Final Review 2024.pptx

Final Review 2024  Frontal Temporal Approache Retro mastoid s Sub Occipital Pterional Posterior Fossa Sub Occipital Position: Usually Prone Choroid Plexus The choroid plexus serves two important functions in the body....

Final Review 2024  Frontal Temporal Approache Retro mastoid s Sub Occipital Pterional Posterior Fossa Sub Occipital Position: Usually Prone Choroid Plexus The choroid plexus serves two important functions in the body. It produces cerebrospinal fluid and helps to provide a barrier that protects the brain and other central nervous system tissue from toxins.  Reasons for Intracranial Surgery Tumor Congenital Abnormalities Anencephaly Encephalocele Hydrocephalus Chiari malformation Trauma – most common MVA Trigeminal Neuralgia Vascular Diseases Aneurysms Vascular malformations (AVM) Stroke/ Brain Bleed or Clot evacuation  Pituitary Tumors https://youtu.be/EwlRdxokdGk?si=XE5IMZjXokTm852U  Circle of Willis This is the circulatory system that supplies blood to the brain and surrounding structures. There are 4 arteries that feed this.  Hydrocephalus This Photo by Unknown Author is licensed under CC BY-SA The Sella Turcica  Chiari Malformation Chiari malformations are structural defects in the cerebellum. They consist of a downward displacement of the cerebellar tonsils through the foramen magnum, sometimes causing non- communicating hydrocephalus as a result of obstruction of  Traditional microscopic This technique is transsphenoidal performed through an incision made under the upper lip (sub-labial) along with removal of the nasal septum to access the tumor. The endoscopic technique is replacing the traditional microscopic approach as it reduces the trauma to the nasal tissues and the recovery time for the patient. The Mayfield Spina Bifida Spina bifida, which literally translates to "split spine", is a birth defect that occurs when the neural tube of an embryo doesn't close completely before birth. This can prevent the spine's bones from forming properly and can expose part of the spinal cord and nerves through an opening in the back.  Methylene Blue Skin dye – is it safe to use in Neurosurgery? AST maintains that Why? Methylene Blue should not be used to mark the skin It may cause irritation if it prior to Neurosurgical procedures. contacts delicate neural tissue MB induced dose-dependent toxicity in peripheral neurons, in vitro. These findings are consistent with studies in brain and myenteric ganglion neurons showing increased neuronal loss and altered membrane electrical properties after MB application. Dec 5, 2022  Cranioplasty, Craniotomy, Cranioplasty Some common reasons for cranioplasty include:​ Traumatic brain injury (TBI)​ Decompressive craniectomy​ Skull tumor removal​ Skull fractures​ Skull bone loss​ Hereditary factors resulting in birth defects​ Lack of skull expansion​ Premature closing of cranial sutures, or craniosynostosis ​ … Cranioplasty Cranioplasty is the surgical repair of a bone defect in the skull that’s left behind after a previous operation or injury. There are different kinds of cranioplasties, but most involve lifting the scalp and restoring the contour of the skull with the original skull piece or a custom contoured graft made Disc Anatomy Nucleus Pulposus-a gelatin-like center mostly consists of water(nucleus) collagen fibers​ It is the inner core of the vertebral disc material ​ The elastic inner structure allows the vertebral disc to withstand forces of compression and torsion. ​ ​ Anulus fibrosus-a fiber-like ring, the outer layer of the disc that encompasses the gel- like nucleus pulposus inside the disc. ​ ​ ​  Disc Discs are located in between the vertebrae and act as "shock absorbers," preventing the vertebrae from rubbing together.  Indications for Spinal Surgery Chiari Malformation Chronic Back Pain Degenerative Back Conditions Degenerative Neck Conditions Radiculopathy Sciatica Spinal Deformities/Scoliosis Spinal Fratures Spinal Stenosis Spinal Tumors Spondylosis/Spondylolisthesis Herniated Nucleus Polposus  Lumbar Discectomy & Laminectomy Indications for a Discectomy: v neurological deficit causing weakness of functionally important muscles such as hip abductors, ankle dorsiflexors, ankle plantar flexors. v Cauda equina syndrome and progressive neurological deficit in spite of conservative treatment. v Herniated Nucleus Pulposus v Indications for Laminectomy v Spinal Stenosis v Degenerative disease v Spinal tumors v Cauda Equina Lumbar Laminectomy/Discectomy Position: Prone, either on a Cloward Saddle or Wilson Frame  Spondylosis Spondylosis – A non-specific degenerative process of the spine. A condition involving changes to the bones, discs, and joints of the neck and back. These changes are caused by the normal wear-and-tear of aging. With age, the discs of the spine gradually break down, lose fluid, and become stiffer. Spondylolisthesis More Spondy a progressive nervous system disorder that occurs when the spinal cord is stretched or pulled down and stuck to the inside of the spinal canal by inelastic structures or tissue. This can happen from birth or develop near a spinal cord injury. TCS can be congenital or acquired, and various forms include tight filum terminale, The Spinal Cord Cervical – 7 vertebrae Thoracic – 12 Vertebrae Lumbar - 5 Vertebrae Sacral - 3-5 vertebrae Begins at the Foramen Magnum and ends at L1 or L2 The four major components of the spine: ​ the vertebrae​ joints ​ discs ​ nerves.