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Neuro/Spine
April 27, 2012
Anatomy Review
 Skull Bones
 Protection for the brain
 Sutures – bony seams
 8 Cranial cavity bones
 Frontal, occipital,
ethmoid, sphenoid,
temporal, parietal
Meninges
 Fibrous membranes support
and protect brain and spinal
cord
 Dura mater
 Arachnoid mater
 Pia mater
Brain Divisions
 Cerebrum
 2 hemispheres connected centrally by corpus callosum
 Controls motor and sensory for contralateral side
 Frontal lobe – higher function of intellect, movement,
language & personality
 Parietal – senses pain and touch
 Occipital – visual
 Temporal- memory, speech, smell
 Thalamus – sensory station
 Hypothalamus – controls fluid/electrolyte balance,
appetite, reproduction, thermoregulation, immune
response, emotional response
 Pituitary – multiple hormones (TSH,GH)
 Brain Stem
 Midbrain – eye movements
 Pons – horozontal eye movement, face movement
 medula oblongata – vital cardiovascular and
respiratory regulatory functions
 Cerebellum – balance & coordination of movement
Ventricular System & CSF
 4 ventricles
 Communicating cavities
within the brain
 Produce and serve as
reservoir for CSF
 Spinal fluid
 Bathes brain and spinal
cord
 Cushion for brain
 Aids in keeping ICP
constant
 Increase volume if brain
atrophies, decreases
volume to compensate for
brain swelling
Cerebral Blood Supply
 Main arteries to the
brain
 2 internal carotid
arteries
 2 vertebral arteries
 Circle of Willis
 Base of brain
 Ensure continuity of
circulation if any main
artery is interrupted
Cranial Nerves
Vertebral Column
 33 vertebra: 7 cervical, 12
thoracic, 5 lumbar, 5 sacral, 1
coccygeal
 Function: maintain stability,
protect neural elements, and
range of motion
 Atlas and axis – shaped
differently to support the skull
and allow for more rotational
movement
Vertebrae Anatomy
 Vertebral body
 oval block of bone
 Pedicles
 connect body to arch
 Lamina
 2 broad plates
 Articular facets
 project from the pedicles
 form joints with the facets of the
vertebra above and below
 Transverse processes
 extend laterally, muscles and
ligaments attach
 Spinous processes
 extend posteriorly and can be felt in
most people
Intervertebral Disks
 Cushion, shock absorbers
 Annulus Fibrosus
 Nucleus pulposus
Spinal Cord
 Downward prolongation of the
brain
 Carries impulses from the brain
to motor neurons of PNS
 Protected by the vertebra of
spinal column
 Spinal canal formed by
vertebral bodies, pedicles &
laminae
Spinal Nerves
 Spinal nerves
 Part of the PNS
 31 pairs of nerve roots branch off
from the spinal cord and control
functions of the body
 Each have an anterior (motor)
and posterior (sensory) nerve
root
 Carry motor and sensory
impulses from CNS and PNS
Spinal Nerves
Dermatomes
 An area of skin that is
innervated by a sensory root
of a spinal nerve
 Symptoms that follow a
dermatome (pain,rash) may
indicate pathology of nerve
root
 Pinched nerve roots causing
radiculopathy
 Herpes zoster (shingles)
Hematoma
 Blood clot causing increase ICP and
compression of brain
 Epidural Hematoma
 Between skull and dura
 Sx: unconsciousness, fixed dilated pupil, extremity
weakness, abnormal posturing
 Subdural Hematoma
 Acute, subacute or chronic
 Between dura and arachnoid
 Sx: loss of consciousness, gradual increase
headache, dizziness, confusion, nausea, vomiting,
seizures
 Intracerebral hematoma
 Tears in brain substance commonly in ant. temporal
and frontal lobes
 Sx: severe headache, confusion, drowsiness,
paralysis of opposite side, speech changes
 Burr Holes or Craniotomy or Craniectomy to
decompress brain and remove/drain blood clots
Tumors
 Intracranial tumors: tumors within the brain or
