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Back to Basics for Surgery
Neurosurgery
R. Moulton
Principles of Neurological
Diagnosis
Questions
What is the lesion
 Where is the lesion

History
 Physical (Neurological) Examination
 Special Tests

Presentation of Neurosurgical
Illness

Raised ICP
– Headache, vomiting
– papilloedema

Neurological Dysfunction
– General – level of consciousness
– Focal – sensory or motor loss
Seizures
 Pain

What is the lesion – history
 Where is the lesion – neurological
exam

History (What is the lesion?)
Symptoms
 Mode of onset
 Speed of onset
 Prior relevant illness
 Progression/regression of symptoms

Neurological Examination
(Where is the Lesion?)




Level of Consciousness – GCS
Mental status – orientation, memory, concentration,
abstraction, calculation
Cranial Nerves
Motor examination
– Upper vs. lower motor neuron
– Cerebellar function
– Gait

Sensory examination
– light touch, pain & temp, joint position sense
– Cortical sensory modalities
Cranial Nerves












I
Olfactory
II
Optic
III Oculomotor
IV Trochlear
V
Trigeminal
VI Abducens
VII Facial
VIII Acoustic
IX Glossopharyngeal
X
Vagus
XI Accessory
XII Hypoglossal
Motor Examination

Upper Motor Neuron
– Weakness (distal > proximal) antigravity
muscles preserved
– Increased reflexes and tone (spasticity)
– Disuse atrophy
– Loss of coordination (ataxia)
– Apraxia
– Upgoing plantar response

Lower Motor Neuron
–
–
–
–
–
Weakness
Decreased tone
Decreased reflexes
Denervation atrophy
Coordination usually intact
Sensory Examination


Special senses – cranial nerves
Basic Modalities
– Light touch, pain & temp, vibration &
proprioception
– Dermatomes, peripheral nerve distribution

Cortical Modalities
– Graphaesthesia, stereognosis, simultaneous
appreciation of tactile stimuli,
somatotopognosis, agnosagnosia, neglect
Special Tests

Biochemical, hematological, microbiology
– Blood
– CSF

Imaging
–
–
–
–

Plain x-rays
CT
MRI
Angiography
Electrophysiology
– EMG, nerve conduction, EEG etc.
Neurological Examination of
the Comatose Patient

Level of Consciousness
– Glasgow Coma Score

Brainstem Integrity
–
–
–
–
Pupillary Reaction
Ocular Movement
Corneal reflexes
Gag/breathing

Eye Opening
spontaneous
to voice
to pain
none

Verbal Response
oriented
confused - sentences
words only
sounds
none

4
3
2
1
5
4
3
2
1
Movement
obeys
localises
flexion withdrawal
abnormal flexion
extension
none
6
5
4
3
2
1
Rostral-Caudal Deterioration

Midbrain
– Bilateral pupillary abnormalities
– Oculomotor abnormalities

Pons
– Loss of corneal reflexes

Medulla
– Loss of gag reflexes
– Respiratory and vasomotor collapse
Brain Tumour Classification
Intra-axial (frequently malignant)
 Primary

–
–
–
–
–
–
–

Glial
Choroid plexus
Neuronal or mixed glial-neuronal
PNET/medulloblastoma
CNS lymphoma
Pineal region
hemangioblastoma
Metastatic
Brain Tumour Classification

Extra-axial (usually benign)
–
–
–
–
Meninges
Cranial nerves (Schwannoma)
Pituitary
skull
Glial Tumours
Astrocytoma (gliobastoma
multiforme)
 Oligodendroglioma
 Ependymoma
 Mixed tumours
 Gr. I - IV

Treatment
Supportive
 Specific

– Corticosteroids (dexamethasone)
– Surgical
» Biopsy
» Excision
» Internal decompression
Treatment contd.
– Radiotherapy
» Conventional
» Stereotactic focused
– Chemotherapy
» Temazolamide (malignant glial tumours)
» Lymphoma protocols
» Specific to tissue of origin for metastases

Observation
No Contrast
With Contrast
Stroke: Classification and
Management
Stroke Definition