​ Positioning  Foraminotomy The foramen is a small opening for the spinal nerve. Once the spinal nerve leaves the spinal cord, it travels down to this opening in the bone. It passes through and goes down the trunk and/or leg. A foraminotomy involves making the foramen larger or removing any tissue inside or around the natural opening. Bone, disc, scar tissue, or enlarged ligaments can compress the spinal nerve as it exits the spinal foramen.  Difference between Foraminotomy/ and Laminotomy The lamina is the portion of bone along the back of the vertebrae that helps form a circle of bone around the spinal cord. This circle of bone is called the vertebral arch. During a laminotomy, the neurosurgeon removes part of the lamina of the vertebral arch. Taking this piece of bone out takes pressure off the spinal cord. Complete removal of the lamina is called a laminectomy. If the spinal (facet) joint next to the lamina is removed,  Facetectomy procedure that removes bone spurs, facet cartilage, or facet joints from the spine. The procedure can help relieve pain and other symptoms of facet disease, which can be caused by bone spurs, also known as osteophytes, growing into the facet joints. These growths can irritate spinal nerves, causing pain and decreased range of motion. Corpectomy A corpectomy is a surgical procedure that involves removing all or part of the vertebral body. Cordotomy  Lordosis and Kyphosis Lordosis - The cervical spine and lumbar spine have a normal inward curvature that is medically referred to as lordosis or "lordotic" curvature by which the spine is bent backward. ​ ​ Kyphosis-The thoracic spine has a normal outward curvature that is medically referred to as kyphosis or the "kyphotic" curve by which the spine is bent forward.​  XLIF Extreme lateral interbody fusion (XLIF) surgery is a minimally invasive procedure that treats spinal disorders and back or leg pain by fusing two levels of the spine. The surgery involves making an incision on the side of the body to place a metal cage filled with bone graft material between damaged vertebrae. The cage acts as a framework to keep the vertebrae spaced consistently and allows the bone graft to fuse the vertebrae together over time. This helps maintain the original spacing between the vertebrae and can also decompress the spinal canal and nerve roots. ​ The sympathetic nerve chain runs up and down along your spine. It is the part of the nervous system responsible for the fight or flight response. During a sympathectomy, a surgeon cuts or clamps this nerve chain. This keeps nerve signals from passing through it.  The CUSA CUSA is the acronym for cavitronic ultrasonic surgical aspirator. This device is used in tumor surgery. It is used to Emulsify and remove benign Tumors. Often in the brain or within the Dura surrounding the spine.  Diagnostic tests associated with Neuro 1. CT Scan – Computed Tomography – uses xRay 2. EEG – Electroencephalography – measures electrical activity of the brain. 3. MRI – Magnetic Resonance Imaging – Brain wave test 4. PET Scan – Positron Emission Tomography - is a functional imaging technique that uses radioactive substances known as radiotracers to visualize and measure changes in metabolic processes, and in other physiological activities including blood flow, regional chemical composition, and absorption. 5. EEG - Electroencephalography is a method to record an electrogram of the spontaneous electrical activity of the brain. 6.  Micro Vascular Surgical Procedures AVM’s - A brain/spine arteriovenous malformation (AVM) is a tangle of abnormal blood vessels connecting arteries and veins in the brain/spine MVD’s - MVD is a surgical procedure to relieve the symptoms (pain, muscle twitching) caused by compression of a nerve by an artery or vein. Surgery involves a craniotomy and exposing the nerve at the base of the brainstem to insert a tiny sponge between the compressing vessel and the nerve. Aneurysm’s - Brain aneurysm repair is a surgical procedure used to treat a bulging blood vessel in the brain that’s at risk of rupturing or tearing open. AVM  Brain In most cases, a brain Aneurysm aneurysm causes no Also called: symptoms and goes unnoticed. intracranial In some cases, the brain aneurysm aneurysm ruptures, releasing blood into the skull and thus causing _______?  