Neurosurgery.

Neurosurgery

Outline A & P Pathology Diagnostics/Pre-operative Testing
Medications/Anesthesia Positioning/Prepping/Draping Supplies/Instrumentation/Equipment Dressings/Drains/Post-op Care Procedures: Carpal Tunnel Release, Craniotomy, Cervical Discectomy, Lumbar Discectomy, Ventroperitoneal Shunt

Nervous System Functions: Senses changes in environment
Interprets changes Stimulates movement to respond to these changes

Organization of the Nervous System
Two systems: 1. CNS Central Nervous System Two major parts: Brain and Spinal Cord 2. PNS Peripheral Nervous System Everything else

Peripheral Nervous System
Two major parts: Afferent Nervous System Sensory neurons take info from PNS to CNS Efferent Nervous System Motor neurons take info from CNS to PNS

Efferent Nervous System
Motor nervous system 2 parts: Somatic Nervous System Skeletal muscle control Conscious control Autonomic Nervous System Cardiac muscle, smooth muscle, and glands Unconscious control Has 2 divisions: Sympathetic Division Parasympathetic Division

Autonomic Nervous System
Sympathetic vs. Parasympathetic Controlled by hypothalamus and medulla oblongata Both are different nerves going to the same effector or target Are antagonistic Parasympathetic = decreased skeletal blood flow, increased organ blood flow (quietly eating) Sympathetic = increased skeletal blood flow, decreased organ blood flow (eatus interruptus by a bear!) Also called fight or flight; prepares body for emergencies

Spinal Cord Functions: Info to and from the brain
Integration of reflexes Location: Begins at foramen magnum and extends to 2nd lumbar About 16-18” in length

Spinal Cord Support Structures
Vertebra 33 total 7 cervical 12 thoracic 5 lumbar Sacrum formed by 5 fused bones Coccyx formed by 4 fused bones

Intervertebral Disks Separate vertebrae
Outer layer is tough and called the annulus fibrosis Inner core is soft and called the nucleus pulposus Bear stress incurred with body weight and when lifting

Spinal Cord Support Structures
Meninges Between vertebra & spinal cord Epidural space between vertebra and dura mater Dura Mater outermost layer extends to S-2 Subdural space between dura mater and arachnoid Arachnoid extends to S-2 Subarachnoid space contains CSF Pia Mater adheres directly to spinal cord and extends to L-2 Meninges also cover brain/continuous layer/difference epidural space not present

Spinal Nerves 31 pair Names and numbers depend on where enter and exit
Each has a ventral and dorsal root Ventral root = motor Dorsal root = sensory 8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal

Brain Protected by the cranium or skull

Brain 4 major parts: Brain stem Diencephalon Cerebellum Cerebrum
Weight about 3 lbs.

Support Structures of the Brain
1. Meninges Continuous layer with spinal cord NO epidural space

2. Cerebrospinal fluid (CSF) About 800ml produced each day by the choroid plexus, a specialized set of capillaries Circulates inside subarachnoid space through central canal of spinal cord and the ventricles of the brain Reabsorbed in arachnoid villus found in the parietal lobe Functions as a shock absorber and circulates nutrients

Blood Brain Barrier Specialized set of capillaries exclusive to the central nervous system Less permeable than any other capillaries in the body Advantage = keeps out unwanted chemicals Disadvantage = difficult to diffuse materials out, hence difficulty in treating conditions such as encephalitis

Brain Stem 3 parts: Medulla oblongata Pons Midbrain

Medulla oblongata Contains: 5 of 12 cranial nerves
Pyramids: function only with motor neurons/a crossing of the spinal nerve impulses Reflex centers: hiccupping, sneezing, coughing Vital reflex centers: Cardiac center – heart rate Vasoconstrictor center-BP via blood vessel diameter control Respiratory center - breathing

Pons Above medulla Switching point for motor neurons
Respiratory center

Midbrain or Mesencephalon
Above pons Involuntary eye and head movement in response to auditory stimuli

Diencephalon 2 parts: Thalmus Hypothalmus

Thalmus Relay center for sensory information
Interprets stimuli for example pain from changes in temperature (hot stove) 1st level of reasoning occurs here Recognizes crude touch NOT localized touch

Hypothalmus Controls large number of subconscious functions
Controls most of Autonomic nervous system Where endocrine and nervous systems interface Homeostasis regulation of the body Controls: body temp, thirst, hunger, sleep and waking habits, psychosomatic disorders, rage and aggression

