Neurosurgery Flashcards
What is a Ventriculoperitoneal shunt (VP) ?
A shunt used to drain excessive cerebral spinal fluid from brain hydrocephalus
What causes excessive CSF?
cerebral spinal fluid
1) Blockages in ventricular system, can be due to congenital defects or infections
2) Overproduction of CSF, body makes too much and can’t get rid of it
3) poor absorption of CSF to blood vessels
Without a VP shunt, what can patients experience?
Brain damage and seizures
Why do adults present more with brain damage and seizures compared to infants?
Because adults skull is fused so theres only a limited of space. Infants skill are not fused so they have some more space
What are the 3 parts of a VP shunt?
1) Ventricular catheter
2) Shunt Valve
3) Distal catheter
What supplies would you need for positioning for a VP shunt?
Mayfield head rest Jelly ring pillow Blankets OR bed Safety straps
Where do we want access for a VP shunt?
Right skull
How do we want the arms during a VP shunt?
Bilateral arms tucked to gain access to both head and abdomen
How is the OR table/bed turned?
90 degrees away from anesthesia for better access to the head.
T/F: General surgeon is in OR room during VP shunt
True
Name the first 4 steps during a VP shunt
1) incision is made behind right ear
2) Burr hole is made into skill
3) Cannula inserted through burr hole into right ventricle
4) catheter is threaded into right ventricle
Name the 4 steps after the catheter is threaded into right ventricle
5) Catheter is superficially tunneled down side of head to abdomen
6) The valve is placed at base of skill/posterior neck for easy access
7) A small incision is made on abdomen to gain access to peritoneal cavity
8) A small hole is made in peritoneum and the catheter is threaded into abdomen cavity
How would you close the abdominal incision dermis/skin ?
Abdominal Dermis: 3-0 Vicryl
Abdominal Skin: 4-0 Monocryl
T/F: VP shunt can be a two-part surgery
True
Abdominal part of surgery can also be performed ____________
Laparoscopically
What are the 5 layers of the skull? Outer–> innermost
Skin Connective tissue Aponeurosis (fascia/galia) Loose areolar tissue Periosteum
What is a craniotomy?
Surgical removal of part of the skull to expose the brain
Bone flap can be ______ after surgery or _____ for later attachment
Reattached
Stored
Why would a patient need a craniotomy surger?
1) Epidural/subdural hematoma
2) Tumor resection
3) Aneurysm clipping
What position would be used for a craniotomy?
Depends on the location of lesion/trauma
- need to know which lateral side
What materials can be used to stabilize the head for a craniotomy?
Mayfield skull clamp
Horseshoe pillow attachment
Jelly Ring pillow
How many parts does a Mayfield skull clamp have and what are they?
1) Bed adaptor: attaches directly to bed (slide or pegs)
2) Base unit: attaches to the adaptor
3) Swivel adaptor: comes off base unity and attaches to clamps
4) Skull clamp
What supplies are need for a Mayfield Skull Clamp prep table?
1) Mayfield skull clamp
2) Mayfield Skull pins
3) Hair clippers
4) Tape
5) Comb
6) Small plastic bag for hair
7) Marking pen
What instruments/supplies are needed during a craniotomy?
1) Rainey Clips: to stop bleeding in highly vascular areas
2) Cottonoids: need to soak in saline and apply tp skull so it doesn’t dry
3) Perforator drill bit
4) Tapered drill bit
Perforator and Tapered Drill Bits are attached to ____
Air power drilled
How would you prep and drape the surgical area for a Craniotomy?
1) 4 towels placed around marked site
2) Craniotomy drape place over marked site
3) Meticulous organization of supplies with cords being attached to drapes: so that there is not tangles cords
While prepping we should take special care of ____ and ____ _______
Eyes
Ear canal
What are the 4 steps for opening a craniotomy?
