back to basics for surgery neurosurgery r. moulton
TRANSCRIPT
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Back to Basics for SurgeryBack to Basics for SurgeryNeurosurgeryNeurosurgery
R. MoultonR. Moulton
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Principles of Neurological Principles of Neurological DiagnosisDiagnosis
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QuestionsQuestions
What is the lesionWhat is the lesion Where is the lesionWhere is the lesion
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HistoryHistory Physical (Neurological) ExaminationPhysical (Neurological) Examination Special TestsSpecial Tests
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Presentation of Neurosurgical Presentation of Neurosurgical IllnessIllness
Raised ICPRaised ICP– Headache, vomitingHeadache, vomiting– papilloedemapapilloedema
Neurological DysfunctionNeurological Dysfunction– General – level of consciousnessGeneral – level of consciousness– Focal – sensory or motor lossFocal – sensory or motor loss
SeizuresSeizures PainPain
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What is the lesion – historyWhat is the lesion – history Where is the lesion – neurological Where is the lesion – neurological
examexam
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History (What is the lesion?)History (What is the lesion?)
SymptomsSymptoms Mode of onsetMode of onset Speed of onsetSpeed of onset Prior relevant illnessPrior relevant illness Progression/regression of symptomsProgression/regression of symptoms
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Neurological Examination Neurological Examination (Where is the Lesion?)(Where is the Lesion?)
Level of Consciousness – GCSLevel of Consciousness – GCS Mental status – orientation, memory, concentration, Mental status – orientation, memory, concentration,
abstraction, calculationabstraction, calculation Cranial NervesCranial Nerves Motor examinationMotor examination
– Upper vs. lower motor neuronUpper vs. lower motor neuron– Cerebellar functionCerebellar function– GaitGait
Sensory examinationSensory examination– light touch, pain & temp, joint position senselight touch, pain & temp, joint position sense– Cortical sensory modalities Cortical sensory modalities
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Cranial NervesCranial Nerves
I I OlfactoryOlfactory IIII OpticOptic IIIIII OculomotorOculomotor IVIV TrochlearTrochlear VV TrigeminalTrigeminal VIVI AbducensAbducens VIIVII Facial Facial VIII AcousticVIII Acoustic IX IX GlossopharyngealGlossopharyngeal XX VagusVagus XIXI AccessoryAccessory XIIXII HypoglossalHypoglossal
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Motor ExaminationMotor Examination
Upper Motor NeuronUpper Motor Neuron– Weakness (distal > proximal) antigravity Weakness (distal > proximal) antigravity
muscles preservedmuscles preserved– Increased reflexes and tone (spasticity)Increased reflexes and tone (spasticity)– Disuse atrophyDisuse atrophy– Loss of coordination (ataxia)Loss of coordination (ataxia)– ApraxiaApraxia– Upgoing plantar responseUpgoing plantar response
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Lower Motor NeuronLower Motor Neuron– WeaknessWeakness– Decreased toneDecreased tone– Decreased reflexesDecreased reflexes– Denervation atrophyDenervation atrophy– Coordination usually intactCoordination usually intact
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Sensory ExaminationSensory Examination
Special senses – cranial nervesSpecial senses – cranial nerves Basic ModalitiesBasic Modalities
– Light touch, pain & temp, vibration & Light touch, pain & temp, vibration & proprioceptionproprioception
– Dermatomes, peripheral nerve distributionDermatomes, peripheral nerve distribution
Cortical ModalitiesCortical Modalities– Graphaesthesia, stereognosis, simultaneous Graphaesthesia, stereognosis, simultaneous
appreciation of tactile stimuli, appreciation of tactile stimuli, somatotopognosis, agnosagnosia, neglectsomatotopognosis, agnosagnosia, neglect
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Special TestsSpecial Tests
Biochemical, hematological, microbiologyBiochemical, hematological, microbiology– BloodBlood– CSFCSF
ImagingImaging– Plain x-raysPlain x-rays– CTCT– MRIMRI– AngiographyAngiography
ElectrophysiologyElectrophysiology– EMG, nerve conduction, EEG etc.EMG, nerve conduction, EEG etc.