Sudden onset of a neurological deficit
due to disease or injury of the blood
supply of the brain.
Stroke Classification

Ischemic
– Bland
– Hemorrhagic transformation

Hemorrhagic (hemorrhage is 10 event)
–
–
–
–
–
Hypertension
Amyloid angiopathy
Aneurysmal
AVM
Other
Ischemic Stroke (Infarction)
Thrombotic (local vessel disease)
 Embolic

–
–
–
–
Artery to artery (usually carotid)
Heart to artery (atrial fibrillation)
Paradoxical (vein to artery)
Other (air, foreign body, iatrogenic)
Intracerebral Hemorrhage

Hypertensive
– Occurs in long narrow perforating
arteries (basal ganglia, thalamus, pons,
cerebellar nuclei)
– Charcot-Bouchard aneurysms
– Related primarily to duration of
hypertension
Intracerebral Hemorrhage

Amyloid angiopathy
– Age related change in cerebral vessels
– Lobar hemorrhage
– Most commonly in posterior part of
cerebral hemispheres
Intracerebral Hemorrhage
AVM
 Berry aneurysm
 Subarachnoid hemorrhage

– Usually exclusively subarachnoid
– May have intracerebral component
– Occasionally exclusively intracerebral
Management

Diagnosis
– History
– Physical Examination
– Special tests (imaging)

Treatment
Stroke Diagnosis

History
– Rapid onset fixed deficit – ischemic
– Rapid onset progressive deficit –
hemorrhage
– Sudden severe headache,
nausea/vomiting/photophobia +/neurological deficit - SAH
Stroke Physical Examination

Focal deficits
– Most often ischemic stroke or ICH
– Much less common in SAH

Alteration in level of consciousness
– SAH
– ICH
– Delayed swelling from large infarcts
Stroke Investigation

CT scan
– First line imaging to distinguish infarct
from hemorrhage
– 1st choice for confirming SAH, LP if
negative

Other
– Cerebral angiography, doppler for
carotids
– MRI in special circumstances
Acute Stroke Treatment

Supportive
– Airway
– Blood pressure

Definitive
– Thrombolysis
– Hematoma evacuation (limited
circumstances)
Stroke Treatment

Prevention
– Risk factor modification
» Hypertension, smoking, diabetes, lipids/cholesterol
– Antiplatelet agents (artery-artery embolism,
local occlusive disease)
– Anticoagulation (heart to artery emboli)
– Surgical prevention
» Carotid endarterectomy, stenting
» Aneurysm obliteration
» AVM excision
Skull
Fracture
Primary Impact Injury

Shear (diffuse) injury of axons

Laceration/contusion of cortical
surface
Blumbergs, Head Injury, 1997:45
Cerebral Contusions
Secondary Insults
Hypoxia
 Ischaemia
 Intracranial hematomas
 Raised intracranial pressure
 Seizures
 Infection
 Fluid and electrolyte disturbance

Respiratory Changes in Head Injury
Depression/abolition of gag and cough
reflexes
 Hypercarbia 2o to respiratory centre
depression
 Hypoxemia -- systemic causes

– inadequate airway management
– chest trauma
– aspiration
Recommendations for Treatment
Resuscitate aggressively with appropriate fluid
Brain oedema is not a concern
Manage source of bleeding in unstable patients
prior to transfer
Do not use mannitol in presence of
hypotension or you will further destabilise the
patient
Consider transient use of vasopressor drugs
while restoring volume and controlling
haemorrhage
Trauma Craniotomy Incision
Pressure Volume Curve
Pressure
Vskull = Vbrain + Vblood + VCSF + Vmass
Volume
Trans-Tentorial Herniation
Use of Mannitol
 .5
- 1 gm./kg of 20% solution
 give as a bolus
 urinary catheter
 Contraindications:
Shock
Anuria
Other ICP Therapies

CPP therapy

Barbiturate Coma

Decompressive Craniectomy
Back to Basics For Surgery
Spine
Pain Generators
Myofascial
 Disc
 Facet Joint
 Nerve
 Visceral
 Vascular