1) incision is made and rainey clips are placed to control bleeding
2) Scalp flap is lifted of skull
3) Perforator drill is used to create burr holes in skill
4) tapered drill is on craniotome attachment to use to connect burr holes
What should we use for suction during a craniotomy?
Frazier suction: used/invented for neuro so that the pressure can be controlled
What should the SA be extra careful doing while a craniotomy opening?
Needs lots of irrigation so that the bone doesn’t burn and don’t want to suction brain (causes damage)
How is the Dura closed during a craniotomy closure?
Dura is sutured together using a 4-0 Nurolon TF needle (pop off form from 8-pack)
Nurolon: braided, permanent and never looses tensile strength
____ may be used instead, for dura substitute
Duragen
How would we close the skull flap for a craniotomy closure?
Reattached using plate and screws
What is done with the skull flap if it is not reattached?
1) Insert into the subcutaneous of the abdomen
2) Bank skull flap
Scalp aponeurosis (fascia) is closed using __ ___ __-1 pop-offs
0 Vicryl CT
____ is closed using 2-0 Vicryl CT-1 pop-offs
Dermis
Skin is closed using ?
Staples
What dressing can we use for a craniotomy?
Telfa- non adherent dressing
4X4s
Kerlix head wrap
What does TLIF stand for?
Transforaminal Lumbar Interbody Fusion
Be able to name the parts of vertebrae
What is a TLIF?
Surgical procedure to remove degenerative lumbar vertebral disc and fuse the lumbar spine to eliminate mechanical back pain
TLIF is recommended for disabling ______ back and ____ symptoms that have not improved with non-surgical treatments
Lower
Leg
What are 3 indications for TLIF surgery?
1) Spondylolisthesisa
2) degenerative disc disease
3) Herniated disc
What instruments are needed for a TLIF surgery?
1) Cerebellar retractor
2) Nerve root retractor
3) Leksell Rongeur
4) Kerrison Rongeur
- Ray tech needed so that bone fragments can be wiped
5) Cobb elevator
- Retractor for muscle
6) Woodsen Elevator
- Used to peel from bone
- Fine dissection sometimes
7) Nerve Hook
- Manipulate under bone
- Feeling tool
8) Midas rex burr
TLIF Position: Patient is _____ on open padded _____ _____
Prone
Jackson Table
Patients face is put on a ____ pillow
prone pillow
Where are the arms during a TLIF surgery?
Arms are at 90 degrees abduction and flexion
Where are the foam padding place during TLIF surgery?
Chest
Mid-chest
Sternum
What should we look for when placing paddings?
Females?
Males?
Females: check breast
Males: check penis and scrotum
Relating to hips, where should the pads be placed? Land mark
ASIS: Anterior Superior Iliac Spine
Foley is placed ____ we flip the patient prone.
before
T/F: Pillows are place under knees and feet are elevated
True
What are the first 4 steps during a TLIF procedure?
1) X-ray taken to confirm correct level for decompression and fusion
2) Midline incision is made: (depends on how many levels) a 3-4 cm incision is made per level
3) Dissect through fascia exposing the spinous processes
4) Dissect tissue off spinous and transverse processes exposing facet joints
After exposing the spinous and transverse processes, what 4 steps come next?
5) Remove Spinous process with Kerrison Rongeur
6) Perform laminectomy: usually done with burr and irrigation should be done downstream so that visual can be accessed
7) Resect Ligamentum Flavum: removed with kerrison rongeur
8) Unilateral facetectomy performed
What 4 steps come after the unilateral facetectomy?
9) Pedicle identified and dissected
10) Box annulotomy: Create window into disk space (using a 15 blade)
11) Disk space distracted and remove from vertebral body
12) Disk space is inserted
What occurs after a disk spacer is inserted during a TLIF procedure? 4 steps
13) Pedicle insertion points prepared using burr
14) Awl and pedicle probe used to create pathway for pedicle screws
15) Pedicle tapped according to size estimates
16) Pedicle screws are inserted
What happens after a pedicle screws are inserted into vertebrae during a TLIF procedure? 4 steps
17) Rods precut to match curve of patients spine and are inserted into screw heads
18) Cap is placed to capture rod in screw head
19) Pedicle scews are compressed and caps tightened
20) Final x-rays taken to ensure pedicle screw placements
What are the last two steps for a TLIF procedure?
