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Essentials of Neurosurgery Michelle Miller, PA-C Primary Care Associate Program July 12, 2005 Introduction Conditions treated by Neurosurgery Other surgical specialties Role of Primary Care Providers Diagnosis When to refer Post-operative follow-up Common post-operative conditions Conditions Treated by Neurosurgeons Hydrocephalus Trauma to head or spine Degenerative spine diseases Disk herniations Spondylotic disease Spinal instability Neurovascular disease Aneurysms & arteriovenous malformations of the brain & spinal cord Carotid stenosis Intracranial hemorrhage of any etiology Conditions Treated by Neurosurgeons Conditions Treated by Neurosurgeons Neurooncology Tumors Brain & meninges Pituitary gland Spine & spinal column Conditions Treated by Neurosurgeons Peripheral nerve injury or entrapment Carpal tunnel syndrome Congenital malformations Medically intractable disorders Movement disorders (Parkinson’s) Epilepsy Chronic pain Other Surgical Specialties Orthopedic Surgery Spinal instrumentation Traumatic injuries Plastic Surgery Peripheral nerve entrapment Other Surgical Specialties Vascular Surgery Carotid endarterectomy (CEA) Role of Primary Care Provider Initial diagnosis and treatment Symptom management Referral to specialty care Identification of emergent versus urgent conditions Coordination of care Pre-operative clearance Post-operative care Healthcare Maintenance Record-keeping Case Study 35 year old female presents to your office following her vacation for c/o of chronic headaches, described as “sinus pain,” for approximately 6 months. She denied any recent illness, fever or congestion. She did mention that during her vacation she fell, but denied any injury. She stated, “ I lost my balance.” Discussion Brain Tumors Primary brain tumors Benign versus malignant Glial cells Neuronal cells Meninges Primary malignant brain tumors rarely metastasize but are locally invasive of surrounding parenchyma Benign tumors are encapsulated Grade IV astrocytoma (glioblastoma) is the most common primary brain tumor of adults Glioblastoma Multiforme (GBM) Brain Tumors Metastatic disease (secondary brain tumors) Malignancies with the greatest tendency to metastasize to brain Lung Breast Renal thyroid Corticosteroids in Neurosurgery Introduced into Neurosurgery in the 1960’s Radically improved the acute management of brain tumors Steroids are used to treat edema caused by recent surgical manipulation How do they work? By stabilizing the blood-brain barrier, corticosteroids effectively reduce vasogenic edema in the brain or spinal cord associated with tumors Corticosteroids in Neurosurgery Decadron (dexamethasone) Most commonly used corticosteroid Pure glucocorticoid with no mineralcorticoid effect (unlike prednisone or hydrocortisone) Can be given enterally or intravenously Side effects GI bleeding Hyperglycemia Immunosuppression Poor wound healing Psychosis Long-term steroid use: osteoporosis, fat redistribution, myopathy Seizures Caused by synchronous paroxysmal discharge from cerebral cortex Frequently, a seizure is the first presentation of an intracranial lesion, especially with brain tumors Anticonvulsant prophylaxis Before & after surgery Titrated according to blood levels and seizure control Anticonvulsants Dilantin (phenytoin) Luminal (phenobarbital) Tegretol (carbamazepine) Depakote (valproic acid) Neurontin (gabapentin) Keppra (levetiracetam) Dilantin Most commonly used first-line anticonvulsant for a patient with a new presentation of generalized or focal seizures Dilantin allergies Red macular rash Unexplained fever Altered liver function Dilantin overdose Arrhythmias Hyperreflexia Dysarthria Confusion Nystagmus ataxia Blood Pressure Control During & after intracranial surgery, control of hypertension is critical for the prevention of brain hemorrhage Fluid & Electrolyte Management Volume status Hyponatremia Disorders of ADH regulation Hyponatremia Should be avoided in neurosurgery patients because it exacerbates brain edema and lowers seizure threshhold Normal adult values: 135-145 mEq/L Ventriculoperitoneal (VP) Shunt A Ventriculoperitoneal shunt is surgically placed to relieve intracranial pressure caused by hydrocephalus Intracranial hemorrhage, spina bifida, brain tumor, meningitis, encephalitis Ventriculoperitoneal (VP) Shunt When ventricles become enlarged with cerebrospinal fluid Brain tissue becomes compressed against the skull Excess fluid accumulates around the brain causing an increase in intracranial pressure Serious neurological problems result Shunting is necessary to drain the excess fluid and relieve pressure in the brain Excess pressure can cause a decrease in blood flow to the brain leading to brain damage Ventriculoperitoneal (VP) ShuntCraniotomy for Cerebral Shunt Performed in the OR under general anesthesia A flap is cut in the scalp and a small hole is drilled in the skull A small catheter