Brain What is it called when a brain aneurysm ruptures? Aneurysm Rupture Depending on the severity of the hemorrhage, brain damage or death may result. Surgical Clipping -The most common treatment for an aneurysm is direct surgical clipping. General anesthesia, craniotomy. -Brain is dissected and a small clip is placed across the neck of the aneurysm to block the normal blood flow from entering the aneurysm. -The clip is made of titanium and remains on the artery permanently. Endovascul ar coiling a catheter is inserted into an artery in the groin and then passed through the blood vessels to the aneurysm. The doctor guides the catheter through the bloodstream while under fluoroscopy. the aneurysm is packed with material, either platinum coils or balloons, that prevents blood flow into the aneurysm Artery occlusion and bypass If surgical clipping is not possible or the artery is too damaged, the surgeon may completely block (occlude) the artery that has the aneurysm. The blood flow bypassed around the occluded section of artery by inserting a vessel graft.  bleeding into the subarachnoid space-the area between the arachnoid membrane and the pia mater surrounding the brain. This can occur spontaneously, usually from a ruptured cerebral aneurysm, or may result from head injury. Epidural Hematoma Vs. Subdural Hematoma  ALIF – Abdominal Inner-body Fusion This Photo by Unknown author is licensed under CC BY.  Common Instruments for Spinal What are some Surgery instruments used for spinal surgery? Instruments used for these Spinal Procedures 10 blade Bovie Cerebellar retractors Cobb Currettes Kerrisons Bipolar Aquamantis  A compression fracture is defined as a fracture that occurs because of compression of the bone in the spine. Most compression fractures occur in vertebrae that have been weakened by osteoporosis or other diseases that weaken bone, such as cancer. The fracture occurs when the bone has deteriorated to the point that it can no longer support the spinal column in daily activities. While compression fractures can occur anywhere in the spine, they typically occur in the thoracic region, which includes the T1 through T12 vertebrae, or in the lumbar spine, the L1 through L5 vertebrae. They rarely occur above the T7 level of the spine. Vertebral compression fractures can occur in one or more vertebrae. Kyphoplasty Vertebroplasty and Kyphoplasty Vertebroplasty Vertebroplasty: Indications; Fractures from Osteoporosis or disease such as cancer. The goal of relieving your spinal pain and restoring your mobility. Not all people with fractured vertebrae are candidates for the procedure Can be done under conscious sedation and local  SI JOINT Fuse The surgeon uses a specially designed system to guide the instruments that prepare the bone and facilitate placement of the titanium implants across the sacroiliac joint. Fluoroscopy, provides the surgeon real-time moving images of internal structures during the procedure. Typically, three iFuse Implants are used in an iFuse procedure. Both the surgical technique and the iFuse Implant System are designed to protect the tissues surrounding the surgical site. The whole MIS SI joint procedure takes about an hour, and recovery time is significantly less than open surgery. Symptoms Pain from sacroiliac joint dysfunction can be felt anywhere in the lower back or spine, buttocks, pelvis, groin, or sometimes in the legs. Chronic SI joint pain symptoms can make it difficult to perform common daily tasks and can affect every aspect of a patient's life.  SI JOINT Fuse The surgeon uses a specially designed system to guide the instruments that prepare the bone and facilitate placement of the titanium implants across the sacroiliac joint. Fluoroscopy, provides the surgeon real-time moving images of internal structures during the procedure. Typically, three iFuse Implants are used in an iFuse procedure. Both the surgical technique and the iFuse Implant System are designed to protect the tissues surrounding the surgical site. The whole MIS SI joint procedure takes about an hour, and recovery time is significantly less than open surgery.  