its membranes
 Metastatic tumors more common than primary
 Over 120 types of primary CNS tumors
 Classified by histologic type: glioblastoma,
menegioma
 Symptoms
 Progressive neurologic deficit usually motor
weakness
 Headaches and seizures
 Diffuse increase in ICP
 Depends on location
 Large left or bifrontal lobe tumors – personality changes
 Left frontotemporal region – aphasia
 Diagnosed by
 history, neurologic exam, CT/MRI &/or biopsy
 Treatment can include steroids, antiepileptic
meds, management of hydrocephalus, surgery,
radiation, chemotherapy
Hydrocephalus
 Excessive accumulation of CSF in ventricles resulting in increased ICP
 Due to obstruction, poor absorption, or overproduction of CSF
 Reasons include congenital abnormalities, aqueductal stenosis, tumor,
subarachnoid hemorrhage, meningitis
 Common among young children and older adults
 Acute or Chronic
 Symptoms vary depending on age
 Infants: enlarged head, seizures, vomitting, sleepy
 Adults – impaired balance, memory loss, poor coordination, headache
 External ventriculostomy catheter placement
 Temporary shunting for acute symptoms
 Catheter placed in ventricle through bur hole and connected to external
drainage system
 Internalized ventriculoperitoneal (VP) shunt
 One way valve system drains CSF away from ventricle into the peritoneum
Brain Approaches
 Bur Holes
 Small hole for minimum exposure to brain
 Hematoma, VP shunt
 Craniotomy
 Remove bone flap and is replaced at end of
case with plates/screws
 Hematoma, aneurism, tumor
 Craniectomy
 permanent removal of section of skull
 Severe head injury, tumor, infected bone
 Transsphenoidal Approach
 used to remove pituitary tumors
 Can use stereotatic navigation
Spine Pathologies
 Tumors
 Most common are metastatic
 cord compression causing pain and weakness
 Treatment goals: pain releif, preservation/restoration of neurologic
function
 Treatment may include surgery or radiation or combo
 Trauma
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Most common type of injuries: fractures, subluxation, disk herniation
Cervical spine most vulnerable to injury
Need early stabilization to minimize cord trauma
Spinal cord injury
 Complete: lacks sensation, position sense, & voluntary motor function below
level of injury
 Incomplete: still has some sensory, position sense & motor impulses present
Spine Pathologies
 Degenerative diseases - arthritis, osteoperosis
 Most common cause for neck pain and back pain
 Herniated disks or bulging disk
 commonly occur at L4-5, L5-S1
 Spinal stenosis – narrowing of spinal canal
 Common in cervical & lumbar regions
 Radiculopathy – compression of nerve roots causing pain &
weakness
 Treatments include rest, physical therapy, steriod injections,
surgery (laminectomy, laminotomy, diskectomy, fusion)
Herniated Disc
Compression Fractures
Spine Surgery
 Laminectomy
 Removal of one or more vertebral lamina from to expose
spinal canal to treat compression fracture, degenerative
changes, dislocation, herniated disk, tumor causing
pressure on spinal cord
 Diskectomy
 Herniated or ruptured disk most common injury seen by
neurosurgeons
 Most occur in lower lumbar region
 Removal of ruptured annulus fibrosus or herniated nucleus
pulposus
Spine Surgery
 Fusion
 Stabilization of spine using plates/screws or rods
 May be indicated following injury or excision of bone
 Cervical, thoracic, lumbar
 Vertebroplasty and Kyphoplasty
 Treats vertebral compression fractures from osteoporosis
or pathologic condition
 Bone cement injected into vertebral body to decrease pain
and prevent body height loss
Lumbar Fusion
Kyphoplasty
Preparation for Surgery:
What is the Plan?