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Neurological Examination of Neurological Examination of the Comatose Patientthe Comatose Patient
Level of ConsciousnessLevel of Consciousness– Glasgow Coma ScoreGlasgow Coma Score
Brainstem IntegrityBrainstem Integrity– Pupillary ReactionPupillary Reaction– Ocular MovementOcular Movement– Corneal reflexesCorneal reflexes– Gag/breathingGag/breathing
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Eye OpeningEye Openingspontaneousspontaneous 44to voiceto voice 33to painto pain 22nonenone 11
Verbal ResponseVerbal Responseorientedoriented 55confused - sentencesconfused - sentences 44words onlywords only 33soundssounds 22nonenone 11
MovementMovementobeysobeys 66localiseslocalises 55flexion withdrawalflexion withdrawal44abnormal flexionabnormal flexion 33extensionextension 22nonenone 11
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Rostral-Caudal DeteriorationRostral-Caudal Deterioration
MidbrainMidbrain– Bilateral pupillary abnormalitiesBilateral pupillary abnormalities– Oculomotor abnormalitiesOculomotor abnormalities
PonsPons– Loss of corneal reflexesLoss of corneal reflexes
MedullaMedulla– Loss of gag reflexesLoss of gag reflexes– Respiratory and vasomotor collapseRespiratory and vasomotor collapse
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Brain Tumour ClassificationBrain Tumour Classification Intra-axial (frequently malignant)Intra-axial (frequently malignant) PrimaryPrimary
– GlialGlial– Choroid plexusChoroid plexus– Neuronal or mixed glial-neuronalNeuronal or mixed glial-neuronal– PNET/medulloblastomaPNET/medulloblastoma– CNS lymphomaCNS lymphoma– Pineal regionPineal region– hemangioblastomahemangioblastoma
MetastaticMetastatic
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Brain Tumour ClassificationBrain Tumour Classification
Extra-axial (usually benign)Extra-axial (usually benign)– MeningesMeninges– Cranial nerves (Schwannoma)Cranial nerves (Schwannoma)– PituitaryPituitary– skullskull
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Glial TumoursGlial Tumours
Astrocytoma (gliobastoma Astrocytoma (gliobastoma multiforme)multiforme)
OligodendrogliomaOligodendroglioma EpendymomaEpendymoma Mixed tumoursMixed tumours Gr. I - IVGr. I - IV
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TreatmentTreatment
SupportiveSupportive SpecificSpecific
– Corticosteroids (dexamethasone)Corticosteroids (dexamethasone)– SurgicalSurgical
» BiopsyBiopsy
» Excision Excision
» Internal decompressionInternal decompression
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Treatment contd.Treatment contd.
– RadiotherapyRadiotherapy» ConventionalConventional
» Stereotactic focusedStereotactic focused
– ChemotherapyChemotherapy» Temazolamide (malignant glial tumours)Temazolamide (malignant glial tumours)
» Lymphoma protocolsLymphoma protocols
» Specific to tissue of origin for metastasesSpecific to tissue of origin for metastases
ObservationObservation
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No Contrast With Contrast
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Stroke: Classification and Stroke: Classification and ManagementManagement
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Stroke DefinitionStroke Definition
Sudden onset of a neurological deficit Sudden onset of a neurological deficit due to disease or injury of the blood due to disease or injury of the blood supply of the brain.supply of the brain.