Cerebellum 2nd largest part of the brain Primarily a motor area
Controls skeletal muscles, subconsciously Receives sensory input from eyes, muscles, joints, and inner ear Posture, balance, coordination, equilibrium Muscle sense tells body where other parts are

Cerebrum Largest part of brain Motor/sensory/association area
4 Lobes: frontal, parietal, occipital, temporal Each controls a specific function be it motor or sensory Limbic system: controls emotion/functions in cerebral cortex and diencephalon See page 970 Figure 24-4 in Price

Cerebrum Lobes’ Function
Frontal Memory, abstract thinking, ethics, judgement, emotion, expressive speech, motor Parietal Sensory, receptive speech, written word Temporal Auditory, olfactory Occipital Visual cortex Visual association

Cranial Nerves All originate in the brain stem EXCEPT the 1st and 2nd
Classified as sensory or mixed (sensory and motor) nerves Directly off of brain Do not go through the spine Identified by Roman numerals and names

Cranial Nerves Olfactory - sense of smell
Optic – sense of sight/vision Occulomotor – eyeball, eyelid movement (medial, inferior, superior rectus, inferior oblique), pupil constriction, lens accommodation Muscle sense for eyeball Trochlear – eyeball movement (superior oblique) Trigeminal – masseter muscle control Sensory part has 3 branches: ophthalmic (forehead to corner of eye), maxillary (corner of eye to upper lip/teeth), and mandibular (lower lip/teeth/tongue) All three convey sense of touch, pain and temp changes Abducens - same as IV eyeball movement (lateral rectus) and eyeball muscle sense FYI: EOM formula LR6(SO4)3

Cranial Nerves Facial- facial muscles, lacrimal and salivary glands anterior 2/3 of tongue (taste) Vestibulocochlear -last of totally sensory nerves; has 2 branches: vestibular conveys balance and cochlear which conveys sense of hearing Glossopharyngeal -salivary gland secretion and posterior 1/3 of tongue Vagus – internal organ control motor and sensory; originates in medulla and goes down through neck into chest and abdomen Accessory – controls head and neck movement, speech, and muscle sense for the head Hypoglossal – tongue muscles: swallowing, speech, muscle sense for tongue

Neuro Pathology

Cervical Spine Pathology
Very serious Can have severe consequences related to all of the spinal cords’ nerve pathways Spondylosis is osteophyte or bone spur formation in the spinal canal Cervical disk extrusion acute or chronic Treatment errs on the side of caution due to potential extreme consequences of surgical intervention

Thoracic Pathology Spondylosis Extrusion of disk

Lumbar Pathology Spondylosis Stenosis Spondylolithesis Disk extrusion

Neoplasms/Tumors Two types: Primary
Originate in nervous tissue or meninges Secondary Are metastasized from other parts of the body May be classified as benign or malignant

Tumors Benign tumors: “Craniopharyngiomas, epidermoids, hemangiomas, menigiomas, acoustic neuromas, and pituitary microadenomas” Price, 2004 Malignant tumors: “Astrocytes or gliomas” Price, 2004 Benign usually excisable via craniotomy Malignant normally cannot be completely removed but efforts are made to remove most

Head Trauma Includes; Scalp lacerations, fractures, hematomas (epidural or subdural), and brain injuries

Spinal Cord Trauma Vertebral Fracture Vertebral Dislocation
Herniated disk into spinal canal Laceration from GSW or MVA

Cerebrovascular Disease
#3 cause of death in US Symptoms reflect ischemia (TIAs) or hemorrhage Intracranial aneurysm Arteriovenous malformations Brain hemorrhage Stroke or cerebrovascular accident (CVA)

Congenital Pathology Craniosynotosis “premature closure of the
cranial sutures” Price, 2004 Hydrocephalus result of obstructed CSF flow Spina bifida

Infection Abscess Subdural empyema Post-op infection

Spinal Cord Tumors Intramedullary in the spinal cord
Intradural in dura, outside spinal cord Extradural outside spinal cord Price, 2004

Peripheral Nerve Pathology
Carpal tunnel syndrome - compression of the median nerve Ulnar nerve compression – compression of ulnar nerve by the ligament of Osborne Price, 2004

