Transcript Neurosurgery

Neurosurgery
Outline
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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
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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
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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
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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
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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
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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
Support Structures of
the Brain
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
Support Structures of
the Brain
3. 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
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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
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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
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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
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IV.
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VI.
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)
Muscle sense for eyeball
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
VII.
Facial- facial muscles, lacrimal and salivary glands
anterior 2/3 of tongue (taste)
VIII. Vestibulocochlear -last of totally sensory nerves; has 2
branches: vestibular conveys balance and cochlear
which conveys sense of hearing
IX.
Glossopharyngeal -salivary gland secretion and posterior
1/3 of tongue
X.
Vagus – internal organ control motor and sensory;
originates in medulla and goes down through neck into
chest and abdomen
XI.
Accessory – controls head and neck movement, speech,
and muscle sense for the head
XII. 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
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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”
• Malignant tumors:
• “Astrocytes or gliomas”
Price, 2004
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
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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”
• Hydrocephalus result of obstructed
CSF flow
• Spina bifida
Price, 2004
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 semilateral
• 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
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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 987-990 in PRice
Equipment
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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/Postop 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
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Infection
Hemorrhage
Nerve damage
CSF leakage
Meningitis
Neurological deficits
Neuro Procedures
Operative Sequence
Carpal Tunnel Release Open
Carpal Tunnel Release - Open
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Overall Purpose of Procedure:
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Carpal Tunnel release is
performed to eliminate or
significantly decrease the
pressure on the carpal canal and
the median nerve.
Carpal Tunnel Release - Open
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Define the
procedure:
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Cutting of the
Transverse Carpal
Ligament to relieve
tension in the
canal.
Carpal Tunnel Release - Open
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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):
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- 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.
Carpal Tunnel Release - Open
 Wound
Classification: 1
Operative Sequence
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123456789-
Incision
Hemostasis
Dissection
Exposure
Procedure (Specimen Collection possible)
Hemostasis
Irrigation
Closure
Dressing Application
Carpal Tunnel Release Open
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Instrumentation: Minor Ortho tray or Hand
Tray.
Positioning: Supine with arms on arm
boards. Affected arm on Hand Table
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Prepping: Surgeon preference. Duraprep,
Hibiclense or a Betadine Prep Kit.
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Draping: Towel around tourniquet. Hand
Table Drape. Possible Stockinette and
Coban.
Carpal Tunnel Release - Open
Begin your Operative Sequence
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Prior to Incision:
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hair on patients arm
is not usually
removed.
Place arm on bump
for circumferential
prep.
Incision:
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Skin is marked across
volar surface.
#3 handle with #15
KB.
Carpal Tunnel Release - Open
cont. Operative Sequence
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Hemostasis: Handheld Bi-Polar Bovie
Carpal Tunnel Release - Open
cont. Operative Sequence
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Dissection and
Exposure:
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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.
Carpal Tunnel Release - Open
cont. Operative Sequence
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Exploration and
Isolation:
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Care is taken to
ID the Median
Nerve so that it is
not damaged
during the
procedure.
Carpal Tunnel Release - Open
cont. Operative Sequence
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Surgical Repair:
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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)
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Carpal Tunnel Video
Carpal Tunnel Release - Open
cont. Operative Sequence
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Hemostasis and Irrigation:
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All bleeding is controlled with cautery.
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Use of warm Saline to irrigate.
Carpal Tunnel Release - Open
cont. Operative Sequence
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Closure:
The incision is closed in one layer. MD
choice of Suture. Usually a 4-0 Nylon.
 A compression dressing will be applied.
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Carpal Tunnel Release Open
 Major
Arteries:
 Radial
Ulnar
and
Carpal Tunnel Release Open
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Major Veins:
Ulnar veins
Major Nerves:
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Ulnar and Radial
Nerve
Plastic Procedures
Operative Sequence
Carpal Tunnel Release Endoscopic
Carpal Tunnel Release - Endoscopic
► 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.
Carpal Tunnel Release - Endoscopic
► Define
the
procedure:
With the aid of an
arthroscope and
arthrscopic
instruments, the
Transverse
Carpal Ligament
will be cut.
► Carpal
Tunnel
Endoscopic
Neuro Procedures
Operative Sequence
Craniotomy
Not to be confused
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Craniotomy
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Surgical opening of the
skull necessary for brain
surgery. The bone is
replaced after surgery.
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Craniectomy
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Surgical opening of the
skull necessary for brain
surgery. The bone is not
replaced after surgery.
Craniotomy
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Overall Purpose of Procedure:
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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.
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Craniotomy
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Overall Purpose of Procedure cont:
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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.
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Craniotomy
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Overall Purpose of Procedure cont:
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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
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Overall Purpose of Procedure cont:
Cysts
 Abscesses
 Metastatic Lesions
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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
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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).
Craniotomy
 Wound
Classification: 1
Operative Sequence
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1- Incision
2- Hemostasis
3- Dissection
4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
Craniotomy
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Instrumentation: Neuro Tray with Microsurgical
Instruments. CT’s and MRI scans. Microscope and
Laser if needed.
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Positioning: Supine with arms on arm boards.
Depends on area that needs correcting.
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Prepping: Surgeon preference. Hibiclense or a
Betadine Prep Kit.
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Draping: Drape according to the area of procedure.
Only expose the area worked upon.
Craniotomy
Begin your Operative Sequence
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Prior to Incision:
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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
Craniotomy
cont. Operative Sequence
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Hemostasis: Handheld Bovie, Bipolar Bovie
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Provide Raney Clips and Raney Clip Appliers
Craniotomy
cont. Operative Sequence
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Dissection and
Exposure:
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Provide a periosteal
elevator and bovie to
peel scalp away from
bone.
Will need to continue to
coagulate galea.
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Provide Fish hooks with
Allis clamps and rubber
bands to hold skin flap
away from surgical site.
Protect skin flap with
wet lap.
Craniotomy
cont. Operative Sequence
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Exploration and
Isolation:
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Place Burr holes with
perforator.
Perforator will have a
clutch built in so that
it will retract when it
meets ZERO
resistance.
Craniotomy
cont. Operative Sequence
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Surgical Repair:
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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)
Craniotomy
cont. Operative Sequence
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Surgical Repair:
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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?
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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.
Craniotomy
cont. Operative Sequence
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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.
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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.
Craniotomy
cont. Operative Sequence
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Surgical Repair:
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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.
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If presented with an
aneurysm:
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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.
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Craniotomy
cont. Operative Sequence
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Surgical Repair:
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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.
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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.
Craniotomy
cont. Operative Sequence
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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.
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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.
Craniotomy
cont. Operative Sequence
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Surgical Repair:
Tumor Removal cont:
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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.
Craniotomy
cont. Operative Sequence