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Stroke ClassificationStroke Classification
IschemicIschemic– BlandBland– Hemorrhagic transformationHemorrhagic transformation
Hemorrhagic (hemorrhage is 1Hemorrhagic (hemorrhage is 100 event) event)– HypertensionHypertension– Amyloid angiopathyAmyloid angiopathy– AneurysmalAneurysmal– AVMAVM– Other Other
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Ischemic Stroke (Infarction)Ischemic Stroke (Infarction)
Thrombotic (local vessel disease)Thrombotic (local vessel disease) EmbolicEmbolic
– Artery to artery (usually carotid)Artery to artery (usually carotid)– Heart to artery (atrial fibrillation)Heart to artery (atrial fibrillation)– Paradoxical (vein to artery)Paradoxical (vein to artery)– Other (air, foreign body, iatrogenic)Other (air, foreign body, iatrogenic)
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Intracerebral HemorrhageIntracerebral Hemorrhage
HypertensiveHypertensive– Occurs in long narrow perforating Occurs in long narrow perforating
arteries (basal ganglia, thalamus, pons, arteries (basal ganglia, thalamus, pons, cerebellar nuclei)cerebellar nuclei)
– Charcot-Bouchard aneurysmsCharcot-Bouchard aneurysms– Related primarily to duration of Related primarily to duration of
hypertensionhypertension
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Intracerebral HemorrhageIntracerebral Hemorrhage
Amyloid angiopathyAmyloid angiopathy– Age related change in cerebral vesselsAge related change in cerebral vessels– Lobar hemorrhageLobar hemorrhage– Most commonly in posterior part of Most commonly in posterior part of
cerebral hemispherescerebral hemispheres
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Intracerebral HemorrhageIntracerebral Hemorrhage
AVMAVM Berry aneurysmBerry aneurysm Subarachnoid hemorrhageSubarachnoid hemorrhage
– Usually exclusively subarachnoidUsually exclusively subarachnoid– May have intracerebral componentMay have intracerebral component– Occasionally exclusively intracerebralOccasionally exclusively intracerebral
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ManagementManagement
DiagnosisDiagnosis– HistoryHistory– Physical ExaminationPhysical Examination– Special tests (imaging)Special tests (imaging)
TreatmentTreatment
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Stroke DiagnosisStroke Diagnosis
HistoryHistory– Rapid onset fixed deficit – ischemicRapid onset fixed deficit – ischemic– Rapid onset progressive deficit – Rapid onset progressive deficit –
hemorrhagehemorrhage– Sudden severe headache, Sudden severe headache,
nausea/vomiting/photophobia +/- nausea/vomiting/photophobia +/- neurological deficit - SAHneurological deficit - SAH
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Stroke Physical ExaminationStroke Physical Examination
Focal deficitsFocal deficits– Most often ischemic stroke or ICHMost often ischemic stroke or ICH– Much less common in SAHMuch less common in SAH
Alteration in level of consciousnessAlteration in level of consciousness– SAHSAH– ICHICH– Delayed swelling from large infarctsDelayed swelling from large infarcts
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Stroke InvestigationStroke Investigation
CT scanCT scan– First line imaging to distinguish infarct First line imaging to distinguish infarct
from hemorrhagefrom hemorrhage– 11stst choice for confirming SAH, LP if choice for confirming SAH, LP if
negativenegative OtherOther
– Cerebral angiography, doppler for Cerebral angiography, doppler for carotidscarotids
– MRI in special circumstancesMRI in special circumstances
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Acute Stroke TreatmentAcute Stroke Treatment
SupportiveSupportive– AirwayAirway– Blood pressureBlood pressure
DefinitiveDefinitive– ThrombolysisThrombolysis– Hematoma evacuation (limited Hematoma evacuation (limited
circumstances)circumstances)
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Stroke TreatmentStroke Treatment
PreventionPrevention– Risk factor modificationRisk factor modification
» Hypertension, smoking, diabetes, lipids/cholesterolHypertension, smoking, diabetes, lipids/cholesterol
– Antiplatelet agents (artery-artery embolism, Antiplatelet agents (artery-artery embolism, local occlusive disease)local occlusive disease)
– Anticoagulation (heart to artery emboli)Anticoagulation (heart to artery emboli)
– Surgical preventionSurgical prevention» Carotid endarterectomy, stentingCarotid endarterectomy, stenting
» Aneurysm obliterationAneurysm obliteration
» AVM excisionAVM excision
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Skull Skull FractureFracture
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Primary Impact InjuryPrimary Impact Injury
Shear (diffuse) injury of axonsShear (diffuse) injury of axons
Laceration/contusion of cortical Laceration/contusion of cortical surfacesurface
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Blumbergs, Head Injury, 1997:45
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Cerebral ContusionsCerebral Contusions
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Secondary InsultsSecondary Insults
HypoxiaHypoxia IschaemiaIschaemia Intracranial hematomasIntracranial hematomas Raised intracranial pressureRaised intracranial pressure SeizuresSeizures Infection Infection Fluid and electrolyte disturbanceFluid and electrolyte disturbance
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Respiratory Changes in Head InjuryRespiratory Changes in Head Injury
Depression/abolition of gag and cough Depression/abolition of gag and cough reflexesreflexes
Hypercarbia 2Hypercarbia 2o o to respiratory centre to respiratory centre depressiondepression
Hypoxemia -- systemic causesHypoxemia -- systemic causes– inadequate airway managementinadequate airway management– chest traumachest trauma– aspirationaspiration