Physical Examination: The Spine
Inspect: deformity
 Palpate: deformity, local tenderness
 Range of motion (limitation, pain)

Myelopathy

‘a general term denoting functional
disturbance and/or pathological
changes in the spinal cord’
Myelopathy
Important Questions


Level of lesion
Nature of lesion
– Surgical (spondylotic, neoplastic, infectious,
hematoma, traumatic)
– Treatment frequently curative
– Non-surgical (degenerative, inflammatory)



Degree of patient disability
Rate of progression
History, physical examination, special
investigations
Myelopathy: History



Patient Complaints:
Numbness (loss of sensation, alteration of
sensation – paraesthesia, awkwardness)
Ataxia (awkwardness, clumsiness)
– Usually:
– Gait (imbalance, unsteadiness, unable to move
quickly)
– Fine movements of hands (doing up buttons,
handwriting)

Weakness – usually a late finding
Myelopathy: History



Patient Complaints:
Numbness (loss of sensation, alteration of
sensation – paraesthesia, awkwardness)
Ataxia (awkwardness, clumsiness)
– Usually:
– Gait (imbalance, unsteadiness, unable to move
quickly)
– Fine movements of hands (doing up buttons,
handwriting)

Weakness – usually a late finding
Myelopathy: History



Limbs involved: lower (may be thoracic or
cervical), upper and lower (always cervical)
Onset: gradual, rapid or sudden
Associated pain:
– Activity related: spondylotic
– Nocturnal: neoplastic
– Associated radicular pain

Previous or concurrent neurological
symptoms/illness
Myelopathy: Physical
Examination

Motor:
– Strength: weakness is usually late
finding in slowly evolving surgical
conditions, occurs in corticospinal
distribution
– Reflexes (change occurs early):
hyperactive distal to lesion in gradually
evolving lesions
» In disc disease may be hypoactive at level of
lesion
Myelopathy: Physical
Examination
– Tone (early): increased distal to lesion
– Coordination (early): impaired distal to
lesion
– Plantar responses: up-going (reliability?)

Sensation:
– Proprioception: frequently impaired in
lower limbs – impossible to establish
precise level
– Pinprick: extremely useful in thoracic
lesions
Special Investigations




Plain x-rays (bone destruction, fracture,
subluxation, spondylotic changes), n.b. no
visualization of nervous tissue
CT scan (same indications/contraindications
as x-ray)
MRI usually the definitive investigation
CT-myelography (most useful for looking at
bone and disc relation to spinal cord/nerve
roots)
Myelopathy: Surgical DecisionMaking


Nature of the lesion
Natural history of the lesion
– Trauma: static/improving unless spine unstable
– Neoplastic: progressive, rate variable depending on
histology
– Infectious: usually rapidly progressive
– Spondylotic myelopathy, usually gradually progressive, rate
variable
– Recovery usually poor with advanced deficits
Myelopathy: Surgical Approach

Lesion site:
– Extradural
– Intra-dural, extra-medullary
– Intramedullary

Extradural:
– Anterior pathology – anterior approach
– Posterior pathology – posterior approach
(laminectomy)


Intradural-extramedullary – posterior
Intradural-intramedullary - posterior
Radiculopathy

a general term denoting functional
disturbance and/or pathological
changes in a spinal nerve root
Radiculopathy

Symptoms
– Pain, paraesthesiae, sensory loss in the
approximate dermatome of the involved
nerve root
– Axial pain is not a symptom of nerve root
involvement
– Weakness in the myotome of the involved
nerve root – pts. frequently can’t be
specific
Radiculopathy

Exam findings
– Lower motor neuron findings in the
appropriate myotome
– Sensory findings in the appropriate
dermatome
Radiculopathy – Investigation

Lumbar
– MRI, CT scan

Cervical/thoracic
– MRI
Radiculopathy - Conservative Tx
Activity modification
 NSAIDS
 Analgesics
 Physiotherapy - active

Radiculopathy
Surgical Indications
Intractable radicular (not axial) pain
which has failed conservative
management
 Progressive or significant neurological
deficit

