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Surgery Clerkship > Neurosurgery > Flashcards

Neurosurgery Flashcards

1
Q

What are the most common cervical spinal levels involved after trauma?

A
  1. Vertebral fracture: C2 (1/3 = odontoid fractures)
  2. C6
  3. C7
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2
Q

What is the most common level of subluxation injury and why?

A

C5-C6 because its the greatest area of flexion and extension in cervical spine

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3
Q

Which dermatome level is the shoulders?

A

C4

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4
Q

Which dermatome is the first in the chest?

A

T2

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5
Q

How do we grade DTRs?

A 
2+ normal
0= no response
1+ sluggish tone
3+ more brisk
4+ clonus
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6
Q

Clinical difference: complete vs. incomplete spinal cord injury?

A

Complete: no motor/sensory below level
Incomplete: some residual function below level of injury

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7
Q

What are devastating clinical exam findings in complete spinal cord injury in high cervical cord (C3 or above)?

A

Diphragmatic paralysis - cannot breathe

Paralysis of all 4 limbs

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8
Q

What is myelopathy?

A

sensory or motor dysfunction caused by pathology of spinal cord

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9
Q

When is Babinski normal?

A

Infants up to age 2

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10
Q

What is spinal shock?

A

temporary, concussive like syndrome associated with flaccid paralysis below level of injury with loss of all reflexes, plus loss of urinary/rectal tone

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11
Q

Why are thoracic spinal injuries less common than cervical in trauma?

A

1 Thoracic vertebrae are more stable due to high facets and ribs that decrease motion
2 More canal space because no anterior enlargements in the spinal cord (vs. cervical/lumbar)

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12
Q

What is sacral sparing?

A

Sparing of function at sacral nerve level

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13
Q

Why is sacral sparing important?

A

It signifies better chance of functional neurological recovery

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14
Q

What are common mechanisms of neck injuries?

A

Flexion
Extension
Axial loading (vertebral compression)
rotational injuries

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15
Q

What is atlanto-occipital dislocation?

A

Superior facets of atlas lose articulation with occipital condyles at the base of the skull: due to ligamentous disruption between occiput and cervical spine

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16
Q

What is most dangerous injury of cervical spine?

A

atlanto-occipital dislocation: higher risk of severe high cervical cord injury.

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17
Q

Who is at increased risk of atlanto-occipital dislocation?

A

Down syndrome patients: screen before sports participation

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18
Q

What is the typical cause of Brown Sequard syndrome?

A

Penetrating trauma

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19
Q

What is the typical cause of anterior cord syndrome?

A

Severe flexion injury

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20
Q

What is the typical cause of central cord syndrome?

A

Severe extension injury in an elderly patient with pre-existing cervical stenosis

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21
Q

Why are the distal lower extremities spared in central cord syndrome?

A

Topographical organization: lower extremity motor function is at the lateral aspects of the cord = spared

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22
Q

Which incomplete cord syndrome carries best prognosis of recovery?

A

Brown Squared

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23
Q

Which incomplete cord syndrome carries worst prognosis of recovery?

A

Anterior cord: 10% recover ambulation

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24
Q

How do we diagnosed spinal cord injuries and cervical vertebral fractures?

A
  1. History
  2. Neuro exam
  3. imaging if needed to confirm
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25
Q

What is NEXUS criteria?

A 
Determines if adult patients need spinal radiographs. Indicated for trauma UNLESS: patient meets NSAID
Neuro deficit
Spinal tenderness
AMS
Intoxicated
Distracting injury
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26
Q

What radiographs do we obtain of the cervical spine in trauma?

A

1 AP
2 Lateral
3 Open mouth (odontoid)

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27
Q

What is indication for ordering CT scan of cervical spine?

A

Detecting vertebral fractures
identify hematomas / disk fragment in spinal cord
clearance of cervical spine in comatose/obtunded patients

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28
Q

What is indication for ordering MRI scan of cervical spine?