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Recommendations for Treatment
Resuscitate aggressively with appropriate fluids Brain oedema is not a concern
Manage source of bleeding in unstable patients prior to transfer
Do not use mannitol in presence of hypotension or you will further destabilise the
patientConsider transient use of vasopressor drugs
while restoring volume and controlling haemorrhage
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Trauma Craniotomy IncisionTrauma Craniotomy Incision
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Pressure Volume CurvePressure Volume Curve
Pressure
Volume
Vskull = Vbrain + Vblood + VCSF + Vmass
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Trans-Tentorial HerniationTrans-Tentorial Herniation
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Use of MannitolUse of Mannitol
.5 - 1 gm./kg of 20% solution.5 - 1 gm./kg of 20% solution give as a bolusgive as a bolus urinary catheterurinary catheter Contraindications:Contraindications:ShockShockAnuriaAnuria
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Other ICP TherapiesOther ICP Therapies
CPP therapyCPP therapy
Barbiturate ComaBarbiturate Coma
Decompressive CraniectomyDecompressive Craniectomy
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Back to Basics For SurgeryBack to Basics For Surgery
SpineSpine
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Pain GeneratorsPain Generators
MyofascialMyofascial DiscDisc Facet JointFacet Joint NerveNerve VisceralVisceral VascularVascular
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Physical Examination: The SpinePhysical Examination: The Spine
Inspect: deformityInspect: deformity Palpate: deformity, local tendernessPalpate: deformity, local tenderness Range of motion (limitation, pain)Range of motion (limitation, pain)
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MyelopathyMyelopathy
‘‘a general term denoting functional a general term denoting functional disturbance and/or pathological disturbance and/or pathological changes in the spinal cord’changes in the spinal cord’
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Myelopathy Myelopathy Important QuestionsImportant Questions
Level of lesionLevel of lesion Nature of lesion Nature of lesion
– Surgical (spondylotic, neoplastic, infectious, Surgical (spondylotic, neoplastic, infectious, hematoma, traumatic)hematoma, traumatic)
– Treatment frequently curativeTreatment frequently curative– Non-surgical (degenerative, inflammatory)Non-surgical (degenerative, inflammatory)
Degree of patient disabilityDegree of patient disability Rate of progressionRate of progression History, physical examination, special History, physical examination, special
investigationsinvestigations
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Myelopathy: HistoryMyelopathy: History Patient Complaints:Patient Complaints: Numbness (loss of sensation, alteration of Numbness (loss of sensation, alteration of
sensation – paraesthesia, awkwardness)sensation – paraesthesia, awkwardness) Ataxia (awkwardness, clumsiness)Ataxia (awkwardness, clumsiness)
– Usually:Usually:
– Gait (imbalance, unsteadiness, unable to move Gait (imbalance, unsteadiness, unable to move quickly)quickly)
– Fine movements of hands (doing up buttons, Fine movements of hands (doing up buttons, handwriting)handwriting)
Weakness – usually a late findingWeakness – usually a late finding
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Myelopathy: HistoryMyelopathy: History Patient Complaints:Patient Complaints: Numbness (loss of sensation, alteration of Numbness (loss of sensation, alteration of
sensation – paraesthesia, awkwardness)sensation – paraesthesia, awkwardness) Ataxia (awkwardness, clumsiness)Ataxia (awkwardness, clumsiness)
– Usually:Usually:
– Gait (imbalance, unsteadiness, unable to move Gait (imbalance, unsteadiness, unable to move quickly)quickly)
– Fine movements of hands (doing up buttons, Fine movements of hands (doing up buttons, handwriting)handwriting)
Weakness – usually a late findingWeakness – usually a late finding
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Myelopathy: HistoryMyelopathy: History
Limbs involved: lower (may be thoracic or Limbs involved: lower (may be thoracic or cervical), upper and lower (always cervical)cervical), upper and lower (always cervical)
Onset: gradual, rapid or suddenOnset: gradual, rapid or sudden Associated pain: Associated pain:
– Activity related: spondyloticActivity related: spondylotic– Nocturnal: neoplasticNocturnal: neoplastic– Associated radicular painAssociated radicular pain
Previous or concurrent neurological Previous or concurrent neurological symptoms/illnesssymptoms/illness
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Myelopathy: Physical Myelopathy: Physical ExaminationExamination
Motor:Motor:– Strength: weakness is usually late finding Strength: weakness is usually late finding
in slowly evolving surgical conditions, in slowly evolving surgical conditions, occurs in corticospinal distributionoccurs in corticospinal distribution
– Reflexes (change occurs early): hyperactive Reflexes (change occurs early): hyperactive distal to lesion in gradually evolving lesionsdistal to lesion in gradually evolving lesions
» In disc disease may be hypoactive at level of In disc disease may be hypoactive at level of lesionlesion
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Myelopathy: Physical Myelopathy: Physical ExaminationExamination
– Tone (early): increased distal to lesionTone (early): increased distal to lesion– Coordination (early): impaired distal to Coordination (early): impaired distal to
lesionlesion– Plantar responses: up-going (reliability?)Plantar responses: up-going (reliability?)
