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1
Q

List the indication for insertion of an ICP monitor

A

GCS 3-8 after resuscitation and abnormal CT (haematomas, contusions, swelling, herniations, compressed basal cisterns)
Severe TBI (GCS≤8) + normal CT with two or more risk factors for ICH
* Age>40
* Unilateral/bilateral motor decorticate / decerebrate motor posturing
* SBP<90mmHg

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2
Q

List the advantages and disadvantages of intraventricular catheter

A

Advantage
* More reliable method of assessing ICP
* Allows CSF drainage when ICP is elevated
* CSF sampling possible
* Can be recalibrated in situ
Disadvantages
* Infection risk
* Difficulty inserting if brain swelling
* May become blocked
* Migration
* Must be kept at a fixed reference point (zero to the level of Foramen of Monroe)

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3
Q

Name the anatomical landmark for insertion of ICP monitor

A

Kocher’s point (1~2cm anterior to the coronal suture in the mid-pupillary line)

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4
Q

List the complications of ICP monitor insertion

A

Mechanical complications
* Breakage of catheter
* Dislocation of the bolt
* Removal of the catheter
Haemorrhage
Infection
ICP drift

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5
Q

What is normal CSF pressure on LP

A

8~24 cm

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6
Q

What is normal CSF cell count on LP

A

No red cells
<5 white cells

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7
Q

What is normal CSF protein count on LP

A

0.15-0.45 g/L

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8
Q

What is normal CSF glucose count on LP

A

70% serum glucose

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9
Q

List the most frequent indications for LP

A

Meningitis
Encephalitis
Subarachnoid haemorrhage
Idiopathic intracranial hypertension
Guillain-Barré syndrome
Multiple sclerosis

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10
Q

List the contraindications for LP

A

Intracranial neurological disease / raised ICP
Obstruction
Coagulopathy
Infection

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11
Q

When should you do a scan before LP

A

Focal signs
Papilloedema
Seizure
Impaired consciousness
Immunosuppression

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12
Q

List the complications of an LP

A

Headache worse on sitting/standing (risk reduced by smaller/blunt needles)
Backache
Infection
Nerve root irritation during the procedure
Venous sinus thrombosis

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13
Q

How is the L3/4 space identified for LP

A

Imaginary line from tip of the right anterior superior iliac crest perpendicular to the spine

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14
Q

How many samples are taken for LP

A

At least 3 samples in sterile plain bottles and one in fluoride tube for glucose
* Samples 1 and 3 to microbiology for cell count and culture
* Sample 2 and fluoride to biochemistry for protein and glucose. Wrapped in silver foil if investigating for SAH
* Cytology if investigating for malignancy

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15
Q

What is CSF positive for 14-3-3?

A

Creutzfeldt-Jakob disease

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16
Q

List the common indications for placement of VAD

A

Hydrocephalus
Intrathecal administration of chemotherapy
Adjuct to III ventriculostomy (aspirate CSF should there be concerns re ventriculostomy function)

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17
Q

What site is selected for placement of ventricular catheter in EVD

A

Frontal horn of the right lateral ventricle

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18
Q

What is the site for burr hole in EVD

A

Kocher’s point: 1~2 cm anterior to coronal suture in mid-pupillary line (3cm from the midline)
Alternatively: 11cm superior and posterior to the nation and 3cm from the midline

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19
Q

Give the anatomical landmark for targets for ventricular catheter

A

Intersection of the lines from ipsilateral medial canthus and the ipsilateral EAM at 90 degrees to the cortex

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20
Q

List the complications for EVD

A

Infection
Intraparenchyma/Intraventricular haemorrhage
Extra-ventricular placement

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21
Q

How long can an EVD catheter stay in for

A

7 days

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22
Q

When would bilateral EVDs be needed

A

Acute hydrocephalus from III ventricle lesions eg. colloid cysts

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23
Q

What is the depth of the frontal horn of the lateral ventricle from the skull

A

5cm

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24
Q

Head Injury - what should be clearly and accurately documented on initial assessment

A

Time and mechanism of injury
On scene GCS
Any delay in achieving adequate ventilation
GCS prior to intubation
Pupil size and reflexes