Spine Pain – Red Flags







Hx of major trauma or minor trauma in elderly,
osteoporotic patients
Age < 20 or > 50
Hx of cancer, fever, chills, unexplained wt. loss
Hx of recent infection, IV drug abuse,
immunocompromise
Hx of bladder or bowel incontinence, urinary
retention
Hx of major or progressive neurological deficit
Hx of pain worsening when supine or severe night
pain
Spine Pain – Red Flags
Exam: major neurological deficit/signs
of upper motor neuron dysfunction
 Exam: peri-anal anaesthesia
 Exam: loss of anal sphincter tone

Indications for Surgery
(Non-Degenerative Back Pain)

Tumour
– primary
– metastatic

Infection
– Discitis/osteomyelitis
– Epidural Abcess

Fracture/subluxation with instability
Clinical Assessment of Spinal Injuries

History
Mechanism of injury
Spinal pain
Paraesthesia or motor weakness

Physical examination
Log roll, inspect and palpate entire spine
Tenderness
Malalignment of spinous processes
Traps for the Unwary
Patient intoxication
 Altered level of consciousness
 Distraction from other injuries
 Cursory examination – failure to
appreciate single root injury

Cervical Spine X-rays
Lateral to T1
 AP
 Open-mouth odontoid
 CT Scan if one or more of above not
available

Treatment of Spine Injuries
Immobilize patient
 Reduce deformity
 Stabilize/fuse spine

Back to Basics for Surgery
Peripheral Nerve
Injury Classification
(Seddon)
• Neurapraxia
• Axonotmesis
• Neurotmesis
Peripheral Nerve Injury
History
– Usually immediate onset of
symptoms/signs from time of injury
– Blunt or penetrating injury
– Blunt injury frequently associated with
fracture or dislocation
– May follow reduction of fracture or
dislocation
– Delayed onset: compartment syndrome or
vascular injury to limb
Peripheral Nerve Injury
Physical Examination
–
–
–
–
Upper vs. lower motor neuron
Root vs. peripheral nerve
Which root?
Which peripheral nerve?
Investigations
 MRI/CT
– Indirect, helpful if question of upper vs. lower
motor neuron, root vs. peripheral nerve
 EMGs/Nerve conduction
– Former useful, latter not
– Most sensitive in detecting early recovery
– Not useful in acute management
 Extremity X-rays:
– helpful with injury site if fracture or dislocation
Investigation
• EMG (all injuries)
 importance of clinical vs. EMG recovery
• Root and trunk injuries
 Metrizamide CT- myelogram
 MRI
Overall Treatment Strategy
• Nerve repair
Restore movement
Restore sensation
• Muscle/tendon/joint reconstructive
surgery
• Prosthetics
• Rehabilitation
• Educational and vocational advice
Timing of Surgery
• Primary repair (penetrating injury)
 immediate
 delayed (2 weeks)
• Secondary repair (blunt injury)
 3 - 4 month delay
Reconstructive Strategies to
Achieve Elbow Flexion
• Steindler flexoroplasty
• Latissimus dorsi transfer
• Pectoralis major transfer
• Triceps transfer
Common Wrist/Hand
Tendon Transfers
• Wrist extension -- pronator teres
• Thumb extension -- palmaris longus
• MCP extension -- flexor carpi radialis
• Finger flexion -- brachioradialis or
extensor carpi radialis longus to flexor
digitorum profundus
• Thumb flexion -- BR or ECRL to FPL
Results Etiology
Etiology
No. of Pts
Lacerations
MVA
Winter sports
Falls
Gunshot wounds
Others
24
22
11
8
4
14
Adjacent fractures in 15 patients
Individual nerve outcome
Nerve
Inc. loss
to f/u
Brachial plexus
33%
Axillary
42.9%
Musculocutaneous 57.1%
Radial
58.3%
Median
75%
Ulnar
66%
Posterior tibial
50%
Exc. loss
to f/u
37.5%
75%
80%
87.5%
85.7%
100%
60%
Outcome by Etiology
Laceration
MVA
Winter sports
Falls
87.5%
32%
57.1%
50%