Sensation:Sensation:– Proprioception: frequently impaired in Proprioception: frequently impaired in
lower limbs – impossible to establish lower limbs – impossible to establish precise levelprecise level
– Pinprick: extremely useful in thoracic Pinprick: extremely useful in thoracic lesionslesions
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Special InvestigationsSpecial Investigations
Plain x-rays (bone destruction, fracture, Plain x-rays (bone destruction, fracture, subluxation, spondylotic changes), n.b. no subluxation, spondylotic changes), n.b. no visualization of nervous tissuevisualization of nervous tissue
CT scan (same indications/contraindications CT scan (same indications/contraindications as x-ray)as x-ray)
MRI usually the definitive investigationMRI usually the definitive investigation CT-myelography (most useful for looking at CT-myelography (most useful for looking at
bone and disc relation to spinal cord/nerve bone and disc relation to spinal cord/nerve roots)roots)
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Myelopathy: Surgical Decision-Myelopathy: Surgical Decision-MakingMaking
Nature of the lesionNature of the lesion Natural history of the lesionNatural history of the lesion
– Trauma: static/improving unless spine unstableTrauma: static/improving unless spine unstable
– Neoplastic: progressive, rate variable depending on Neoplastic: progressive, rate variable depending on histologyhistology
– Infectious: usually rapidly progressiveInfectious: usually rapidly progressive
– Spondylotic myelopathy, usually gradually progressive, rate Spondylotic myelopathy, usually gradually progressive, rate variablevariable
– Recovery usually poor with advanced deficitsRecovery usually poor with advanced deficits
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Myelopathy: Surgical ApproachMyelopathy: Surgical Approach
Lesion site:Lesion site:– ExtraduralExtradural– Intra-dural, extra-medullaryIntra-dural, extra-medullary– IntramedullaryIntramedullary
Extradural:Extradural:– Anterior pathology – anterior approachAnterior pathology – anterior approach– Posterior pathology – posterior approach Posterior pathology – posterior approach
(laminectomy)(laminectomy) Intradural-extramedullary – posteriorIntradural-extramedullary – posterior Intradural-intramedullary - posteriorIntradural-intramedullary - posterior
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RadiculopathyRadiculopathy
a general term denoting functional a general term denoting functional disturbance and/or pathological disturbance and/or pathological changes in a spinal nerve rootchanges in a spinal nerve root
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RadiculopathyRadiculopathy
SymptomsSymptoms– Pain, paraesthesiae, sensory loss in the Pain, paraesthesiae, sensory loss in the
approximate dermatome of the involved approximate dermatome of the involved nerve rootnerve root
– Axial pain is not a symptom of nerve root Axial pain is not a symptom of nerve root involvement involvement
– Weakness in the myotome of the Weakness in the myotome of the involved nerve root – pts. frequently involved nerve root – pts. frequently can’t be specificcan’t be specific
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RadiculopathyRadiculopathy
Exam findingsExam findings– Lower motor neuron findings in the Lower motor neuron findings in the
appropriate myotomeappropriate myotome– Sensory findings in the appropriate Sensory findings in the appropriate
dermatomedermatome
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Radiculopathy – InvestigationRadiculopathy – Investigation
LumbarLumbar– MRI, CT scanMRI, CT scan
Cervical/thoracicCervical/thoracic– MRIMRI
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Radiculopathy - Conservative TxRadiculopathy - Conservative Tx
Activity modificationActivity modification NSAIDSNSAIDS AnalgesicsAnalgesics Physiotherapy - activePhysiotherapy - active
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RadiculopathyRadiculopathySurgical IndicationsSurgical Indications
Intractable radicular Intractable radicular ((not axialnot axial)) pain pain which has failed conservative which has failed conservative managementmanagement
