1. Pathologies, Procedures and Room Set-Up
Neurosurgery
Pathologies, Procedures and Room Set-Up

2. Common 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
Tumors
Most common are metastatic
Cord compression causing pain and weakness

3. Herniated Disk

4. Spinal Trauma
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

5. Compression Fracture

6. Laminectomy
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

8. Disketomy/Decompression
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

9. Fusion Stabilization of spine by locking vertebrae together Uses:
Plates
Screws
Rods
May be indicated following injury or excision of bone

10. Spinal Fusion

11. 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
Pillow under knees
Anterior Lumbar/Thoracic
Supine
Radiolucent table
Rails clear for retractor (bookwalter, omni)
General surgeon needed to gain access to spine

12. Positioning Posterior Spine Surgery
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
Make sure there are enough people to safely transfer

13. Lateral Spine Repair 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

14. Spinal Equipment Needs
Bovie, suction and warmer at foot of bed
C-arm available
May use flat plate instead
Midas
Headlight
May use microscope

15. Intracranial Hematoma
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

16. Intracranial Tumors 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

17. Hydrocephalus
Excessive accumulation of CSF in ventricles resulting in increased ICP
Due to obstruction, poor absorption, or overproduction of CSF
Reasons
Congenital abnormalities, aqueductal stenosis, tumor, subarachnoid hemorrhage, meningitis
Common among young children and older adults
Acute or Chronic
Infants
Enlarged head, seizures, vomitting, sleepy
Adults
Impaired balance, memory loss, poor coordination, headache

19. Brain Approaches Bur Holes Craniotomy Craniectomy
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

20. Craniotomy/Craniectomy/ Burr Holes
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
For occipital approach

21. Craniotomy Mayfield pins May turn the bed 90 or 180 degrees
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

22. Craniotomy Equipment Needs
Mayfield with pins or horseshoe headrest
Bovie, suction and warmer at foot of bed
Midas
Microscope
Headlight
Clippers

23. Transphenoidal Resection of Pituitary Tumor
Supine
Arms tucked
Pillow under knees
Head on pillow or in mayfield
May turn bed
Often assisted by an ENT surgeon

24. Transphenoidal Equipment Needs
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

25. VP Shunt
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

26. Medications and Implants
Local
Bacitracin ointment
Bacitracin irrigation
Hemostatic agents
Bone grafts
Crani plates
Fusion hardware

27. Physical Hemostatic Agents
Electosurgery: monopolar, bipolar
Bone wax
Sponges
Cottonoids
Hemaclips

28. 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

29. 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

30. 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