is passed into a ventricle of the brain A pump (valve which controls flow of fluid) is attached to the catheter to keep fluid away from the brain Ventriculoperitoneal (VP) Shunt The fluid is shunted from the ventricles of the brain into the abdominal cavity In some cases, the fluid is shunted to the pleural space in the chest A pump controlling fluid flow is attached to the catheter to keep the fluid away from the brain Another catheter is attached to the pump It tunnels under the skin, behind the ear, down the neck and chest and into the abdominal cavity When to Refer Emergent referrals Emergency Department Mental status changes Cauda equina syndrome (nerve compression) Motor deficits Sensory deficits Bowel/bladder incontinence or retention radiculopathy Urgent referrals Neurosurgeon Conservative therapies fail Post-operative Follow-up Surgery date? Suture/staple removal Wound care Laboratory follow-up? Infection, drainage, swelling, pain? Drug levels Chemistries Medication management Long & short term management Antiepileptic Sleep aides GI upset Post-operative Follow-up Pain management Physical Therapy DMV clearance Support groups Precautions Drug interactions Depression Issues of death & dying Chemotherapy and Radiation Catheters Hickman catheter Long-term, central venous indwelling catheter with external port(s) Venous placement- subclavian, under clavicle Placement in OR or via radiology Infusion of blood products, nutrition, chemotherapy Must be meticulously cared for to prevent infection Fluoroscopy-guided placement Requires CXR to confirm placement prior to use Hickman Catheter Review Questions Questions A 6 year old male is struck by a car while riding his bicycle. He is reported to be unconscious for 2 min following the accident. He is conscious and alert upon arrival to the ED, but within 45 min, he begins to vomit and shortly thereafter he becomes completely unresponsive. Which of the following most likely explains the child’s injury? Answer A. B. C. D. E. Acute subdural hematoma Chronic subdural hematoma Acute epidural hematoma Acute traumatic subarachnoid hemorrhage Grade III concussion Answer A. B. C. D. E. Acute subdural hematoma Chronic subdural hematoma Acute epidural hematoma Acute traumatic subarachnoid hemorrhage Grade III concussion Answer This is a classic history of an epidural hematoma. The typical presentation is that of a child who sustains a hard blow to the head and experiences a brief loss of consciousness, followed by a lucid interval, when the child is awake and alert. As the hematoma expands, the patient experiences a headache followed by vomiting, lethargy and hemiparesis and may progress to coma if left untreated. This injury usually results from a temporal bone fracture with a laceration of the middle meningeal artery or vein and less often a tear in a dural venous sinus. Epidural hematomas are treated with surgical evacuation of the clot and ligation of the bleeding vessel. Question Which of the following is/are true of lumbar disc herniation? Answer A. B. C. D. E. Most common at the L5-S1 disc Radiating pain to the buttocks, thigh, calf, and foot Often associated with a positive straight leg raise test May be complicated by cauda equina syndrome All of the above Answer A. B. C. D. E. Most common at the L5-S1 disc Radiating pain to the buttocks, thigh, calf, and foot Often associated with a positive straight leg raise test May be complicated by cauda equina syndrome All of the above Answer A herniated lumbar disc compresses the nerve root, resulting in a radicular pain called lumbar radiculopathy. The pain characteristically radiates to the buttock, thigh, leg, and foot. When the pain is severe, the pain can be worsened by straight leg raising and may be limited to 20 to 30 degrees. The patient may have decreased or absent reflexes, weakness, and paresthesias or decreased sensation in a dermatomal distribution. It is most common at the L5-S1 disc followed by the L4-L5 disc. Question The most common intracerebral neoplasm is: Answer A. B. C. D. E. Glioma Meningioma Lymphoma Metastasis adenoma Answer A. B. C. D. E. Glioma Meningioma Lymphoma Metastasis adenoma Answer Glioma account for nearly 50% of primary brain tumors. The remainder are meningiomas (15%), pituitary tumors (7%) and other tumors. Break Essentials of Cardiothoracic Surgery Michelle Miller, PA-C Primary Care Associate Program July 12, 2005 Conditions Treated by Cardiothoracic Surgeons Coronary Artery Bypass Graft (CABG) Valve Replacement or Repair Tissue Mechanical Video Assisted Thoracotomy (VATS) Xenograft (porcine or bovine) Homograft (cadaveric human) Tumor ressection AAA Repair Trauma Transplant Surgery Heart Lung Coronary Artery Bypass Graft Cardiac bypass surgery is an operation to restore the flow of blood through the arteries that supply blood to the heart, when a blockage or partial blockage occurs in these arteries. The arteries that supply the heart