Diagnosis History and physical
Symptoms usually specific to area of pathology Electroencephalogram (EEG) X-ray Myelogram CAT Scan MRI Cerebral arteriograms

Medications Lidocaine 1% with epinephrine
Topical hemostatic agents: gelfoam, avitene, surgicel, bone wax Antibiotic irrigants Topical papaverine for prevention of spasm during intracranial artery surgery Methyl methacrylate with cranioplasty Heparin saline irrigation again with intracranial artery surgery Contrast solutions with cerebral arteriography Gliadel wafers (tumor bed of glioblastoma)

Anesthesia General Could be local with MAC for minor laceration suturing

Positioning Cranial Surgery
Supine primarily, with a specialty headrest and or fixation devices Can be lateral or semi-lateral Sitting Prone Varies with location of access Spinal surgery Anterior procedures require supine Posterior procedures require prone

Preps Will require shave especially on head
Varies with surgeon preference: betadine, alcohol, chlorohexidine Care taken NOT to get in patient’s eyes or facial orifices

Draping Toweled out Adhesive type drape
Specialty drapes: laparotomy, thyroid, craniotomy, lumbar Stockinette for peripheral procedures

Supplies Marking pen Disposable bi-polar cord Monopolar pencil/bovie
Cottonoids/patties Raney clips Hemostatic clips Shunt catheters, tubing, connectors Cotton balls Hemovac drain Nerve stimulator Telfa Microscope drape C-Arm drape Ultrasound wand drape

Instruments Minor tray if laminectomy and craniotomy trays do not have basic instrumentation Laminectomy tray Craniotomy tray Basic ortho tray Plates and screws Specialty self-retaining retractor trays: Greenburg

Miscellaneous Instrumentation
See pages in PRice

Equipment microscope Video tower YAG or CO2 laser
Positioning equipment: Mayfield headrest, Gardner-Wells Operative Ultrasound machine Stereotaxis system CUSA Cavitron ultrasonic aspirator Bipolar and monopolar ECU Nitrogen source for power equipment (saws/drills) Mayfield overbed table Headlight and light source C-Arm and monitor Cell saver Fluid warming and temperature regulating equipment

Dressings/Drains/Post-op Care
Dressings surgeon preference Drains surgeon preference Post-op care: keep field sterile until patient has left the OR Careful with moving patient to avoid patient injury and hemorrhage

Post-operative Complications
Infection Hemorrhage Nerve damage CSF leakage Meningitis Neurological deficits

Carpal Tunnel Release - Open
Neuro Procedures Operative Sequence Carpal Tunnel Release - Open 63

Overall Purpose of Procedure: Carpal Tunnel release is performed to eliminate or significantly decrease the pressure on the carpal canal and the median nerve. 64

Define the procedure: Cutting of the Transverse Carpal Ligament to relieve tension in the canal. 65

Any condition that decreases the size of the canal may cause pressure on the median nerve with resultant symptoms of carpal tunnel syndrome. This manifests as pain and parathesia in the thumb, the index finger and the radial half of the ring finger. Conditions which contribute to the compression of the medial nerve include (but are not limited to): - fracture of a carpal bone, hypertrophic synovitis of RA, tumors, ganglion, lipomas, systemic conditions such as: Obesity, diabetes melitis, thyroid dysfunction, and Raynaud's disease (is a vascular disorder that affects blood flow to the extremities) and pregnancy. This syndrome occurs more often in women. 66

Wound Classification: 1 67

Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible) 6- Hemostasis 7- Irrigation 8- Closure 9- Dressing Application 68

Instrumentation: Minor Ortho tray or Hand Tray. Positioning: Supine with arms on arm boards. Affected arm on Hand Table Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Draping: Towel around tourniquet. Hand Table Drape. Possible Stockinette and Coban. 69

Carpal Tunnel Release - Open Begin your Operative Sequence
Prior to Incision: hair on patients arm is not usually removed. Place arm on bump for circumferential prep. Incision: Skin is marked across volar surface. #3 handle with #15 KB. 70

Carpal Tunnel Release - Open cont. Operative Sequence
Hemostasis: Handheld Bi-Polar Bovie 71

Dissection and Exposure: The incision is made across the wrist surface and base of the palm to expose the Transverse Carpal Ligament. Skin hooks, single or double toothed. Senns. 72

Exploration and Isolation: Care is taken to ID the Median Nerve so that it is not damaged during the procedure. 73