the Procedure Position: Prone Equipment and supplies; C-arm, bair hugger, power drill, Bovie, Floseal with long tip, Gelfoam possibly cut into "cigarettes", basic instrument tray and Rep Trays. #10KB C-arm to mark level – skin marker Small incision 2-3cm Guide pin and pin holder with mallet – C-arm used liberally PRN Tissue dissector Tissue Protector Measuring device  Procedure continued Drill or Reamers Tissue protector removed Implant inserted down guide wire Impactor and mallet to seat implant C-arm for exact placement determination Pin guide/ new pin placed with mallet and C-arm. First pin removed Procedure is now repeated for a total of 3 implants usually. Incision irrigated, floseal used Incision closed with 2-0 Vicryl on an SH and 3-0 Monocryl. Dressings placed  The RISKS and COMPLICATIONS WHAT ARE SOME RISKS ASSOCIATED WITH THE iFUSE PROCEDURE? Adverse reactions to anesthesia; Hemorrhaging or bleeding Muscle and/or nerve damage; Localized bruising or swelling; Blood clots; Wound site infections, wound dehiscence and damage to the tissues surrounding the surgical site; Excessive radiation exposure; Lung damage Death. Risks specific to the iFuse Procedure include, but are not limited to: Local injury to the pelvis; Increased pain in the sacroiliac joint or surrounding tissues and joints; Allergic reaction to or rejection of the implants; Migration, loosening, breakage or failure of the implant; Muscle pain due to the change in function of the SI joint; Stress to and fracture of the bones in the pelvis surrounding the implants; and Need for additional surgery to remove or adjust the positioning of one or more implants. Carpal Tunnel Surgery Carpal tunnel surgery, also known as carpal tunnel release, is a procedure that treats carpal tunnel syndrome by cutting through the carpal ligament in the wrist to relieve pressure on the median nerve. This creates more space for the median nerve and tendons, which can help improve The basic constructio n  Spine surgery, as with any surgery, carries the risk of complications. Though rare, neurological injury has the potential of incurring serious sensory and motor injuries. Due to the nature of complications that can occur with spine surgery, intraoperative neurophysiological monitoring (IONM), or neuromonitoring, is increasingly being used to avoid post-surgical neurological complications. This Photo by Unknown author is licensed under CC BY-SA.  The Problem The nervous system is suppressed by anesthetics, Aim: To ensure the integrity hypothermia, hypotension and of the spinal cord and anemia; depending on anatomical nerve roots especially site, specific drug & dose, site at the site of surgery, while providing safe of stimulation, and site of and adequate monitoring. anesthesia. The Alphabet Soup of Neuromonitoring Motor Evoked Potentials (MEP)MEPs involve transcranial motor cortex stimulation to elicit a response from muscles and thereby assess the integrity of motor pathways. EMG: EMG's generate a stimulus either at the level of the spinal cord or at the motor cortex. Somatosensory Evoked Potentials (SSEP) SSEPs generate a stimulus either at the level of the spinal cord or at the motor cortex. Disruption along any part of this pathway may disrupt normal SSEP responses. The following spinal procedures benefit most from neuromonitoring Posterior cervical and thoracic decompressions 3 or more level ACDF Intradural spinal cord surgery (e.g. intradural intra and extramedullary tumors; tethered cord release; syringomyelia surgery) Spinal deformity surgery Complex revision surgery  Somatosensory evoked potentials SSEP (SSEPs): SSEP is the most frequently used intraoperative spinal monitoring modality. Peripheral stimulating electrodes generate cortical responses. This process allows the surgeon to monitor sensory pathways and detect any perioperative neurologic changes. Pros: Excellent reliability. Allows for continuous monitoring during surgery. Cons: Despite continuous monitoring during surgery, the interpretation requires temporal summation. As such, detection of a signal change can be delayed by up to 16 minutes. Several false-positives and false-negatives have also b een reported , which indicate that SSEPs may not be as useful as a standalone monitorin  EMG's Spontaneous and triggered electromyography (EMG): EMG actually has two forms: stimulated or spontaneous (sEMG) and triggered (tEMG). tEMG recordings are obtained when the center of the tulip of the pedicle screw is stimulated, generating a response that is then recorded from the applicable muscle group. measures muscle response or electrical activity in response to a nerve's stimulation of the muscle. Pros: EMG is a valuable for neuromonitoring specific nerve roots that may be at risk of injury during spinal instrumentation. sEMG is recorded continuously, which provides the surgeon the advantage of real-time feedback throughout the entire procedure. Since its introduction, this technique has also been shown to be an effective tool for detecting cortical bone breaches during pedicle screw insertion. Cons: To obtain a proper sEMG response, neuromuscular blockade is prohibited with sEMG, but not tEMGs. Lower thresholds in tEMGs might indicate a cortical breach, putting the Crani plates Instruments to know  Spinal Cord Stimulator A spinal cord stimulator is an implanted device that sends low levels of electricity directly into the spinal cord to relieve pain Vagus nerve stimulation involves using a device to stimulate the vagus nerve with electrical impulses.