A
  • Detect injury to spinal cord itself in patients with neurological deficits
  • Areas of edema, ruptured disks, ligamentous injury
  • Sees hematoma well
  • Detects abnormalities in patients with SCIWORA
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29
Q

What is SCIWORA?

A

Spinal Cord Injury Without Radiographic Abnormalities

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30
Q

Who is susceptible to SCIWORA?

A

Children/young adults due to tearing or contusion of spinal cord from overstitching and spinal column subluxation due to ligamentous laxity/flexibility of developing spine

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31
Q

Where is more common SCIWORA injury? Who gets it?

A

C2, patients < 3 years

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32
Q

How may SCIWORA present?

A

after brief episodes of UE weakness or paresthesias –> delayed development of near deficits

33
Q

How can we identify spinal cord abnormalities in patients with SCIWORA?

34
Q

What are general treatment principles for patients with cervical spine injury?

A 
Rigid cervical collar on spine board
early closed reduction with tongs or halo traction for awake patients with obvious subluxation on imaging: causing spinal cord compression
- IV fluids
- Vasopressors if neurogenic shock
- Foley
- stool softener
- VTE prophylaxis
35
Q

What is neurogenic shock?

A

Hemodynamic state: SNS outflow through spinal cord disrupted: vasodilation, bradycardia and dangerous hypotension

36
Q

How do we treat neurogenic shock?

A

1 Normal saline
2 Dopamine or phenylephrine if needed
3 Treat bradycardia with atropine or dopamine

37
Q

What are goals of management for patients with complete spinal cord injuries or high cervical cord injuries?

A

Facilitate nursing and rehab

Prevent decubitus ulcers, bowel/bladder management, avoid DVT, avoid pneumonia

38
Q

What are general indications of emergent surgery with spinal cord injury? (3)

A

1 Unstable vertebral fracture
2 Non reducible spinal cord compression with deficit
3 Ligamentous injury with facet instability

39
Q

Why is restoration of spinal stability so important?

A

Minimize risk for secondary injury and allow for early mobilization of patient to minimize risk

40
Q

Do we treat acute spinal cord injury with IV steroids?

A

NO: no evidence for it

41
Q

What is the most common complication of exposure of the anterior cervical spine?

A

Recurrent laryngeal nerve injury: paralyze vocal cords, risk of dyspnea with bilateral injury, transient dysphagia, rarely esophageal perforation (high risk of infection)

42
Q

What is diffuse axonal injury due to and what happens?

A

Rotational acceleration and deceleration causes stretching of axons between grey and white matter

43
Q

What is common cause of DAI?

A

Shaken baby syndrome

44
Q

What is the definition of TBI?

A

Criteria:

  • Period of LOC
  • Loss of memory for events immediately before/after accident
  • Alteration in mental state at time of accident
  • And/or FND
45
Q

What are components of GCS?

A

Eye opening (1-4)
Best verbal response (1-5)
Best motor response (1-6)

46
Q

What GCS scores encompass severe vs. moderate vs. mild TBI?

A

Severe: 3-8
Moderate 9-12
Mild 13-15

47
Q

What do we do with patient with GCS < 8?

A

Considered to be in coma

mandates establishment of airway

48
Q

What non-head trauma factors can affect GCS?

A

ETOH/drug intox, sedatives, severe hypoxia, shock, severe hypothermia

49
Q

What are Raccoon eyes?

A

bilateral periorbital ecchymosis

50
Q

What is Battle’s sign?

A

Retroauricular ecchymosis

51
Q

What makes us think of basilar skull fracture?

A

raccoon eyes and Battle’s sign: bilateral periorbital ecchymosis, Retroauricular ecchymosis

52
Q

How do we use hemiparesis and blown pupil to localize lesion in uncal herniation?

A

Hemiparesis: C/L to lesion
Pupil: ipsilateral to lesion

53
Q

Which has better prognosis: decorticate or decerebrate posturing?