muscle with oxygen and nutrients are known as the coronary arteries. The word "coronary" means a crown, and is the name given to these arteries that circle the heart like a crown. The narrowing of the arteries of the heart is known as coronary artery disease, which is the most common form of heart disease. Coronary Artery Bypass Graft Coronary Artery Bypass Graft Saphenous Vein Harvest Saphenous Vein Harvest What to Expect Following CABG Surgery Cardiologist follow-up in 7 to 10 days after discharge from hospital Discuss recovery Make lifestyle change recommendations Fine tune medications as needed What to Expect Following CABG Surgery 6 weeks post-op: most people resume almost all of their regular activities As activity increases, strength increases Patient should be able to walk 2-3 miles in an hour Driving Travel Sexual activity Return to work Avoid overexertion What to Expect Following CABG Surgery Sternum 12 weeks to heal Should avoid the following: Heavy lifting Golf Tennis Vigorous swimming Light activities are o.k. Graft site Leg, arm or both Wound healing pain CABG Discharge Instructions D/C Home Instructions Call your Surgeon to report any of the following No driving while taking narcotic pain medications No lifting anything heavier than 10 lbs No baths or swimming May shower, must “pat dry” incision Fever greater than101F Bleeding or pus draining from incisions Difficulty breathing Chest Pain Surgical site pain unrelieved by prescribed medication F/U in clinic with surgeon approximately 2wks (1 wk if patient has staples) F/U with referring cardiologist 4 wks Valve Replacement Valve Replacement Valve Replacement Valve Replacement Valve Replacement Valve Replacement Valve Replacement Discharge Instructions Discharge Medications ASA or Coumadin B-Blocker +/- ACE inhibitor Isosorbide or Ca-channel Blocker if radial artery graft used Pain medications Previous prescription meds Anticoagulation Aspirin Coumadin PT/INR monitoring Pro time International Normalized Ratio A comparative rating of PT ratios (representing the observed PT ratio adjusted by the International Reference Thromboplastin) The PT is an important screening test used during management of oral anticoagulant therapy (Coumadin) Prothrombin is a protein produced by the liver for clotting of blood Surgical Population In the United States, the fastest growing population segment includes people 65 or older More than half of these individuals will require some form of surgery in their lifetime Improvements in surgical techniques, anesthesia and ICU’s have made surgery in this population possible 1 Delirium Post-operative delirium Overall incidence 5-10% all age groups 10-15% elderly patients Incidence varies with type of surgery 1-3% following cataract surgery 5-10% following general surgery 28-61% following major orthopedic surgery 47% following cardiac surgery Delirium A significant proportion of these patients will experience postoperative cognitive impairment The most common forms are: Delirium Postoperative cognitive dysfunction (POCD) Frequency of POCD Definition “Deterioration of intellectual function presenting as impaired memory or concentration.” Clinical features Range from mild forgetfulness to permanent cognitive impairment resulting in a loss of independence POCD diagnosis can only be made if cognitive decline can be corroborated by the results of neuropsychological testing presurgical and postsurgical Post-operative cognitive dysfunction Overall incidence 20-60% following coronary artery bypass surgery 10-16% elderly patients following major non-cardiac surgery Primary Care Issues What are your thoughts? Primary Care Issues Endocarditis Prophylaxis High-risk category Prosthetic cardiac valves Previous bacterial endocarditis, even in the absence of heart disease Complex cyanotic congenital heart disease Single ventricle states Transposition of the great arteries Tetralogy of Fallot Moderate-risk category Most congenital cardiac malformations Rheumatic & other acquired valvular dysfunction Hypertrophic cardiomyopathy Mitral valve prolapse with valvular regurgitation Endocarditis Prophylaxis Dental procedures Extractions Peridontal procedures Endodontic procedures (root canal) Prophylactic cleaning where bleeding is antipated Other surgical procedures Endocarditis Prophylaxis Oral Antibiotics Amoxicillin 2 grams 1 hour before procedure Clindamycin 600mg 1 hour before procedure Cephalexin 2 grams 1 hour before procedure Azithromycin or Clarithromycin 500mg 1 hour before procedure Post-operative Complications Post-operative Complications Wound infection Atrial Fibrillation Neurological deficits Pulmonary Embolus Transplant anticoagulation Stroke Sternum Chest tube sites Graft site Rejection of organ Other systemic infections Death Post-operative Follow-up Pain management Physical Therapy DMV clearance Support groups Precautions Drug interactions Depression Transplant Primary Care Discussion