21) Bone graft is placed around screws
22) Drain is placed and fascia is closed using 0 Vicryl CT-1 needle pop offs
TLIF closure:
Dermis is closed using ___
___ CT-1 needle pop offs
2-0 Vicryl
TLIF closure:
Skin is closed using ____ ____ PS-2 needle
4-0 monocryl
What type of stictch is used during closure of skin for a TLIF procedure?
Intracuticular stitch
What dressing may be used for a TLIF incision ?
1) Dermabond
2) Steristrips
3) Telfa
4) Tegaderm
5) extra tape to secure drain in place
What is a kyphoplasty?
Surgical procedure to releive pain from vertebral compression fractures
What can cause Kyphoplasty surgery?
Compression fractures either from osteoporosis or falls
How is the patient positioned for a Kyphoplasty surgery?
Patient is prone on a Wilson frame place on flat top jackson table
What is necessary at each level of fracture vertebra during surgery?
c-arm
What type of surgery is a Kyphoplasty?
Percutaneous Procedure
What are the 3 steps for a Kyphoplasty?
1) Needle is inserted into vertebral body under C-arm guidance
2) Balloon is passed though needle and used to expand compression fracture
3) Cement is then inserted into expanded vertebral body to maintain correct position of body
What is an ulnar nerve transposition surgery?
Inflamed ulnar nerve is moved more superficially from current location under medial epicondyle
Ulnar nerve arises from the _____ cord of the ____ plexus
Medial
Brachial
What spinal root is the ulnar nerve
Spinal roots C8-T1
Where is the ulnar nerve located?
Runs medially along humerus and ulna, passing under medial epicondyle of humerus through the cubital tunnel
What are the sensory function of the ulnar nerve?
Anterior and posterior little finger and 1/2 of ring finger and associated palm area
What are the motor function of the ulnar nerve?
- Muscles of hand
- Flexor carpi ulnaris
- Medial half of flexor digitorum
What is cubital tunnel syndrome?
When ulnar nerve becomes compressed or inflamed at the elbow (seen a lot with baseball, tennis, and careers that use arms a lo- repetitive motion with elbow)
What are possible causes of cubital tunnel syndrome?
- Prior fracture
- Swollen joint
- repetitive bending motion at elbow
What are symptoms of Cubital tunnel Syndrome?
- Numbness or tingling in ring and little finger
- Weakening grip
- Muscle atrophy
- Difficulty with finger coordination
- “Claw finger”
What position should patient be in for an Ulnar Nerve Transposition?
Patient should be supine with operative arm extended on a hand table
Arms can be left extended on table or flexed at elbow to gain access medially
_____ may be used around upper arm
Tourniquet
What are the first 2 steps of an Ulnar nerve transposition?
1) Incision made medial to elbow above ulnar nerve
2) Ulnar nerve dissected from cubital tunnel and surrounding tissue
What are the last 2 steps of an Ulnar nerve transposition?
3) Ulnar nerve free from all attachments. Umbilical tape place around either end to gain control of nerve
4) Ulnar nerve transposed to above medial epicondyle of humerus to prevent impingement
Ulnar nerve is sutured into new location using 3-0 _____ ____ needle
Vicryl
SH (fine thin needle)
The deep ____ is closed using a _____ vicryl SH needle
Dermis
3-0
_____ is closed using a 4-0 monocryl PS-2 needle
Skin
What dressings can be used for an ulnar nerve transposition?
- Steristrips
- 4X4s
- Webril
- Arm wrapped in 4in & 6in ACE wrap from HAND to ABOVE ELBOW
- May be placed in a posterior splint