A

Decorticate

54
Q

What is decorticate posturing?

A

Flexion in UE, Extension in LE in response to painful stimuli

55
Q

What is decerebrate posturing?

A

Extension in UE and LE in response to painful stimuli

56
Q

How to distinguish between acute and chronic SDH?

A

Acute: W/in 72 hours head injury
Chronic: delayed onset in elderly usually: presentation often insidious: gait abnormalities, decreased consciousness, aphasia, cognitive dysfunction, memory loss and/or personality changes

57
Q

Who is particularly susceptible to SDH?

A

Alcoholics, elderly, patients on anti-coagulation

58
Q

Why are elderly patients more susceptible to SDH?

A

Relatively atrophic brain increases tension on bridging veins: making them more susceptible to head trauma

59
Q

What is the formula for cerebral perfusion pressure?

A

= mean arterial pressure - intracranial pressure

60
Q

What affects ICP? (3)

A

Brain tissue, CSF and blood

61
Q

What is the most powerful intracranial vasodilator?

62
Q

Can TBI cause hypotension?

A

NO - look for other factors

63
Q

What is Cushing’s triad and the pathophys behind it?

A

Hypertension, bradycardia, irregular RR

  • Increased ICP –> systemic BP rise to maintain CPP –> increased BP to carotid sinus biofeedback causes bradycardia
  • Respiratory center in medulla: will become impaired as result of elevated ICP
64
Q

What is coup vs. contrecoup injury?

A

Coup: injury to brain tissue just below skull at point of impact
Force of impact may thrust brain tissue against skull to opposite side and cause injury = contrecoup

65
Q

What is initial management of GCS patient <= 8?

A

1 Intubation: protect airway, can help facilitate ICP management
2 Neurologic exam
3 Noncon CT STAT

66
Q

Key thing to keep in mind in patient with GCS < 8 after trauma?

A

Cannot use PE to identify other injuries! Need to assess for other injuries to chest abdomen, pelvis

67
Q

What are indications for head CT with TBI?

A

1 Moderate or severe GCS: scores 3-12

2 Mild GCS with anticoagulation, alcohol abuse, elderly

68
Q

Which drugs can increase ICP and are C/I in TBI?

A

Succinylcholine, ketamine

Use rocuronium/etomidate instead

69
Q

How can we decrease intracranial hypertension?

A 
1 Hyperventilation
2 Bed elevation to 30-45 degrees
3 Mannitol
4 Paralyze patient --> hypothermia
5 Barbituate coma or decompressive craniotomy
70
Q

What is the role of hyperventilation?

A

CT findings or clinical signs of Intracranial HTN

- Initiate hyperventilation to PaCO2 of 30-35 –> temporarily reduce ICP via vasoconstriction

71
Q

Who should NOT receive mannitol?

A

Hypotensive/hypovolemic patients due to effects of volume depletion

72
Q

What is role of corticosteroids in TBI?

73
Q

What is craniotomy?

A

Removing skull flap to evacuate hematoma

74
Q

When do we use craniotomy?

A

Indicated for acute subdural and epidural hematomas:

  • Midline shift > 10mm
  • Hematoma thickness > 5mm
  • ICP > 20mm Hg (despite medical management)
75
Q

What is craniectomy?

A

Removal of skull flap without replacing bone flap, allowing the brain to swell beyond the skull

76
Q

When do we repeat imaging for TBI patients who are being medically managed?

A

Use urgent followup CT for:

  • New neurologic signs
  • Continued vomiting
  • Worsening HA
  • Loss of > 2 points on GCS
  • Any signs of increase ICP
77
Q

What are criteria for brain death?

A

GCS of 3 while not hypoxic, normotensive, euthermic, non on sedatives/paralytics

  • No CN reflexes
  • No respiratory effort during apnea test
78
Q

How do we define concussion?

A

Disruption of inflow and outflow tracts from reticular activating system

Surgery Clerkship (16 decks)

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