Neurosurgery

*HNP* - Sx of acute nerve root compression? The longer you ____, prognosis? Tx?

*Acute*: Weakness, numbness. (e.g. footdrop, inability to lift leg). The longer you irritate the nerve, the more it will die. Will be promptly fixed surgically.

*SCI* Complications - Pulmonary (2)

Ventilatory failure Impaired cough

*Upper vs. lower motor neuron* Hyperreflex, spastic paralysis

Upper

________ dysfunction is an important determinant of site, extent, and severity of spinal cord pathology. For clinical evaluation, the most useful symptoms relate to ________

*Autonomic* dysfunction is an important determinant of site, extent, and severity of spinal cord pathology. For clinical evaluation, the most useful symptoms relate to *bladder control*.

Hematogenous spread of CA or infection (Discitis) to the vertebral body can spread can occur through the ______ plexus. What might clue you in that discitis could be tumor formation? (Hx of what?)

*Baston* plexus. Hx of *CA* such as: - Prostate CA - Breast CA

Craniotomy vs. craniectomy

*Craniotomy*: Cutting a hole or removing bone that will be later put back. Subdural, epidural - relieve pressure. *Craniectomy*: Removing the bone flap

*SCI* General complications

*Dec life expectancy* d/t secondary health issues - recurrent UTIs bc they can't go themselves - ventilators - pressure sores

Causes of intracerebral hemorrhage

*HTN* Trauma Anticoagulation - clot buster can convert ischemic to hemorrhagic Vascular lesion Tumor Embolus Stroke conversion

MRI of spine - herniated disk vs. DJD (image) DDx herniated disk vs. degenerated

*Herniated*: Jelly filled donut is squished, and jelly oozes out *Degenerative*: "Jelly donut w/o jelly", flattens but does not "ooze" out. Dries out, not as spongy, collapses on itself.

Types of aneurysms (2) - MC type? - MCC of?

*Saccular* - (AKA "Berry if it forms at a "Y" branch of two arteries/bifurcations). MC type of intracranial aneurysm (80-90%) and MCC of non-traumatic SAH. Fusiform - no stem, seldom ruptures.

Examples of disk problems

- thinning - degenerated (w or w/o osteophyte formation) - bulging - herniated

*SCI* Frankel Classification Frankel observed that?

A: Complete - absent motor & sensory Fx B: Sensation present, motor power absent C: Sensation present, motor power not useful D: Sensation present, motor power present & useful E: *Normal* sensory & motor *Frankel observed that 60% of patients w partial cord lesions improved spontaneously by one grade regardless of Tx type & a significant number are able to walk again*

*Upper vs. lower motor neuron* Hyporeflexic is ____, hyperreflexic is _____.

Hyporeflexic = *LMN* Hyperreflexic = *UMN*

AVM

Arteriovenous malformation - a tangle of abnormal blood vessels connecting arteries and veins in the brain. Disrupts process of arteries carrying oxygenated blood to brain and veins carrying de-oxygenated blood away. Some people with brain AVMs experience signs and symptoms, such as headache or seizures. AVMs are commonly found after a brain scan for another health issue or after the blood vessels rupture and cause bleeding in the brain (hemorrhage).

*Autonomic NS* Autonomic bladder control is primarily _______, and is unaffected by isolated injury to the _____ fibers.

Autonomic bladder control is primarily *parasympathetic*, and is unaffected by isolated injury to the *sympathetic* fibers.

*SCI* Complications - Urinary (4)

Bladder problems UTIs Stones Sexual

*SCI* Complications - GI - above L-spine - below L-spine

Bowel dysfunction - L-spine and up = hyperreflexive sphincter tone (constipation and retention) - Below L-spine = hyporeflexive sphincter tone (constipation and incontinence)

*Cross Section of the Cord* Grey matter - shape - contains

Butterfly shaped Axonal bodies; Dorsal (sensory) and ventral (motor) roots

W/u for Discitis? (4) 3 populations at risk?

CBC +/- Sed rate CRP MRI DM - uncontrolled w A1C of 9+ Immunocompromised IVDA

Odontoid Fx's - risk? what are they?

Can sever cord, may cause death, quadriplegia (C7), ect depending on level of spine affected

One Tx of aneurysm is ___. 3 types? Neurosurgeons do not ____ after doing this procedure. This cannot be done in what part of the brain?

Clipping They do not take the aneurysm out after and sew up after clipping it; This can't really be done in the circle of willis bc not reachable w/o taking brain out.

Second treatment of aneurysm is ___. Essentially does what to the aneurysm?

Coiling Essentially *clots off* the aneurysm.

*SCI* Emergency surgery indications? (7) - deteriorating ____ - _____ syndrome - compression of ____ evident on what imaging? - 2 types of injuries - _____ in the spinal canal - unstable ______ Timeline?

Deteriorating *neuro status* (*not mental status; more motor/sensory issues) *Caudal equina* syndrome (emergency) Compression of *cord* evident on *MRI* *Penetrating* cord injuries; *gunshot* injuries *Bony fragments* in the spinal canal Unstable *vertebral body* Timeline: Usually w/in the next *2-12 hours*

SDH on CT scan (image). Eventually brain will ___.

Eventually brain can/will herniate.

Epidural bleeding on CT scan (image) - eventually will ____. - Tx?

Eventually will herniate down the brainstem through foramen magnum. Tx - craniotomy to allow blood to escape.

