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Pathologies, Procedures and Room Set-Up Degenerative diseases - arthritis, osteoperosis Herniated disks or bulging disk Commonly occur at L4-5, L5-S1 Spinal stenosis Most common cause for neck pain and back pain Narrowing of spinal canal Common in cervical & lumbar regions Tumors Most common are metastatic Cord compression causing pain and weakness Most common injuries are 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 Removal of one or more vertebral lamina from to expose spinal canal to treat Used to treat: Compression fracture Degenerative changes Dislocation Herniated disk Tumor causing pressure on spinal cord Removal of ruptured annulus fibrosus or herniated nucleus pulposus Often replaced with bone graft Herniated or ruptured disk most common injury seen by neurosurgeons Most occur in lower lumbar region Stabilization of spine by locking vertebrae together Uses: Plates Screws Rods May be indicated following injury or excision of bone Anterior Cervical Spine Supine with mayfield pins or horseshoe on radiolucent table or regular bed May need cervical traction Arms tucked to side Pillow under knees Anterior Lumbar/Thoracic Supine Pillow under knees Radiolucent table Rails clear for retractor (bookwalter, omni) General surgeon needed to gain access to spine Posterior cervical 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 are enough people to safely transfer 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 Bovie, suction and warmer at foot of bed C-arm available May use flat plate instead Midas Headlight May use microscope Blood clot causing increase ICP and compression of brain Three types Epidural Subdural Intracerebral Burr Holes or Craniotomy or Craniectomy to decompress brain and remove/drain blood clots Tumors within the brain or its membranes Metastatic tumors more common than primary Classified by histologic type glioblastoma, menegioma Symptoms Progressive neurologic deficit motor weakness Headaches and seizures Diffuse increase in ICP Depends on location Excessive accumulation of CSF in ventricles resulting in increased ICP Reasons Congenital abnormalities, aqueductal stenosis, tumor, subarachnoid hemorrhage, meningitis Common among young children and older adults Acute or Chronic Infants Due to obstruction, poor absorption, or overproduction of CSF Enlarged head, seizures, vomitting, sleepy Adults Impaired balance, memory loss, poor coordination, headache Bur Holes Craniotomy Small hole for minimum exposure to brain Hematoma, VP shunt 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 Supine Prone Approach most commonly for frontal, parietal and temporal lobes Mayfield pins or horseshoe or head on gel doughnut Approach for occipital lobe Head in mayfield pins Semi fowlers 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 or 180 degrees At least 1 arm tucked Clip hair Save hair for patient Mayfield with pins or horseshoe headrest Bovie, suction and warmer at foot of bed Midas Microscope Headlight Clippers Supine Arms tucked Pillow under knees Head on pillow or in mayfield May turn bed Often assisted by an ENT surgeon Bovie, suction and warmer at foot of bed Microscope Stereostatic navigation Mayo prep stand to include: Local, bayonet forceps, nasal speculum, syringe and neuro patties Catheter placed in ventricle through bur hole and connected to external drainage system One way valve system drains CSF away from ventricle into the peritoneum Supine May need access to abdomen Arms tucked Pillow under knees May turn bed May send CSF Confirm implant with surgeon Local Bacitracin ointment Bacitracin irrigation Hemostatic agents Bone grafts Crani plates Fusion hardware Electosurgery: monopolar, bipolar Bone wax Sponges Cottonoids Hemaclips Thrombin Floseal/Surgiflo Catalyzes conversion of fibrinogen to fibrin Soak cotton patties or gelfoam in thrombin and then apply topically Gelatin matrix is mixed with thrombin Topical gel that clots bleeding site Gelfoam Absorbable gelatin sponge placed topically over bleeders, often soaked in thrombin Avitene Surgicel Collagen hemostat, usually a loose fibrous form that is placed topically with bleeding surface, attracts platelets to the area Oxidized regenerated cellulose pad, placed topically & forms clot, as absorbs it becomes gel Local Anesthetic with epinephrine 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