Carpal Tunnel Video Surgical Repair: The Transverse Carpal Ligament is incised along its entire length with a FRESH 15 KB. Procedure can be accompanied by a Synovectomy (Surgical removal of the joint lining. Commonly performed in RA patients) 74

Hemostasis and Irrigation: All bleeding is controlled with cautery. Use of warm Saline to irrigate. 75

Closure: The incision is closed in one layer. MD choice of Suture. Usually a 4-0 Nylon. A compression dressing will be applied. 76

Major Arteries: Radial and Ulnar 77

Major Veins: Ulnar veins Major Nerves: Ulnar and Radial Nerve 78

Carpal Tunnel Release - Endoscopic
Plastic Procedures Operative Sequence Carpal Tunnel Release - Endoscopic 79

Overall Purpose of Procedure: Endoscopic Carpal Tunnel release is performed to eliminate or significantly decrease the pressure on the carpal canal and the median nerve through a very small incision, utilizing a scope. 80

Carpal Tunnel Endoscopic Define the procedure: With the aid of an arthroscope and arthrscopic instruments, the Transverse Carpal Ligament will be cut. 81

Neuro Procedures Operative Sequence
Craniotomy 82

Not to be confused Craniotomy Craniectomy
Surgical opening of the skull necessary for brain surgery. The bone is replaced after surgery. Craniectomy Surgical opening of the skull necessary for brain surgery. The bone is not replaced after surgery.

Craniotomy Overall Purpose of Procedure: a surgical operation of the cranium resulting from removal of: Hematoma - A localized swelling filled with blood resulting from a break in a blood. Aneurysm – widening or weakening in blood vessels in the brain. 84

Craniotomy Overall Purpose of Procedure cont: Tumor removal:
There are more than 120 different types of brain tumors. Brain tumors are often assigned different grades, ranging from a Grade I (least malignant) to Grade IV (most malignant). It is important to note that non-malignant, or benign, brain tumors can be just as difficult to treat as malignant brain tumors.

Craniotomy Overall Purpose of Procedure cont:
Arteriovenous malformations (AVM) - A spectrum of congenital (developmental) blood vessel malformations. An AVM occurs when brain or spinal cord arteries attach directly to veins without the blood passing through the capillary network. AVM's can cause bleeding within the nervous system (a kind of stroke), or progressive neurologic deficits, headaches or seizures.

Craniotomy Overall Purpose of Procedure cont:
Cysts Abscesses Metastatic Lesions It is very important to know the topography of the skull to help determine your approach and to help determine the amount and extent of bone removal.

Layers of the Scalp

Craniotomy Define the procedure: Surgery involving the removal of skull bone to gain access to the brain and the bone is put back at the end of the operation (not always). 89

Wound Classification: 1
Craniotomy Wound Classification: 1 90

Craniotomy Instrumentation: Neuro Tray with Microsurgical Instruments. CT’s and MRI scans. Microscope and Laser if needed. Positioning: Supine with arms on arm boards. Depends on area that needs correcting. Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit. Draping: Drape according to the area of procedure. Only expose the area worked upon. 92

Craniotomy Begin your Operative Sequence
Prior to Incision: Have Papaverine available for AVM or aneurysm case for prevention of vasospasm. Have blood product available prior to case. Incision: Must mark skin prior to incision due to the fact that landmarks will be covered when head is draped. Incise Skin and Galea (epicranial aponeurosis) with 10 KB. layer of dense fibrous tissue which covers the upper part of the cranium 93

Craniotomy cont. Operative Sequence
Hemostasis: Handheld Bovie, Bipolar Bovie Provide Raney Clips and Raney Clip Appliers 94

Dissection and Exposure: Provide a periosteal elevator and bovie to peel scalp away from bone. Will need to continue to coagulate galea. Provide Fish hooks with Allis clamps and rubber bands to hold skin flap away from surgical site. Protect skin flap with wet lap. 95

Exploration and Isolation: Place Burr holes with perforator. Perforator will have a clutch built in so that it will retract when it meets ZERO resistance. 96

Surgical Repair: Bone wax will be provided to edges of cut skull bone. Provide a Dural separator. I.E. a Penfield #3 to separate the Dura from the skull. You will protect the galea with a retractor (Cushing). Pass up the Midas Rex, bone saw, to connect burr holes and TURN bone flap. (can not remove at this point) 97

