. Surgical drains

Many procedures require use of post-operative drains. This can entail hemovacs
or JP drains left after craniotomy or lumbar drains left after spinal surgeries where
there is a concern for CSF fistula formation.

This is crucial to evaluating both the quality (blood, CSF) and quantity of drain
output. It is advisable to never remove a post-operative drain until you have
specifically discussed its purpose with the surgeon.
6. Imaging

CT and MRI investigations in critically ill neurosurgical patients are useful to
monitor the course of the illness and for the early detection of complications and
should be considered when neurological deterioration occurs or the expected
postoperative improvement does not occur.
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POSTOPERATIVE MONITORING AFTER
INTRACRANIAL PROCEDURES
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POSTOPERATIVE COMPLICATIONS
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SYSTEMIC COMPLICATIONS AFTER NEUROSURGERY
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COMMON CONDITIONS IN NEUROLOGY
WHICH NEEDS SURGERY INCLUDES
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1. HYDROCEPHALUS
2. SPINA BIFIDA
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1. HYDROCEPHALUS

From Greek hydrokephalos, from hydr- + kephalE head

Definition:
An abnormal increase in the amount of cerebrospinal fluid within the cranial cavity
that is accompanied by expansion of the cerebral ventricles, enlargement of the skull
and especially the forehead, and atrophy of the brain
Overview of CSF production

The CSF volume of an average adult ranges from 80 to 160 ml

The ventricular system holds approximately 20 to 50 ml of CSF

CSF is produced in the choroid plexuses at a daily rate of 14-36 ml/hr
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Overview of CSF circulation

The CSF flows from the
lateral ventricles
downward to the
foramina of Magendie and
Luschka, to the
perimedullary and
perispinal subarachnoid
spaces, and then upward
to the basal cistern and
finally to the superior and
lateral surfaces of the
cerebral hemispheres
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Overview of CSF circulation

The CSF flows from the
lateral ventricles
downward to the
foramina of Magendie and
Luschka, to the
perimedullary and
perispinal subarachnoid
spaces, and then upward
to the basal cistern and
finally to the superior and
lateral surfaces of the
cerebral hemispheres
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CSF pressure

Normal intracranial
pressure (ICP) in an adult
is between 2-8 mmHg.

Levels up to 16 mmHg are
considered normal

ICP higher than 40 mmHg
or lower BP may combine
to cause ischemic damage
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The function of the CSF

The CSF acts as a
“water jacket” for the
brain and spinal cord

The 1300 g adult brain
weighs approximately
45 g when suspended
in CSF
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Types of Hydrocephalus
There are 2 types
A. Non-communicating (Dandy) or Obstructive
B. Communicating or Non obstructive

This is an old classification of hydrocephalus

The terms refer to the presence or absence of a
communication of the lateral ventricles with the spinal
subarachnoid space
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A. Non-communicating
Hydrocephalus
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 There is no communication between the
ventricular system and the subarachnoid
space.
 The commonest cause of this category is
aqueduct blockage or stenosis.
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Clinical features of Non communicative
Hydrocephalus

Obstructive
hydrocephalus: presents
with macrocephaly and/or
intracranial hypertension.

Parinaud's
syndrome.
Inability to elevate eyes

Collier's sign. Retraction of
the eyelids
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Treatment of NCH

Remove underlying cause of obstruction if possible.

Third ventriculostomy as initial treatment of choice.

VP shunt if technical reasons do not allow third ventriculostomy or if the
child fails after ventriculostomy.

Aqueductal stent can be placed if technically feasible. Usually rarely
done due to risk of upper brain stem injury.
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B. Communicating
Hydrocephalus
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 In communicating or non-obstructive
hydrocephalus there is communication
between the ventricular system and the
subarachnoid space.
 The commonest cause of this group is post-
infectious and post-hemorrhagic
hydrocephalus.
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Causes of communicating Hydrocephalus

Overproduction of CSF

Blockage of CSF circulation

Blockage of CSF resorption

Hydrocephalus ex-vacuo

Normal pressure hydrocephalus
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Treatment of Hydrocephalus

The two most commonly used shunt
systems are

1. ventriculoatrial (VA) and

2. ventriculoperitoneal (VP) shunts.
3. Ventriculo pleural shunt (V-PL)-Less
commonly used


The VP shunt is most commonly used as it
is simpler to place, extra tubing may be
placed in the peritoneum and the
consequences
of infection are less.
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
The VA shunt must be accurately located in the atrium and
requires frequent revisions as the child grows to maintain the
proper position of the distal end.