 Age, weight, allergies, NPO status
 Diagnosis and procedure, approach
 LOC – able to sign consent? Family available
 Stability of spine and other injuries
 Communication barriers
 Surgical site marked and matches consent: side of head,
level of spine, approach site
What is the Plan? Continued
 Diagnostic studies (xrays, CT, labs, MRI, etc): have available
 Surgical approach, position needed, need to communicate with
anesthsia
 Equipment, instruments, supplies: neuromonitoring,
microscope, midas, positioning equipment, stereotactic
navigation, ICP monitor
 Implants, bone grafts
 Blood products
 Medications
 Preliminary procedures: placement of lines, foley etc
 Radiology
Assessment
 LOC, mental status, orientation, follow commands
 GCS: eye opening, verbal, and motor response
 ROM: neck, arms, legs
 Skin assessment
 Other injuries from trauma
 Pain, location, which side for spine
 Anxiety
Positioning Cranial Surgery
 Supine
 Approach most commonly for frontal, parietal and temporal lobes
 Mayfield pins or horseshoe or head on gel doughnut
 Prone
 Approach for occipital lobe
 Head in mayfield pins
 Semi fowlers or sitting position
 Head in mayfield pins
 For occipital approach
 Mayfield pins
 Bacitracin ointment for pins
 Surgeon will place pins and have control of head while transferring patient
 Do not move the patient after pins placed and head locked in place, could
break neck
 May turn the bed 90-180 degrees
 At least 1 arm tucked
 Placement of microscope, headlight
Mayfield Skull Pins & Horseshoe
Sitting Position with Pins
Positioning Anterior Spine Surgery
 Anterior Cervical Spine
 Supine with mayfield pins or horseshoe on radiolucent table or
regular bed
 May need cervical traction
 Arms tucked to side
 Anterior Lumbar/Thoracic
 Supine
 Radiolucent table
 Rails clear for retractor (bookwalter, omni)
Positioning Posterior Spine Surgery
 Posterior cervical
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Prone with head in mayfield pins or face on foam pillow
Gel chest rolls, wilson, or jackson frame
Arms tucked down to side
Radiolucent table
 Posterior lumbar/thoracic
 Prone on gel chest rolls, Jackson, Wilson frame, or Cloward
 Arms overhead not extended greater than 90 degrees
 Radiolucent table
 Make sure there is enough people to safely transfer
OSI Jackson Frame
OSI Jackson Frame
OSI Bed with Flat Top
Wilson Frame
Cloward Saddle
Lateral Approach to Spine
 XLIF (eXtreme
lumbar interbody
fusion)
 Incision on
patient’s side
 Lateral decubitus
position (90º)
 Secure body so no
moving
 Iliac crest at break
in bed
Skin Preparation
 Hair Removal
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Do as close to surgery time as possible
Use clippers
Save hair for patient
Hold hair back: Ointment, rubberbands
 Skin Prep
 Have appropriate solution: surgeon preference, allergies
 Prep area: incision site, VP shunt placement, ICBG site
Physical Hemostatic Agents
 Electosurgery: monopolar,
bipolar
 Bone wax
 Sponges
 Cottonoids
 Hemaclips
Pharmacological Hemostatic Agents
 Thrombin
 Catalyzes conversion of fibrinogen to
fibrin
 Soak cotton patties or gelfoam in
thrombin and then apply topically
 Floseal/Surgiflo
 Gelatin matrix is mixed with thrombin
 Topical gel that clots bleeding site
 Gelfoam
 Absorbable gelatin sponge placed
topically over bleeders, often soaked in
thrombin
Pharmacological Hemostatic Agents
 Avitene
 Collagen hemostat, usually a loose
fibrous form that is placed topically
with bleeding surface, attracts
platelets to the area
 Surgicel
 Oxidized regenerated cellulose
pad, placed topically & forms clot,
as absorbs it becomes gel
 Local Anesthetic with epinephrine
Bone Autograph
 Patient’s own bone
 ICBG
 Bone Mill
 “coffee grinder”
Bone Allograft Products
 Cancellous bone chips
 DBX bone putty
 Demineralized Bone Matrix used
to fill gaps or voids in bone
 Absorbs as bone grows and
takes up the space
 BMP
 Bone Morphogenetic Protein
(synthetic) is reconstituted then
absorbed into a collagen sponge
 The BMP stimulates bone growth
and the sponge gets absorbed
 Osteocel
 Contains stem cells so acts like
autographs because biologically
active
 Kept in freezer
Basic Neuro Equipment
 Midas
 Microscope
 Cusa
 Bone Mill
 ICP monitor
 Stereotatic Navigation
 Wilson Frame
 Cloward
 OSI Jackson frame
 OSI Flat Top
 Mayfield: skull pins, horseshoe
 Radiology: C-arm, flat plates
Basic Neuro Instruments
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Rongeurs
Pituitary
Kerrisons
Currettes
Frazier suctions
Raney clips
Perforators
Hibbs
Myerding
Clowards retractor
Laminar Spreader
Nerve Hooks
Room Set Up
*Think Meds, Beds, Equipment, & Implants*
 Meds: Local, hemostatic agents, etc.
 Beds: positioning equipment for the bed
 Wilson frame, Jackson, Mayfield, etc.
 Equipment: microscope, midas, c-arm, etc.
 Available and working
 Implants: fusion, crani plates, bone graft
Documentation
 Remember to document!
 Pre-existing skin lesions, lack of motor strength or difficulty
with movement
 Other injuries
 Specifics of positioning
 “If it is not documented, it was not done.”
 Implant Documentation is critical