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25
Head Injury - what blood investigations should be sent for on initial assessment
FBC Electrolytes Clotting screen Sample for transfusion (group and save / cross match)
26
What should be ordered for head injury patients on warfarin
Prothrombin complex concentrate
27
Describe the CT appearance of cerebral contusions
Intraparenchymal patchy hyperdensity most commonly in the frontal and temporal lobes
28
Head injury - what happens when patient is unable to consent for surgery due to consciousness level / capacity
Surgeon should act in the best interest of the patient (consent form 4)
29
List the indications for urgent surgery in head injury
Extra-axial haematoma (CT mass effect + low consciousness level) Haemorrhagic contusions Penetrating injury Depressed skull fracture Diffuse axonal injury (ICP monitor)
30
What is important to ensure when using head clamp for trauma craniotomy
Pins are not placed over any skull fractures
31
Trauma craniotomy - if the brain is very contused / swells out of the craniotomy following evacuation of the haematoma, what should be done
Dura should not be closed, the bone flap may be left out
32
What is the anatomical relationship between coronal suture and the motor strip
Motor strip lies 2.5cm behind coronal suture
33
When inserting an EVD prior to posterior fossa surgery, where should the entry point for the occipital burr hole be
3cm lateral, 6cm cranial to the inion EVD inserted targeted at the contralateral medial canthus
34
Describe the positioning and support for frontal burr holes
Position - supine with head in neutral position Support * Horseshoe / head ring. * Pins if craniotomy likely to be needed
35
Describe the positioning and support for parietal/temporal burr holes
Position - supine with neck rotation and sandbag under the shoulder. * Avoid heads up positioning in CSDH Support * Horseshoe / head ring. * Pins if craniotomy likely to be needed
36
Describe the positioning and support for occipital burr holes
Position - prone with some flexion of the head. Support - head pins
37
Where should the exit site for subgaleal and extraventricular drains be
5cm away from the wound
38
How should bleeding from skull addressed
Bone wax
39
What size blade is used for cruciate durotomy
Size 11
40
How can post-op haematoma be prevented during surgery
Meticulous haemostasis Before closing, ask anaesthetist to bring BP up to pre-op levels. (Haemostasis at higher BP)
41
List the steps to assessing post-op haematoma
ABC GCS - is this less than the pre-op status? Wound - is it full, tense/blood seeping through the wound? Drains - full/blocked? Lateralising neurology - locates haematoma
42
How is the age of blood on MRI assessed
Hyper-acute - T1 isodense T2 dark Acute - T1 bright T2 dark Sub-acute - T1 bright T2 bright Chronic - T1 dark T2 dark
43
What is the appearance of very acute blood with ONGOING active haemorrhage on a CT scan?
Mixed density, mostly hyperintense (lighter) but some areas of hypointensity (darker)
44
What is the appearance of acute blood that has stopped actively bleeding on a CT scan?
Uniformly hyperintense (lighter) than brain tissue
45
What is the annulus fibrosis made of
Type 1 collagen
46
What is the nucleus pulposus made of
95% water, proteoglycans, type 2 collagen
47
What is the embryological origin of nucleus pulposus
Notocord
48
Describe where the anterior longitudinal ligament is
Anterior edge of the vertebrae and extends from the skull base to the sacrum
49
Describe where the posterior longitudinal ligament is
Posterior edge of the vertebral bodies and forms the anterior wall of the spinal canal from C2 to sacrum
50
What is the cranial extension of the posterior longitudinal ligament
Tectorial membrane
51
Why is ligament flavum yellow
Rich in elastin
52
Describe where the ligamentum flavum is
Runs between the laminae, extends from C2 to S1
53
List the ligaments of the spine
Anterior longitudinal ligament Posterior longitudinal ligament Intertransverse ligament Interspinous ligament Supraspinous ligament Ligamentum flavum
54
What does the posterior longitudinal ligament become at C2 level
Tectorial membrane
55
List the ligaments at C1/C2
Anterior longitudinal ligament Posterior longitudinal / tectorial membrane at C2 Cruciate ligament Transverse ligament Apical ligament Alar ligament Atlantooccipital membrane Atlantoaxial membrane
56
Where is the transverse ligaments of C1 and what does it do?
Runs between the inside faces of the C1 lateral masses behind the odontoid peg Prevents C1/C2 subluxation
57
Where is the alar ligaments of C1/C2 and what does it do?
Runs from the side of the odontoid peg to the skull base Resists side to side movements of the head
58
Moral spine movement - how much can the spine rotate
C1/C2: 45 degrees C3-T8: 7~10 degrees Rest: 4 degrees
59
Moral spine movement - how much can the cervical spine flex/extend
C0/1 15 degrees C2/3 7 degrees C5-7 20 degrees
60
What anatomical landmark can be used to assess the sagittal and coronal balance of spine
C7 plumb line A plumb line dropped from the middle of C7 vertebrae should pass through the back of the L5/S1 disc space - sagittal balance Bisect the pelvis - coronal balance
61
Define the Dennis 3 column theory of spinal stability