Progressive or significant neurological Progressive or significant neurological deficitdeficit
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Spine Pain Spine Pain – Red Flags– Red Flags
Hx of major trauma or minor trauma in elderly, Hx of major trauma or minor trauma in elderly, osteoporotic patientsosteoporotic patients
Age < 20 or > 50Age < 20 or > 50 Hx of cancer, fever, chills, unexplained wt. lossHx of cancer, fever, chills, unexplained wt. loss Hx of recent infection, IV drug abuse, Hx of recent infection, IV drug abuse,
immunocompromiseimmunocompromise Hx of bladder or bowel incontinence, urinary Hx of bladder or bowel incontinence, urinary
retentionretention Hx of major or progressive neurological deficitHx of major or progressive neurological deficit Hx of pain worsening when supine or severe night Hx of pain worsening when supine or severe night
painpain
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Spine Pain Spine Pain – Red Flags– Red Flags
Exam: major neurological deficit/signs Exam: major neurological deficit/signs of upper motor neuron dysfunctionof upper motor neuron dysfunction
Exam: peri-anal anaesthesiaExam: peri-anal anaesthesia Exam: loss of anal sphincter toneExam: loss of anal sphincter tone
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Indications for SurgeryIndications for Surgery (Non-Degenerative Back Pain)(Non-Degenerative Back Pain)
Tumour Tumour – primary primary – metastaticmetastatic
Infection Infection – Discitis/osteomyelitisDiscitis/osteomyelitis– Epidural AbcessEpidural Abcess
Fracture/subluxation with instabilityFracture/subluxation with instability
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Clinical Assessment of Spinal InjuriesClinical Assessment of Spinal Injuries
HistoryHistoryMechanism of injuryMechanism of injurySpinal painSpinal painParaesthesia or motor weaknessParaesthesia or motor weakness
Physical examinationPhysical examinationLog roll, inspect and palpate entire spineLog roll, inspect and palpate entire spineTendernessTendernessMalalignment of spinous processesMalalignment of spinous processes
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Traps for the UnwaryTraps for the Unwary
Patient intoxicationPatient intoxication Altered level of consciousnessAltered level of consciousness Distraction from other injuriesDistraction from other injuries Cursory examination – failure to Cursory examination – failure to
appreciate single root injuryappreciate single root injury
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Cervical Spine X-raysCervical Spine X-rays
Lateral to T1Lateral to T1 APAP Open-mouth odontoidOpen-mouth odontoid CT Scan if one or more of above not CT Scan if one or more of above not
availableavailable
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Treatment of Spine InjuriesTreatment of Spine Injuries
Immobilize patientImmobilize patient Reduce deformityReduce deformity Stabilize/fuse spineStabilize/fuse spine
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Back to Basics for SurgeryBack to Basics for Surgery
Peripheral NervePeripheral Nerve
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Injury Classification Injury Classification (Seddon)(Seddon)
• NeurapraxiaNeurapraxia
• AxonotmesisAxonotmesis
• NeurotmesisNeurotmesis
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Peripheral Nerve InjuryPeripheral Nerve Injury
HistoryHistory– Usually immediate onset of Usually immediate onset of
symptoms/signs from time of injurysymptoms/signs from time of injury– Blunt or penetrating injuryBlunt or penetrating injury– Blunt injury frequently associated with Blunt injury frequently associated with
fracture or dislocationfracture or dislocation– May follow reduction of fracture or May follow reduction of fracture or
dislocationdislocation– Delayed onset: compartment syndrome or Delayed onset: compartment syndrome or
vascular injury to limbvascular injury to limb
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Peripheral Nerve InjuryPeripheral Nerve Injury
Physical ExaminationPhysical Examination– Upper vs. lower motor neuronUpper vs. lower motor neuron– Root vs. peripheral nerveRoot vs. peripheral nerve– Which root?Which root?– Which peripheral nerve?Which peripheral nerve?