Surgical Repair: You will need to provide the MD with the Penfield of choice to free bone flap completely from the dura. BE SURE TO PROTECT THE BONE FLAP! If you are going to replace the flap at the end of the case, you will need what you have removed. In what situation would you not replace the bone flap? Next we will need to prepare the bone flap for reinsertion at the end of the case. The flap will be repositioned with surgical wire. Pass up a drill to make holes in the bone flap for wires to pass. Holes will be placed in flap and in surrounding bone. 98

Surgical Repair: Surgical wires can be placed the skull at this stage or at the end of case. Provide: Gelfoam and Thrombin, Cottonoids, Raytex’s, etc to be sure all bleeding is under control. Hand sterile blue towels to MD to cover wires if placed prior to rest of case. We now prepare to open the Dura. To open the Dura, we will pass up the Dural Hook to lift it up and away from the cortex. Hand 15 Kb to MD to nick the Dura. Hand small scissors of choice to MD to continue opening the Dura. 99

Surgical Repair: MD may need bipolar forceps or hemoclips to maintain hemostasis. MD will need to retract the Dura. Have fish hooks ready. Provide damp sponge or damp cottonoid patty to keep Dura moist at all times. Continue procedure based on pathology. If presented with an aneurysm: Have mico-suction available to clear clot away. Pass up self retaining retractor of choice if needed (Greenburg). The brain's lobes are gently retracted until the location of the aneurysm is reached, using a surgical microscope and microsurgical instruments. 100

Surgical Repair: Aneurysm: The paper-thin aneurysm is carefully freed from the scar tissue surrounding it, and its junction with the brain's blood vessels is identified. One of various kinds of clips is placed across the base of the aneurysm and is adjusted until its position is accurate. This allows the aneurysm to collapse, but spares the essential blood vessels around it. At times the aneurysm will rupture again while surgery is taking place. The surgeon then carefully tries to control the hemorrhage while continuing the delicate clipping procedure. 101

Surgical Repair: Tumor Removal: Once the Dura is exposed, an ultrasound probe is used to confirm the location and depth of the underlying tumor and help the surgeon plan his approach. The tumor is carefully dissected from normal brain tissue with microsurgical instrumentation. For an intracranial tumor, a small incision is made through the surface of the brain and into brain tissue until the tumor is reached. Ultrasound frequently is used to monitor the tumor's removal. 102

Surgical Repair: Tumor Removal cont: instrumentation may be used by the neurosurgeon to visualize, cut into, and remove the tumor, include a surgical microscope or special magnification glasses, a surgical laser that vaporizes the tumor and an ultrasonic tissue aspirator that breaks apart and suctions up the abnormal tissue. At this time the biopsy is sent to the laboratory for analysis. Unlike elsewhere in the body, where some extra tissue around a tumor may be surgically removed "just to be sure," only tissue that can clearly be identified as abnormal may be removed from the brain-and even then only if its removal is possible without devastating consequences. 103

Hemostasis and Irrigation: All bleeding is controlled with cautery. Use of warm Saline to irrigate. Provide chemical hemostatic of choice. I.E. Surgicel. 104

Closure: Close Dura with suture on a small, cutting needle. After the dura has been stitched closed, the piece of bone is replaced and sutured/wired into place. An ICP (intracranial pressure) monitoring device may then be implanted. Closure of muscle and galea layer with suture of choice. Skin staples or suture for scalp. If a drain is required, provide Nylon or Prolene drain stitch. 105

ICP monitoring : Intracranial pressure monitoring is a device, placed inside the head, which senses the pressure inside the brain cavity and sends its measurements to a recording device. The intraventricular catheter is thought to be the most accurate method.

ICP monitoring : To insert an intraventricular catheter, a burr hole is drilled through the skull and the catheter is inserted through the brain matter into the lateral ventricle, which normally contains liquid that protects the brain and spinal cord (cerebrospinal fluid). Not only can the intracranial pressure (ICP) be monitored, but it can be lowered by draining cerebral spinal fluid (CSF) out through the catheter.

ICP monitoring : This catheter may be difficult to place with increased intracranial pressure, since the ventricles change shape under increased pressure and are often quite small because the brain expands around them from injury and swelling. Normally, the ICP ranges from 1 to 15 mm Hg.

