Consult Page 38M pw severe pain with severe trauma to the back Initial Imaging Walking Thoughts ■ What was the mechanism of injury? Was it witnessed? ■ What treatments have been given en route to the hospital? ■ Has the patient been evaluated by the trauma team? ■ What other injuries does he have, and which is the most critical? Is he hemodynamically stable? ■ Any…
Consult Page 60 year old male pedestrian struck, found to have C1 burst fracture Initial Imaging Walking Thoughts ■ What is the mechanism of injury? ■ Does the patient have any neurological deficits? ■ What is the exact fracture pattern on imaging? Is this a stable or unstable fracture? ■ Are there any other injuries, including other spinal fractures? ■ Is a hard cervical collar in…
Consult Page A 75 year old man with syncope and fall with dens fracture Initial Imaging Walking Thoughts ■ Does the patient have any other injuries? ■ Is the patient hemodynamically stable? ■ What is his neurological exam? ■ Is he wearing a cervical collar? ■ Is the fracture unstable? Will he need surgery? ■ What are his medical comorbidities? Does he have any bleeding disorders?…
Consult Page TRAUMA; 24M gunshot wound to the head, GCS 7 in field Initial Imaging Walking Thoughts ■ What is the current GCS and neurological exam? ■ Is the patient hemodynamically stable? ■ Are there any additional injuries or other gunshot wounds (GSW)? ■ Is the patient on anticoagulation? If so, have reversal agents been given? ■ Are coagulation labs available or pending? ■ What is…
Consult Page STAT MVC trauma, 2Y with GCS3 Initial Imaging Walking Thoughts ■ What is the patient’s current neurological exam? Is the patient intubated? ■ Why is the patient’s GCS so poor? Is the patient currently paralyzed or sedated? ■ Do the imaging findings explain the physical exam findings? ■ Does the patient have any other injuries? ■ Does the patient have any lab abnormalities that…
Consult Page 69F altered after a fall, CT brain bleed. Initial Imaging Walking Thoughts ■ What is the current GCS of the patient? Is she able to protect her airway? ■ What is the baseline function of the patient? ■ Does the patient take anticoagulation? If so, have reversal agents been given? ■ Are coagulation labs available or pending? ■ What are the patient’s medical comorbidities…
Consult Page 77 year old woman with syncope and fall 3 days ago with intracranial bleed on CT Initial Imaging Walking Thoughts ■ What was the etiology of her syncopal event? Why is she presenting 3 days after the fall? ■ What is the patient’s baseline functional status and neurological exam? ■ What is her current neurological exam? ■ Is the pattern of the subarachnoid hemorrhage…
Consult Page 3 year old girl status post fall with head strike, worsening GCS, CT with large brain bleed Initial Imaging Walking Thoughts ■ What is the patient’s current GCS score and neurological exam? ■ Does the patient have any other injuries? ■ Is the patient hemodynamically stable? ■ What is her past medical history? Does she have any bleeding disorders or take any anticoagulants or…
You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log in here
44.1 Introduction: airliners and operating rooms After the Institute of Medicine reported up to 98,000 annual deaths in the United States from medical errors, a new focus on error causation and its possible amelioration began . As many as two-thirds of all errors were shown to arise from dysfunctional team dynamics, rather than incompetent care . More recent data in the United States continues to reveal…
43.1 Introduction Evidence-based medicine (EBM) has been described as a search for a science of clinical care . Many of its core concepts and methods in use today can be traced to the field of epidemiology and the pioneering efforts of Archie Cochrane and Alvan Feinstein in the 1970s. Both promoted randomized controlled trials (RCTs) to reduce bias in medical practice. The Cochrane Collaboration was named…
42.1 Introduction Intraoperative neurophysiology (ION) evolved from existing technologies in evoked potentials, electromyography (EMG), and nerve-conduction studies to give real-time information for surgeons performing procedures that may imperil nervous system structures. The usage of ION has spread over time from skull-based surgeries—monitoring acoustic nerve function with brainstem auditory evoked potentials—to the now more common usage in adult spinal surgeries. Every surgery carries an inherent risk, however…
41.1 Introduction Intraoperative neurophysiology normally improves patient safety, but like any medical procedure it can cause inadvertent harm. This chapter reviews electrical and procedure-specific safety, infection control, and essential performance in terms of potential hazards and their means of protection. 41.2 Electrical safety Electrical dangers inherent to the devices, electrodes, stimuli, and materials employed for neurophysiologic testing include shock, hazardous output, electrode burns, and fire. 41.2.1…
40.1 Anesthesia: safety, comfort, and facilitation of the procedure The anesthesiologist is a key member of the team conducting the intraoperative neurophysiology (ION), whether the monitoring is surgical in the operating room, or procedures such as neurovascular embolization, in the interventional radiology suite. The anesthesiologist works to insure the safety and comfort of the patient through management of the patient’s medical issues (e.g., heart disease and…
39.1 History Despite clear advantages over complex repair-strategies of irreversible structural changes, selective dorsal rhizotomy (SDR) is still not recognized as an early prophylactic surgical option in most current guidelines. This striking reluctance can be understood by examining the fraught history of SDR. Initial attempts at using SRD to treat spasticity date to the early 20th century, yet due to an allegedly high rate of intraoperative…
38.1 Introduction When chronic pain becomes refractory to medications and all available medical arsenal, one can have recourse to functional neurosurgery. Chronic pains are of many kinds. Main varieties include pain due to the alteration of the musculoskeletal apparatus, complex regional pain syndromes (CRPSs), pain from visceral or vascular origins, pains related to neoplasia (frequently the consequence of the association of several of the previously stated…
37.1 Introduction Spinal cord stimulation (SCS) is a common therapy used to treat medically refractory neuropathic back and other limb pain syndromes . Historically, placement of SCS leads required direct interaction with the patient to ascertain where the patient felt paresthesias during stimulation. Obtaining this feedback necessitated the use of a sedative anesthetic technique and waking the patient during periods of the surgery. The patient needed…
36.1 Introduction Persistent vegetative state (VS) (PVS) was first described as wakefulness without awareness . VS, a clinical entity known as a coma vigile , apallic syndrome , or PVS , includes complete unawareness of the self and environment, usually accompanied by variable sleep–awake cycles, with preserved spontaneous respirations, digestion, and thermoregulation. Giacino et al. proposed the concept of the minimally conscious state (MCS) that is…
35.1 Introduction Spasticity should only be treated when excess of tone leads to functional impairment, discomfort, pain, and deformities. Functional neurosurgery can be a recourse when spasticity cannot be controlled by physical therapy, relaxant medications, and botulinum toxin injections. Spasticity is defined as a velocity-dependent resistance to passive movement of a joint and its associated musculature, and is characterized by hyperexcitability of the stretch reflex. Disorders…
34.1 Introduction The full potential of intraoperative neurophysiology is realized during the performance of so-called functional neurosurgical procedures. During these interventions, therapeutic lesions or stimulating electrodes are stereotactically placed within deep brain structures to treat movement disorders, such as Parkinson’s disease (PD), essential tremor (ET) and dystonia, mood and affective disorders, or chronic neuropathic pain. The deep location of these structures precludes direct surgical approaches. Instead,…