Transcript Common Neurosurgical Hospital Consult Diagnoses

Common Neurosurgical Hospital
Consult Diagnoses
Jeff Crecelius
Neurosurgeon
Goodman Campbell Brain and Spine
Disclosures
• None really
• Will use word Kyphoplasty which is
commercial but in widespread use
• No financial interest in Kyphon, but did first
case in Lafayette, and received free barbecue
at training course in Memphis many years ago
Brain Bleeds
• Sounds dramatic, and sometimes it is; but
often not.
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Epidural
Subdural
Subarachnoid
Intracerebral
Epidural Hematoma
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Relatively uncommon-only1-2% of TBI
Good prognosis if “pure” i.e. isolated
Lucid interval is classic, but uncommon (20%)
Prompt surgery is important
Usually in younger patient with relatively low
energy trauma
Subdural Hematoma
• Acute in high energy injury associated with
other brain involvement
• Acute in low energy may be tolerated if in
elderly with atrophy and room to spare
• Subacute (from clot to red liquid) may be
treated with “just” burr hole
• Chronic (crankcase fluid) commonly
recognized in elderly weeks after minor injury
Subarachnoid Hemorrhage
• Traumatic usually from high energy injury
• Spontaneous from many sources
– Aneurismal cause in about 75%
– Others causes include AVM, tumor, vasculitis
Cause usually apparent from CT pattern and
history—if likely from aneurysm, we transfer
to Indianapolis for evaluation
Intracerebral
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Hypertensive
Ischemic
Vascular Malformations (AVM, Cavernous)
Amyloid Angiopathy
Trauma (DTICH)
Tumor
THIN Blood (growing incidence of
iatrogenic)—another day for that!
Normal Pressure Hydrocephalus
• Misnomer and really a spectrum of disease
• Triad of symptoms
– Gait Disturbance=“Stuck”, but not unique
– Incontinence (which is common with immobility)
– Dementia
• Difficult diagnosis (especially in hospital
otherwise ill with co morbidity)
– Clinical
– Imaging (CT, MR, Isotope Cisternogram)
– Tap Test vs. Ambulatory Lumbar Drainage
Radiculopathy
• Common especially C6&C7, L5&S1
• Red Flags
– Age<20,>50; Weight loss; Fever; Worse at rest
– Cauda Equina Syndrome
• Rare but increasingly reported
– Insurance restriction of MR>PCP staff overwhelmed>Street
knowledge of incontinence as the key to cut the red tape.
• Uncommon to have normal reflexes and exam though
No Red Flag Radiculopathy
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Brief rest (2-3days)
Walk
PT if gentle (but conditioned to be Aggressive)
Analgesic
Muscle relaxants
Education/reassurance
SMT
Steroids? (IV, oral, ESI)
Osteoporotic Thoracolumbar
Compression Fractures
• Risk Factors
– Low Weight
– Cigarettes
– Family History
– Female (especially postmenopausal)
– Alcohol
– Steroids
– Inactivity
Evaluation of Fracture
• X-ray
– Compare if available
• MRI
– Acuity?
• CT and Bone Scan
– If MR contraindicated (ex. Implants like
pacemaker)
Treatment of Fracture
• Non-invasive
– Rest with DVT prophylaxis
– Analgesics
– PT
– Brace
• Typical time course about 6 weeks
• Follow up x-rays about 2 week intervals
– Assess progression
Treatment of Fracture
• Invasive (augmentation)
• Vertebroplasty
• Kyphoplasty
• Multilevel Stabilization
– Rare
Indications for Augmentation
• At least 5% height loss
• Intractable Pain
– Activity related and at fracture site
• Acute or Subacute on MR or Bone Scan
• Also may be used for hemangiomas, myeloma,
or metastases (off label)
Contraindications to Augmentation
• Healed (cold on bone scan/old on MR)
• Coagulopathy
– Evolving leniency by IR re anti-platelet agents
• Retropulsion
• Planum
Questions
• Thanks