ICP monitoring : Raised intracranial pressure means that both nervous system (neural) and blood vessel (vascular) tissues are being compressed. If left untreated, it can result in permanent neurologic damage. In some cases, it can be fatal.

Craniotomy Major Arteries and Nerves
110

Lumbar Discectomy Video

Lumbar discectomy is a surgical procedure to remove part of a problem disc in the low back. The discs are the pads that separate the vertebrae. This procedure is commonly used when a herniated, or ruptured, disc in the low back is putting pressure on a nerve root.

An incision is made down the middle of the low back
An incision is made down the middle of the low back. After separating the tissues to expose the bones along the low back, the surgeon takes an X-ray to make sure that the procedure is being performed on the correct disc. A cutting tool is used to remove a small section of the lamina bone.

Next, the surgeon cuts a small opening in the ligamentum flavum, the long ligament between the lamina and the spinal cord. This exposes the nerves inside the spinal canal. The painful nerve root is gently moved aside so the injured disc can be examined. A hole is cut in the outside rim of the disc.

Forceps are placed inside the hole in order to clean out disc material within the disc. Then the surgeon carefully looks inside and outside the disc space to locate and remove any additional disc fragments.

Finally, the nerve root is checked for tension
Finally, the nerve root is checked for tension. If it doesn't move freely, the surgeon may cut a larger opening in the neural foramen, the nerve passage between the vertebrae. Before closing and suturing the wound, some surgeons will implant a special foam pad or a piece of fat over the nerve root to keep scar tissue from growing onto the nerve. Some surgeons also insert a small drain tube in the wound.

Cervical Discectomy 119

Cervical Discectomy Overall Purpose of Procedure: Pain Relief Millions of people suffer from pain in their necks or arms. A common cause of cervical pain is a rupture or herniation of one or more of the cervical discs. This happens when the annulus of the disc tears and the soft nucleus squeezes out. As a result, pressure is placed on the nerve root or the spinal cord and causes pain in the neck, shoulders, arms and sometimes the hands. Cervical disc herniations can occur as a result of aging, wear and tear, or sudden stress like from an accident. 120

Cervical Discectomy Define the procedure:
The goal is to relieve pressure on the nerve roots or on the spinal cord by removing the ruptured disc. It is called anterior because the cervical spine is reached through a small incision in the front of the neck (anterior means front). 121

Wound Classification: 1
Cervical Discectomy Wound Classification: 1 122

Cervical Discectomy Instrumentation: Major Disc tray. Anterior Cervical Tray. Cervical Implant Tray. Positioning: Supine with arms on arm boards. Head hyper extended to exposed neck. Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Draping: standard T,T,T,A, Ioban, ¾ sheet for feet in on Jackson Table, Lap sheet. 124

Cervical Discectomy Begin your Operative Sequence
Prior to Incision: Incision site will marked and shoulders will taped and placed under traction. Incision: 10 KB on one side of the neck. Incision will be over the effected area. 125

Cervical Discectomy cont. Operative Sequence
Hemostasis: Handheld Bovie 126

Dissection and Exposure: Can use a retractor such as the Versa-Trac or Shadowline to retract the fat of the neck and the muscles – sternocleidomastoid and the sternohyoid are divided, not cut. 127

Exploration and Isolation: After fat and muscle are pulled aside with a retractor, the disc is exposed between the vertebrae. An operating microscope may be used at this stage. 128

Surgical Repair: A needle is then inserted into the disc space and an x-ray is done to confirm that the surgeon is at the correct level of the spine. After the correct disc space has been identified on x-ray, the disc is then removed by first cutting the outer annulus fibrosis (fibrous ring around the disc) and removing the nucleus. 129

Surgical Repair: Dissection is carried out from the front to back to a ligament called the posterior longitudinal ligament. Often this ligament is gently removed to allow access to the spinal canal to remove any osteophytes (bone spurs) or disc material that may have extruded through the ligament. 130

Surgical Repair: Once the disk is removed, we can do one of three things: 1) leave the space open to hopefully fuse in time – not common. 2) place a bone graft for support in between to vertebral bodies without the aid of a plate (less common). 3) More commonly – place a cervical plate over the bone graft to hold it in place and ensure fusion.