Spinal canal stenosis What part of the spine is this more of a problem?

Facet hypertrophy More of a problem for *cervical* and *thoracic* than lumbar bc less room

Common Tx for 3 column injury (compression injury)

Fusion w screws/plates OR separate adequately to make sure not pinching on a nerve root

*VP Shunt* Used to Tx? How does it work? Problems? Sx of this?

Hydrocephalus - usually presents in childhood Shunt from ventricle in the head down to the abdomen where it can drain Problems: Can become infected or blocked off. Can present as HA, behavioral/performance/mental status change.

*Intracerebral Hemorrhage* - types (and some have causes)

Intraparenchymal Subarachnoid Hemorrhage (SAH) - trauma Interventricular Hemorrhage (IVH) - trauma, anticoagulants Epidural Subdural (SDH) - trauma Pituitary

*Upper vs. lower motor neuron* Atrophy is injury to ___.

LMN

MRI of HNP with Cauda Equina Compression Why does level of compression matter?

Level of compression matters bc nothing below said level will work In the case of lumbar compression, the arms still work, for example.

*Upper vs. lower motor neuron* Hyporeflexic, flaccid paralysis, atrophy

Lower

X-ray of DDD and DJD Characteristics? More wearing where?

More narrowing *posteriorly* than anteriorly, this is relatively normal

*Neurogenic Bladder* Neurogenic/"automatic" bladder injury occurs where in the spinal cord? Overflow incontinence is caused by injury at what level?

Neurogenic bladder is caused by injury *above S2* Overflow incontinence is d/t injury *at the level of S2-S4*

DJD w nerve root compression Is this a problem d/t the disk?

Not a disk problem, is an OA-related "bony" problem

*Autonomic NS* Parasympathetic neurons originate in the _____.

Parasympathetic neurons originate in the sacral area.

Cervical Spine Trauma - remember the ____, especially if bones are not broken? - what should you do? - what could happen aside from the primary injury? - Meds for swelling?

Remember the *ligaments* Should *immobilize* the patient; must be cleared w x-rays and clinical suspicion (MOI) *Secondary injury* from swelling in head for e.g. Steroids +/- for swelling. No proof this actually helps neurologic swelling.

*SCI* Until what level of Frankel classification is sensation present?

Sensation is present for all classifications, up until 'A' when sensation & motor are completely gone. Motor is first to go

*Upper vs. lower motor neuron* Spastic paralysis is injury to ____. Flaccid paralysis is injury to ____.

Spastic = *UMN* Flaccid = *LMN*

*Upper vs. lower motor neuron* Sympathetic vs. parasympathetic

Sympathetic - UMN Parasympathetic - LMN **Unsure if this is correct....

*Autonomic NS* Sympathetic neurons lie in the _____ horn of the _____ at spinal levels _____

Sympathetic neurons lie in the *lateral* horn of the *central gray matter* at spinal levels *T1-L3*

Vertebral Fxs vs. Retrolisthesis (Dislocation)

Tearing of the ligaments allow for vertebral mobility and vertebrae may slide forward/backward (sliding of vertebrae above compared to vertebra below) Fracture (Wedge fracture shown) can be caused by axial load (ski jumping example) *A lot of us have retrolithesis w/o knowing it...kyphosis in elderly

There are ___ spinal cord segments; a pair of _____ and _____ spinal nerve roots that are responsible for _____ and _____ function (respectively). The nerve roots combine on each side to form the _____ as they exit from the vertebral column through the _____.

There are *31* spinal cord segments; a pair of *ventral (anterior)* and *dorsal (posterior)* spinal nerve roots that are responsible for *motor* and *sensory* function (respectively). The nerve roots combine on each side to form the *spinal nerves* as they exit from the vertebral column through the *neuroforamina*.

Causes of SAH (aside from bad luck - burst aneurysm)

Trauma Tumor AVM (brain, spinal cord)

*Neurogenic Bladder* Voluntary bladder control is under _____ control, mediated by motor fibers originating from the _____ cells at levels _____. A spinal cord lesion that interrupts descending motor and autonomic tracts ABOVE the S2 level produces an "automatic bladder" that _____, the so-called neurogenic bladder. INJURY TO S2-S4 spinal levels interrupts the _____ reflex circuit; the bladder becomes _____, and fills beyond capacity with _____ incontinence.

Voluntary bladder control is under *somatomotor* control, mediated by motor fibers originating from the *anterior horn* cells at levels *S2-S4*. A spinal cord lesion that interrupts descending motor and autonomic tracts ABOVE the S2 level produces an "automatic bladder" that *cannot be emptied voluntarily, but empties reflexly when expanded to a certain degree*, the so-called neurogenic bladder. INJURY TO S2-S4 spinal levels interrupts the *bladder* reflex circuit; the bladder becomes *flaccid*, and fills beyond capacity with *overflow* incontinence.

Spinal column anatomy (image) - what happens when discs are flat?

When disc is flattened d/t herniation or degeneration; the foramina where the spinal roots exit become narrowed

MOI - Whiplash

When you have forced flexion, you separate everything in the back - resultant hypermobility causes problems (semi-permanent bony disorder) To note - still injury possible even if buckled in; airbags

Discitis (image) - risks? (2) - cause?

While it is not herniating or bulging, it can break down (result = bone on bone) or harden Can also spread to spinal cord itself It is usually *infectious*...can come from IV drugs, bad pharyngitis that causes retropharygneal infection.