Hemostasis and Irrigation:

All bleeding is controlled with cautery.

Use of warm Saline to irrigate.
Provide chemical hemostatic of choice. I.E. Surgicel.

Craniotomy
cont. Operative Sequence

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.
Craniotomy
cont. Operative Sequence

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.

Craniotomy
cont. Operative Sequence

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.
Craniotomy
cont. Operative Sequence

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.

Craniotomy
cont. Operative Sequence

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
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. 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.
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.
Neuro Procedures
Operative Sequence
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.

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).
Wound
Classification: 1
 1-
Incision
 2- Hemostasis
 3- Dissection
 4- Exposure
 5- Procedure (Specimen Collection possible)
 6- Hemostasis
 7- Irrigation
 8- Closure
 9- Dressing Application
 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.
 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.
 Hemostasis:
Handheld Bovie
 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.
 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.
 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.
 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.
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.

 Hemostasis
and Irrigation:

All bleeding is controlled with cautery.

Use of warm Saline to irrigate.
 Closure:

Small 3-0 or 4-0 Vicryl followed by Monocryl for a
plastics type closure.
 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


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
Major
Arteries:
 Superior
Thyroid
Artery
 Major
Veins:
Middle and Inferior
Thyroid vein.
Major Nerves:

Spinal Cord
Neuro Procedures
Operative Sequence
Ventriculoperitoneal
Shunt
Ventriculoperitoneal Shunt
• 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.
Ventriculoperitoneal Shunt
• 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.
Ventriculoperitoneal Shunt
• 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)
Ventriculoperitoneal Shunt
• 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).
Ventriculoperitoneal Shunt
• 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
Ventriculoperitoneal Shunt
Ventriculoperitoneal Shunt
•Wound Classification: 1
Operative Sequence
•
•
•
•
•
•
•
•
•
1- Incision
2- Hemostasis
3- Dissection
4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
Ventriculoperitoneal Shunt
• 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.
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.
Ventriculoperitoneal Shunt
cont. Operative Sequence
• Hemostasis: Handheld Bovie and Bipolar
bovie
Ventriculoperitoneal Shunt
cont. Operative Sequence
• 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.
Ventriculoperitoneal Shunt
cont. Operative Sequence
• Exploration and
Isolation:
• Retractors placed in
head and in
abdomen to expose
surgical sites.
Ventriculoperitoneal Shunt
cont. Operative Sequence
• 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.
Ventriculoperitoneal Shunt
cont. Operative Sequence
• 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.
Ventriculoperitoneal Shunt
cont. Operative Sequence
• 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.
Ventriculoperitoneal Shunt
cont. Operative Sequence
• 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).
Ventriculoperitoneal Shunt
cont. Operative Sequence
• Hemostasis and Irrigation:
• All bleeding is controlled with cautery.
• Use of warm Saline to irrigate.
Ventriculoperitoneal Shunt
cont. Operative Sequence
• 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.
Ventriculoperitoneal Shunt
• Major Arteries:
• Anterior, Middle,
Posterior
Cerebral Artery.
• Mostly superficial
vessels.
• All vascularity is
monitored due to
the extensive
tunneling process.
Ventriculoperitoneal Shunt
• Major Veins:
Superficial vessels
Major Nerves:
The brain!
Neuro Procedures
Operative Sequence
DBS
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 (gammaaminobutyric 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
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