Neurosurgery

Question 1

physical post-concussive symptoms

Answer 1

*headache
*nausea/vomiting
*dizziness
*fatigue
*blurred vision
*sleep disturbance
*loss of appetite
*sensitivity to light/noise
*balance problems

Question 2

cognitive post-concussive symptoms

Answer 2

*impaired attention, concentration, memory, speed of processing, judgement, executive function

Question 3

behavioral post-concussive symptoms

Answer 3

*depression
*anxiety
*agitation
*irritability
*impulsivity
*aggression

Question 4

is prescription medication recommended for post-concussive symptoms

Answer 4

NOT recommended

Question 5

return to play after concussion

Answer 5

no hits to the head for 7 days after last symptoms (otherwise, stepwise)

Question 6

stupor vs coma

Answer 6

*stupor = responsive to vigorous stimulation
*coma = unarousable to physical stimuli

stimulation: sternal rub, supraorbital pressure, trapezius squeeze (all above the nipple line; important for localization vs withdrawal to pain)

Question 7

localizing to pain (on GCS)

Answer 7

*patient must actively try to push away pain
*must cross the nipple line in order for it to be considered localizing

Question 8

which cranial nerves are important in acute care neurosurgery?

Answer 8

*CN2 & CN3 (pupils)
*CN6
*CN7

Question 9

pupillary changes: bilaterally fixed and dilated

Answer 9

*death
*hypovolemic shock
*drugs (atropine, ecstasy)

Question 10

pupillary changes: unilaterally fixed and dilated

Answer 10

*head injury
*stroke

Question 11

pupillary changes: bilateral pinpoint constriction

Answer 11

*opiate overdose

Question 12

pupillary changes: bilateral constriction

Answer 12

brainstem stroke

Question 13

pupillary changes: irregular pupil

Answer 13

*trauma
*previous eye surgery

Question 14

brainstem reflexes

Answer 14

*protective reflexes: cough, gag, corneals
*oculocephalic (doll’s eyes)
*oculovestibular (cold caloric)

Question 15

cushing’s triad

Answer 15

*increase systolic blood pressure with widened pulse pressure (hypothalamus triggers increased heart contractility)
*bradycardia (baroreceptors register increased SBP)
*apneusis/neurogenic breathing (loss of vagal and pneumotaxic center stimulation)

*indicates increased intracranial pressure

Question 16

Monroe-Kellie Doctrine

Answer 16

*the volume of the cranial vault is fixed
*the cranial vault contains: brain, blood, and CSF

Question 17

treatment of increased ICP

Answer 17

*elevate head of bed
*hyperventilation
*hypertonic therapy (mannitol or hypertonic saline)
*CSF drainage
*decrease brain metabolism
*surgical decompression

Question 18

contusions

Answer 18

*parenchymal damage from the bony ridges at the base of the skull
*associated with edema

Question 19

how does hypertonic saline help reduce ICP

Answer 19

*use osmotic gradient to pull fluid out of brain and into the vascular space, decreasing brain volume (mannitol + hypertonic saline)

Question 20

methods for decreasing cerebral metabolic rate

Answer 20

-sedation
-paralytics
-barbiturate coma
-control seizures, fever, restlessness, pain
-normothermia

Question 21

diffuse axonal injury

Answer 21

*deceleration injury (usually MVA)
*shear-strain forces on the axons during rotation/deceleration of the head
*poor prognosis

Question 22

aneurysm management

Answer 22

*prevent rerupture (surgical clipping, endovascular coiling/remodeling, observation)
*manage complications (hydrocephalus, vasospasm)

Question 23

AVM (arteriovenous malformations)

Answer 23

*tangles of blood vessels
*less dangerous than aneurysms
*arteries go directly into veins (no capillary beds)

Question 24

“red flags” for back pain

Answer 24

*bowel or bladder changes (urinary retention, NOT incontinence)
*saddle anesthesia/erectile dysfunction
*rectal exam

Question 25

dermatomes

Answer 25

*trace pain/numbness with 1 finger
C5 = shoulder
C6 = lateral forearm
C7 = middle finger
C8 = medial forearm
T1 = medial upper arm
L3 = medial upper leg
L4 = below knee to medial malleolus
L5 = big toe and lateral leg below knee

Question 26

myotomes

Answer 26

C5 = deltoid
C6 = biceps, wrist extension
C7 = triceps
C8 = interosseous muscles
L3 = iliopsoas
L4 = quadriceps, patellar reflex
L5 = dorsiflexion
S1 = plantar flexion, achilles reflex

Question 27

disk dessication

Answer 27

*loss of water in the disks
*loss of disk height

Question 28

disk bulge

Answer 28

*loss of water leads to bulging against the annulus
*car tire analogy (when car tire loses air, it gets flatter and wider)
*rarely surgical

Question 29

neurogenic claudication

Answer 29

*chronic lumbar stenosis
*buttock/posterior thigh pain when walking
*position to open the canal (leaning on the shopping cart) differentiates from vascular claudication

Question 30

cervical stenosis

Answer 30

*myelopathy
*hyperreflexia
*proprioceptive loss
*wide based gait
* + Hoffmans/Babinski