In addition, infection is a more serious complication with a VA
shunt as its location in the blood stream may lead to sepsis.

In situations where both the abdomen and vascular system can
no longer function to absorb CSF, the distal catheter can be
placed in the pleural space (V-PL shunt).

The distal catheter is placed through a small incision in the
anterior chest wall. As with the peritoneal shunt, extra tubing
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can be placed,
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Components of Shunt systems
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(1) a ventricular catheter,

(2) a one way valve and
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(3) a distal catheter.

The ventricular catheter is a
straight piece of tubing, closed
on the proximal end and
usually with multiple holes for
the entry of CSF along the
proximal two centimeters of
the tube.
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The most common sites for entry of the
ventricular catheter

1. a frontal position in line with the pupil at the coronal suture,

2. a parietal position just above and behind the ear, or

3. a occipital position three centimeters off the posterior midline.
The position used varies with the configuration of the ventricles, the
shape and size of the head and the surgeon’s preference.
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Shunt malfunction
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
Common complications of VP shunt include shunt malfunction or blockage and infection.

Malfunction may be related to growth and the shunt will need to be replaced with a longer
catheter.

Symptoms of shunt malfunction or infection includes
Headache, fever, drowsiness, convulsions, increased head circumference and bulging
fontanelle.
If left untreated, shunt malfunction or infection is associated with high morbidity and
mortality rates.
A shunt series and head CT scan are part of the initial evaluation. Empiric antibiotic therapy is
initiated to cover Gram-positive organisms, predominantly S. epidermidis, as well as the less
common Gram-negative and anaerobic organisms responsible for shunt infections.
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2. Spina Bifida

A condition that refers to
a developmental defect of
the spinal column in
which the arches of one
or more of the spinal
vertebrae fail to fuse.

Failure of closure in the
midline or lower end of
the neural tube. (Cleft
Spine)
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SPINA BIFIDA
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Signs and Symptoms

Swelling

Dimple in skin

Tuft of hair

Muscle weakness

Paralysis

Loss of a sensation

Fluid build up (hydrocephalus)

Brain damage

Seizures

Blindness
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Secondary Complications

Low fitness

Obesity

Poor functional strength

Pressure sores

Respiratory difficulties

Learning and Perceptual difficulties

Motor functioning seizures
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Types of Spina Bifida
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A. Spina Bifida Occulta – an abnormality is confined
to the vertebrae only and is due to an unclosed
posterior vertebral arch.
B. Spina Bifida Cystica – A more severe type of spina
bifida that has two classifications.
1. Meningocele
2. Myelomeningocele
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a. Spina Bifida Occulta

Approximately 40% of all Americans may have spina bifida occulta, but because
they experience little or no symptoms, very few of them ever know that they
have it.
b. Spina Bifida Cystica

Meningocele – Where the meninges protrude through the defect. (4%)

Myelomeningocele – Elements of the cord also protrude through the defect,
resulting in severe neural deficits. (96%)

1 out of 1,000 births
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Surgical management

Usually performed with in 24 hours after birth.

They remove the infected area and
replace it with muscle tissue and skin.

Helps protect against hydrocephalus.
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PT MANAGEMENT
OF NEURO
SURGERIES
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GOALS
The primary goal of postoperative neurosurgical
intensive care is early detection and treatment of
post- surgery complications.
The second goal is prevent secondary insults,
which may initiate or exacerbate secondary
damage in a vulnerable central nervous system
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Considerations Post-Neurosurgery
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Read surgery reports. Medical orders must be checked and followed. e.g. :

Head position - may be flat and possibly positioned with drainage hole down (eg
following SDH drainage) or 30 degrees up (eg where there is  ICP or vasospasm
following aneurysm repair)

Rest in bed versus allowed to Sit out of Bed (SOOB) or mobilise (and if so, what
distances e.g. to and from toilet)

Monitored fluid intake / output – e.g. by mouth / intake related to maintaining
cerebral perfusion pressure and cerebral blood flow

Restraint e.g. with irritable patient
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Considerations Post-surgery

DVT (both lower and upper limb)

Cardiorespiratory e.g. aspiration, secretion retention

Neurological deterioration e.g.  weakness

Musculoskeletal issues e.g. shoulder pain, contractures

Neuropraxia, pressure areas (e.g. from compression while on operating
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table)

Bone flap / helmet to be worn if flap left out
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Physical therapy AIMS
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1. To prevent chest complication
2. To prevent chest complication
3. To maintain muscle power and joint range of motion
4. To prevent pressure sores
5. To maintain good posture
6. To improve and enhance bed mobility
7. To gain co operation and Confidence
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