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InvestigationsInvestigations
MRI/CTMRI/CT– Indirect, helpful if question of upper vs. lower Indirect, helpful if question of upper vs. lower
motor neuron, root vs. peripheral nervemotor neuron, root vs. peripheral nerve
EMGs/Nerve conductionEMGs/Nerve conduction– Former useful, latter notFormer useful, latter not
– Most sensitive in detecting early recoveryMost sensitive in detecting early recovery
– Not useful in acute managementNot useful in acute management
Extremity X-rays: Extremity X-rays: – helpful with injury site if fracture or dislocationhelpful with injury site if fracture or dislocation
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InvestigationInvestigation
• EMG (all injuries)EMG (all injuries)importance of clinical vs. EMG recoveryimportance of clinical vs. EMG recovery
• Root and trunk injuriesRoot and trunk injuriesMetrizamide CT- myelogramMetrizamide CT- myelogramMRIMRI
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Overall Treatment StrategyOverall Treatment Strategy
• Nerve repairNerve repairRestore movementRestore movementRestore sensationRestore sensation
• Muscle/tendon/joint reconstructive Muscle/tendon/joint reconstructive surgerysurgery
• ProstheticsProsthetics• RehabilitationRehabilitation• Educational and vocational adviceEducational and vocational advice
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Timing of SurgeryTiming of Surgery
• Primary repair (penetrating injury)Primary repair (penetrating injury)immediateimmediatedelayed (2 weeks)delayed (2 weeks)
• Secondary repair (blunt injury)Secondary repair (blunt injury)3 - 4 month delay3 - 4 month delay
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Reconstructive Strategies to Reconstructive Strategies to Achieve Elbow FlexionAchieve Elbow Flexion
• Steindler flexoroplastySteindler flexoroplasty
• Latissimus dorsi transferLatissimus dorsi transfer
• Pectoralis major transferPectoralis major transfer
• Triceps transferTriceps transfer
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Common Wrist/Hand Common Wrist/Hand Tendon TransfersTendon Transfers
• Wrist extension -- pronator teresWrist extension -- pronator teres• Thumb extension -- palmaris longusThumb extension -- palmaris longus• MCP extension -- flexor carpi radialisMCP extension -- flexor carpi radialis• Finger flexion -- brachioradialis or Finger flexion -- brachioradialis or
extensor carpi radialis longus to flexor extensor carpi radialis longus to flexor digitorum profundusdigitorum profundus
• Thumb flexion -- BR or ECRL to FPLThumb flexion -- BR or ECRL to FPL
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Results EtiologyResults EtiologyEtiology Etiology No. of PtsNo. of Pts
Lacerations 24Lacerations 24MVA 22MVA 22Winter sports 11Winter sports 11Falls 8Falls 8Gunshot wounds 4Gunshot wounds 4Others 14Others 14
Adjacent fractures in 15 patientsAdjacent fractures in 15 patients
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Individual nerve outcomeIndividual nerve outcome
Nerve Nerve Inc. loss Exc. lossInc. loss Exc. loss
to f/u to f/uto f/u to f/u
Brachial plexus 33% 37.5%Brachial plexus 33% 37.5%
Axillary 42.9% 75%Axillary 42.9% 75%
Musculocutaneous 57.1% 80%Musculocutaneous 57.1% 80%
Radial 58.3% 87.5%Radial 58.3% 87.5%
Median 75% 85.7%Median 75% 85.7%
Ulnar 66% 100%Ulnar 66% 100%
Posterior tibial 50% 60%Posterior tibial 50% 60%
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Outcome by EtiologyOutcome by Etiology
LacerationLaceration 87.5%87.5%
MVAMVA 32%32%
Winter sportsWinter sports 57.1%57.1%
FallsFalls 50%50%