Closure: Small 3-0 or 4-0 Vicryl followed by Monocryl for a plastics type closure. 133

Complications: Possible risks and complications of anterior cervical discectomy surgery may include: Inadequate symptom relief Failure of bone graft healing (a.k.a. non-union or pseudarthrosis) Persistent swallowing or speech disturbance Nerve root damage Damage to the spinal cord (about 1 in 10,000) Bleeding Infection Damage to the trachea/esophagus 134

Complications: The small nerve that supplies innervation to the vocal cords (recurrent laryngeal nerve) will sometimes not function for several months after neck surgery because of retraction during the procedure, which can cause temporary hoarseness. Retraction of the esophagus can also produce difficulty with swallowing, which has usually resolved within a few weeks to months. There is little chance of a recurrent disc herniation because most of the disc is removed with this type of surgery. Anterior Cervical Decompression & Spine Fusion Video 135

Cervical Discectomy Major Arteries: Superior Thyroid Artery 136

Cervical Discectomy Major Veins: Major Nerves:
Middle and Inferior Thyroid vein. Major Nerves: Spinal Cord 137

Ventriculoperitoneal Shunt
Neuro Procedures Operative Sequence Ventriculoperitoneal Shunt 138

Overall Purpose of Procedure: VP shunts are placed to treat hydrocephalus (hydro = water, cephalus = head) that can result from a number of diseases including: subarachnoid hemorrhage, meningitis, or tumors. Mostly commonly performed on children. Hydrocephalus is a condition that occurs due to an obstruction in the ventricular system, an overproduction of CSF by a rare tumor called a Choroid Plexus Papilloma, or an imbalance of production or reabsorption of CSF. Hydrocephalus can be acquired or congenital. It is recognized by dilation of the ventricles on CT or MRI. 139

Define the procedure: Ventriculoperitoneal (VP) shunt insertion is an operation performed to place a catheter into a brain ventricle to drain cerebrospinal fluid (CSF) from the ventricular system into the peritoneal space. 140

Anatomy: CSF is produced within the Choroid Plexus within the four normally communicating ventricles of the brain. The CSF acts as a cushion to protect the brain from mechanical trauma and assists with intracranial pressure (ICP) 141

The Shunt: Ventriculoperitoneal (VP) shunt is a small catheter that drains excess CSF from a ventricle in the brain to another area in the body. One end of the shunt is in the ventricle inside the patients brain where the extra CSF is causing problems. A small valve in the tube controls the pressure in the patients head by controlling the amount of fluid running through it. It also makes sure the fluid flows in only one direction, away from the brain. The catheter tubing continues on to an area where the body can reabsorb the fluid. The most common area is the stomach area (abdomen). 142

The Shunt: Shunts usually consist of three parts: (1) Proximal end that is radiopaque and is placed into the ventricle. This end has multiple small perforations. (2) Valve- this allows for unidirectional flow. Can adjust various opening pressures. Usually has a reservoir that allows for checking shunt pressure and sampling CSF (3) Distal end that is placed into the peritoneum or another absorptive surface by tracking the tubing subcutaneously 143

144

Wound Classification: 1 145

Instrumentation: Minor tray. Spine Tray. Drill for Burr holes. Positioning: Supine with arms on arm boards. Head turned to the side for catheter placement. Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Will prep head ( 2 incisions) and belly (sub- xiphoid incision). Draping: Head drape, standard belly draping with Blue Towels and Lap drape. 147

Ventriculoperitoneal Shunt Begin your Operative Sequence
Prior to Incision: Since most shunts are done on children, warm the room. Must shave the pt’s head. Incision: Two small incisions are made in the scalp. Later, will have another incision, sub- xiphoid, for distal end of catheter. 148

Ventriculoperitoneal Shunt cont. Operative Sequence
Hemostasis: Handheld Bovie and Bipolar bovie 149

Dissection and Exposure: Head – retract the skin flap with skin hooks or Senns. Provide a periosteal elevator, Followed by a burr. Burr will be used to make an access port for shunt/catheter. Now make the abdominal incision. Incise down to the peritoneum. Provide retractors, forceps and scissors for this step. The peritoneum is not opened at this time. The distal catheter is left lying on top of the peritoneum at this point in the procedure. 150

Exploration and Isolation: Retractors placed in head and in abdomen to expose surgical sites. 151

Surgical Repair: A tunneling device is inserted distally. The tunneling is usually done distally to proximally. Be sure to provide an a tissue obturator to prevent tissue damage. You will pass the distal catheter next. Check patency by flushing with normal saline. This distal catheter is very long. Clamp to the draped with rubber shods to prevent form falling off field. If the type of catheter has an external valve it is placed behind the patients ear (another incision). If not, then the valve is internal (passed to the second incision or just distal) and will automatically control the flow of CSF. 152