Three anatomical columns. If one is damaged, the injury is stable. If two are damaged is unstable. Anterior - anterior 2/3rds of the vertebral body + ALL Middle - posterior 1/3rd of vertebral body + PLL Posterior * Pedicles * Lateral mass * Lamina * Spinous and transverse processes
62
Does the C7 vertebrae have a transverse foramen
Yes. But the vertebral artery does not run through it.
63
Give the Punjabi and White definition of spinal instability
The loss of ability of the spine under physiological loads to maintain relationships between vertebrae in such a way, that spinal cord or nerve roots are not damaged or irritated and deformity or pain does not develop.
64
Does lumbar disc protrusion affect the nerve above or below the disc
Below
65
Do nerve roots exit above or below the pedicle
Below
66
What does a lateral/posterolateral disc prolapse compress
The transiting nerve root as it appears from the thecal sac and travels down the spinal canal IE: L5/S1 prolapse will press on the transiting S1 nerve root but spare the exiting L5 root
67
What will a far-lateral disc prolapse compress
The exiting nerve root within the foramen at the disc level IE: L5/S1 far-lateral disc will compress the exiting L5 nerve root in the L5/S1 foramen but will not involve the transiting S1 nerve root
68
95% of lumbar disc prolapse occur at which level? Which age group and gender are most affected?
L4/L5 and L5/S1 level Most common between 30 and 50 Male preponderance
69
DIsc prolapse at which level causes foot drop
L4/5 with compression of L5 nerve root
70
List the symptoms of S1 root compression
Pain + numb form posterior thigh and calf to lateral heel and foot Diminished ankle jerk Weak plantar flexion Limited straight leg raising
71
List the symptoms of L5 root compression
Pain down postero-lateral thigh, calf, and dorsum of the foot Numb on the outside of shin, foot, and great toe Weakness in extensor hallucis longus, foot drop Restricted straight leg raise No reflex loss specific to this level
72
List the symptoms of L4 root compression
Pain down anterior thigh and medial leg Numb above and below the knee Weak knee extension Depressed knee jerk Straight leg raise may be normal
73
How much is straight leg raise (Lasegue's sign) positive in L5/S1 involvement
83% Reproduces radicular symptoms in the leg Ankle dorsiflexion can augment the pain
74
Described the crossed straight leg raise (Fajersztajn test)
SLR on the asymptomatic leg causes pain in the opposite leg More specific of disc prolapse
75
What is the femoral stretch test (reverse SLR) positive in
L2, 3, 4 root compression
76
How to measure urinary retention in CES
Post-void residual volume
77
Distinguish CES vs conus lesion
Radicular pain * CES - More severe * Conus - Less severe Back pain * CES - less * Conus - more Sensory symptoms * CES - saddle area, asymmetrical * Conus - perianal area, symmetrical Sensory dissociation * CES - No * Conus - Common Motor weakness * CES - asymmetrical * Conus - symmetrical Reflexes * CES - reduced * Conus - increased Sphincter dysfunction * CES - late * Conus - early Bulbocavernosus reflex * CES - diminished * Conus - increased Impotence * CES - less frequent * Conus - frequent
78
List the red flag features in CES
Severe low back pain Bilateral sciatica Saddle/genital numbness Bladder, bowel, sexual dysfunction Not passing urine for 6 hours
79
Distinguish CES with retention (CESR) and incomplete CES (CESI)
CESR - painless retention with overflow incontinence CESI - altered urinary sensation, loss of desire to void, poor stream, strain when passing urine
80
List the non-surgical treatment approaches to disc herniation
Bed rest (<4 days) Activity modification - avoid heavy lifting, prolonged sitting, or extremes of lumbar spine movement NSAIDs, opioids, gabapentin, pregabalin, amitriptyline Physical therapy
81
List the surgical treatment approaches to lumbar disc prolapse
Epidural steroid injection (interlaminar, transforaminal, caudal) Microdiscectomy
82
List the indications for elective surgery in lumbar disc prolapse
Painful motor deficit Progressive symptoms Lack of symptom control Recurrent disease
83
List the independent predictors of good outcome following discectomy
No pre-operative co-morbidity Sciatica <6 months duration No back pain Absence of previous surgery No work-related / compensation issues Positive SLE without back pain Crossed leg pain Radicular pain to the foot Loss of reflexes Type of disc herniation
84
List the complications of lumbar discectomy
CSF leak from dural tear Neural injury with persistent deficit Bladder/bowel, sexual dysfunction Infection, discitis Residual disc Recurrent disc herniation (15%) * Recurrence in the immediate post-operative period is seen in up to 8% cases Bleeding - epidural haematoma Peridural fibrosis Back pain Abdominal vessel injury (aorta/iliac) Wrong level surgery
85
What is the first choice for investigating CES
MRI
86
In adults, where is cerebral ischaemic injury most marked
Arterial watershed areas eg. borders of anterior and middle cerebral arteries Summer's sector of the hippocampus Basal ganglia Purkinje cell layer of the cerebellum
87
What bone is often fractured in extradural haemorrhage
Squamous temporal bone
88
List the grading for traumatic axonal injury
Grade 1 - axonal damage Grade 2 - axonal damage + haemorrhagic lesions in corpus callousum Grade 3 - axonal damage + haemorrhage lesions in corpus callousum and brainstem
89

Neurosurgery (4 decks)

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