Neurosurgery PPT RPN Student Copy PDF 2023

Neurosurgery S425: RPN PERIOPERATIVE PROGRAM Learning Outcomes Explain relevant neurosurgical anatomy. Understand basic procedural considerations for neurosurgery. Differentiate between a subdural and epidural hematoma. Compare and contrast a burr hole, craniotomy, and stereotactic brain su...

Neurosurgery S425: RPN PERIOPERATIVE PROGRAM Learning Outcomes Explain relevant neurosurgical anatomy. Understand basic procedural considerations for neurosurgery. Differentiate between a subdural and epidural hematoma. Compare and contrast a burr hole, craniotomy, and stereotactic brain surgery. Describe ventriculoperitoneal shunts and their functionality. Describe transphenoidal surgery for pituitary pathology. Anatomy Nervous System is divided into: 1. Central Nervous System (CNS) Brain and spinal cord 2. Peripheral Nervous System (PNS) Neurologic structures – cranial and spinal nerves Cerebrum, midbrain, cerebellum, pons, and the medulla oblongata 12 cranial nerves Skull Cerebrum Divided into Right and Left hemisphere Right side controls left side of the body Left side controls the right side of the body Frontal: Behavriour Parietal: Sensation Temporal: Speech, Hearing Occipital: Vision Midbrain and Cerebellum Brain stem (midbrain) Controls basic vital functions (HR, respirations) Cerebellum Coordinated movement and balance Meninges Covers the brain and spinal cord Located between the skull and brain 3 Layers: 1. 2. 3.  Ventricular System 4 ventricles Filled with CSF CSF – keeps brain and spinal cord moist and protected 2 lateral ventricles 3rd ventricle 4th ventricle communicates with subarachnoid space Blood Supply Arterial Blood Supply Enters cranium through: 2 Internal Carotid Arteries (Anterior) 2 Vertebral Arteries (Posterior) Both meet at the Circle of Willis (COW) Blood Supply Lack of oxygen to the brain longer than 5 minutes = irreversible brain damage! COW is protective mechanism → Collateral Circulation Supplies blood to all parts of the brain Even if one or more of 4 supplying vessels are ligated Perioperative Nursing Considerations Anesthesia: GA or awake Position: Supine, lateral, prone Count: Dura count* - minor Blood loss: Instrumentation Equipment Neuro Instrumentation Instrumentation Equipment Sugita Pin Sugita Fixation Device Mayfield Headrest and Pins Sugita Headrest and Pins Equipment Equipment Surgical Interventions Craniotomy Burr Holes Shunt Insertion Transphenoidal Hypophysectomy Cranioplasty Craniotomy Removal of piece of cranium (bone flap) to expose an area of the brain GA or awake Surgical procedure for: Brain tumours Hemorrhage or Hematoma Cerebral aneurysm Arteriovenous Malformation (AVM) Epilepsy Craniotomy Scalp Local infiltration (Lidocaine or Marcaine with epi = control bleeding); #20 blade incision Subcutaneous Tissue Galea Periosteum of Skull Love adson periosteal elevator Skull Drill with perforator to create burrhole Dura #15 blade; Metzenbaum scissors Craniotomy Set-Up Cerebral Aneurysm Aneurysm – vascular dilation caused by defect in arterial vascular wall Asymptomatic until bleeding/rupture Hemorrhage into subarachnoid space Sudden severe headache – “worst headache ever!” Craniotomy Approach: Aneurysm clips occlude the neck of the aneurysm 1. Temporary 2. Evacuate aneurysm sack of debris 3. Permanent Clip placed Cerebral Aneurysm Endoscopic Approach: Interventional Radiology uses a “coiling” technique Guide catheter fed through femoral artery under fluoroscopy → aorta → aneurysm vessel Coils treaded through catheter into aneurysm wall Smaller coils fill the center Reduces blood flow → thrombosis → prevents rupture Brain Tumour Uncontrollable growth of cells Benign or Malignant Primary – localized tumour stemming from brain tissue Secondary – tumour from elsewhere in the body that metastasized to brain Surgery – Craniotomy Specimen: Quick Section (dry container) or Permanent (formalin) Burr Holes Provide minimal exposure to brain access Craniotomy Hematoma Epidural – collection of blood ______________ the dura Laceration of meningeal artery Subdural – collection of blood ______________ the dura Venous bleed Burr Holes Layers of Dissection before a Burr Hole or Craniotomy Skin → Galea → Pericranium → Skull  Shunt Hydrocephalus Accumulation of CSF → Dilation of Ventricular system → Increased ICP Shunt inserted to drain CSF Two types: 1. External Ventricular Drain (EVD) 2. Ventriculoperitoneal (VP) Shunt EVD Inserted through burr hole into ventricle Distal end tunneled beneath scalp Connected to external drainage system Shunt left in until hydrocephalus is resolved VP Shunt Long term hydrocephalus Burr hole to insert catheter in ventricle Catheter connected to valve at distal catheter that drains into the peritoneum Use a long flexible shunt passer STERILITY IS OF UTMOST IMPORTANCE! Shunt is left in situ! Transphenoidal Hypophysectomy Surgical procedure to treat pituitary disorders (tumours) and endocrine disorders Usually benign tumour found during routine eye exam Close proximity to optic chiasm (optic nerve) Symptom: __________________ Pituitary Gland Endocrine gland at base of the brain Close to optic nerve Produce hormones that regulate growth, reproduction, blood pressure  Endoscopic Transnasal approach Access through the sphenoid sinus to pituitary fossa Stereotactic Surgery Use CT/MRI guidance to locate a target structure in 3D Real time navigation Destroy or biopsy target structure by inserting a needle into the brain Indications: Biopsy of brain tumour Deep brain stimulation for movement disorders – Parkinson’s Disease Cranioplasty Repair of a skull defect from trauma, malformation or surgical procedure Bone flap can sometimes not be replaced after surgery *Increased ICP! Bleeding, swelling Bone flap can be sent to blood bank (Frozen) or stored in patient’s abdomen Patient returns at a later date for bone flap to be re-applied Defect in cranium can also be replaced with titanium mesh or bone cement for trauma or tumour invaded skull References Rothrock, J. (2022). Alexander’s care of the Patient in Surgery (17th ed.) Mosby Elsevier. Tighe, S. (2015). Instrumentation for the Operating Room (9th ed.) Mosby. ORNAC Standards 2023 Spry, C. (2010). Essentials of Perioperative Nursing (4th ed.) Jones and Bartlett Mayo Foundation for Medical Education and Research (2021)