Surgical Repair: Connect the valve to the proximal end of the distal catheter. Make sure the arrow that depicts the flow of fluid is pointed towards the patients feet. This will be secured in place with small NON-absorbable sutures. Now we will open the Dura with a 15kb. Once the Dura is open and retracted, we will begin threading the ventricular catheter. A stylet will be inserted into this catheter to provide stability. Most catheters have distal markers for placement determination under fluoroscopy. 153

Surgical Repair: Provide the MD with a TB syringe filled with antibiotic of choice. MD will flush ventricular catheter with this antibiotic solution. MD will need to cut the ventricular catheter to the desired length so provide small scissors. Have a medicine cup ready to collect CSF for the lab. Be prepared to hand off this specimen ASAP. MD will then connect the ventricular catheter to the proximal end of the valve. Suture into place. MD will move back to the abdomen. MD will want to visualize the flow of CSF before the catheter is placed through the peritoneum. 154

Surgical Repair: To lift the peritoneum, pass two hemostats or mosquitoes and a 15 KB. A small incision is made. The distal end of the catheter is placed into the abdominal cavity, leaving plenty of coil for growth (in the infant and child patient). 155

Closure: Provide suture of choice to secure the distal catheter to the peritoneum. Closure of the peritoneum – surgeon choice of absorbable suture. Same with skin and head incisions. Frequent antibiotic washing is used during the closure process. 157

Major Arteries: Anterior, Middle, Posterior Cerebral Artery. Mostly superficial vessels. All vascularity is monitored due to the extensive tunneling process. 158

Major Veins: Superficial vessels Major Nerves: The brain! 159

DBS 160

DBS Dystonia is a neurological movement disorder in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures. Dystonia def: Dystonia video Primary dystonia is suspected to be caused by a pathology of the central nervous system, likely originating in those parts of the brain concerned with motor function, such as the basal ganglia, and the GABA (gamma-aminobutyric acid) producing Purkinje neurons. The precise cause of primary dystonia is unknown. In many cases it may involve some genetic predisposition towards the disorder combined with environmental conditions. Dystonia and DBS: Dystonia and DBS video

Dystonia Secondary dystonia refers to dystonia brought on by some identified cause, usually involving brain damage, or by some unidentified cause such as chemical imbalance. Some cases of (particularly focal) dystonia are brought on after trauma, are induced by certain drugs (tardive dystonia), or may be the result of diseases of the nervous system such as Wilson's disease.

Symptoms of Dystonia Symptoms vary according to the kind of dystonia involved. In most cases, dystonia tends to lead to abnormal posturing, particularly on movement. Many sufferers have continuous pain, cramping and relentless muscle spasms due to involuntary muscle movements. Early symptoms may include loss of precision muscle coordination (sometimes first manifested in declining penmanship, frequent small injuries to the hands, dropped items and a noticeable increase in dropped or chipped dishes), cramping pain with sustained use and trembling. Significant muscle pain and cramping may result from very minor exertions like holding a book and turning pages.

Parkinson's disease Parkinson's disease (also known as Parkinson disease or PD) is a degenerative disorder of the central nervous system that often impairs the sufferer's motor skills and speech, as well as other functions. Vid: Understanding Parkinson's Disease Video

Parkinson's disease Parkinson's disease belongs to a group of conditions called movement disorders. It is characterized by muscle rigidity, tremor, a slowing of physical movement (bradykinesia) and, in extreme cases, a loss of physical movement (akinesia). The primary symptoms are the results of decreased stimulation of the motor cortex by the basal ganglia, normally caused by the insufficient formation and action of dopamine, which is produced in the dopaminergic neurons of the brain.

DBS Overall Purpose of Procedure: The news story:
Vanderbilt Deep Brain Stimulation Video The procedure: OR Live 167

Summary A & P Pathology Diagnostics/Pre-operative Testing
Medications/Anesthesia Positioning/Prepping/Draping Supplies/Instrumentation/Equipment Dressings/Drains/Post-op Care Procedures: Carpal Tunnel Release, Craniotomy, Cervical Discectomy, Lumbar Discectomy, Ventroperitoneal Shunt

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Neurosurgery.

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