Anticoagulants!

(+classic CV-RF)

CT ⇒ exclusion DDx (aneurysm, AVM, tumor)

⇒ DYNAMIC EVALUATION! (repeat)

1. Medical Tx
1. vital function
2. ↓ICP
3. Anti-hypertensive drugs
4. Correct Coagulation
2. Surgery

1. Clinical
• ↑ICP
• Neurolog. detoriation
• <50y
2. Imaging:
• 10-30 cm3
3. Location:
1. Lobar
2. Cerebellum

adult → supratentoriell

children → infratentoriell (brainstem + cerebellum)

benign → mass effect = tumor volume

malignant → mass effect > tumor volume (marked perilesional edema)

• benign characteristics (Øinvasion, well delineated, homog, minimal edema)
• ↑vascularized
• +/- calcification
• mass effect

T

neuroepithelial

1. Major analgesics (opioids) → respiratory depression! ⇒ give minor analgesics
2. Benzos (for seizures) → anti-epileptics instead

1. Decompression = Tumor removal
2. obtain Histo
3. Fix cerebral function + CSF course

⇒ Piecemeal removal (Øen-bloc) via microsurgery

(palliative tx → ↓iCP)

F

1. <65y
2. ≥1y progression-free
3. Ø irrevers. neuro detoriation
4. high enough performance index (karnofsky score

glioblastoma → any combination (surgery, RT, chemo)

meningioma → Removal: total (surgery) OR partial (surgery +RT)

‣

💬

Surgery

1. Trans-sphenoidal
2. Craniotomy
3. Radiosurgery (gamma knife)

⇒ ❗ hypopituitarism

1. Spinal shock

⇒ DOWNWARD from lesion ⇒ COMPLETE LOSS OF FUNCTION:

‣

💬

• C1 - C4: Cervical plexus (muscles of the neck and diaphragm)
• C5 - T1: Brachial plexus (muscles of the upper limb)
• T2 - T12: Intercostal muscles, subcostal muscles, abdominal wall muscles
• T7 - L1: Abdominal wall muscles
• L1 - L4 (+ram. S3): Lumbar plexus
• L5 - S3 (+ram. L4): Sacral plexus
• L2 - S5: Cauda Equina (muscles of the lower limb and innervation of the rectum, bladder, and genitalia)

→ depending on type of spinal cord syndrome ⇒ see neuro

1. ØMOTOR: flaccid paralyis +
• Øreflex
2. ØSENSORY: sensory loss
3. ØAUTONOMIC: bladder / bowel
2. Local signs
1. pain + paravertebral contracture
2. skin + ST injury (wound, contusion)

1. MRI ⇒ Ø in emergencies
2. CT (vascular → angio-CT; spinal cord compression → Myelo-CT)
3. Xray ⇒ for surgical approach (detects only bone)

1. Immobilize (esp Ø flexion)
2. DVT prophylaxis
3. Manage autonomic dysfunction
‣
💬
• Hypotension
• Vasodilatation
• Poikilothermia
• Paralytic ileus → NG tube
• Urinary retention → catheter
4. QUICK transport ⇒ NEUROSURGERY

1. Decompression
2. Stabilzation
3. Prevent Infection (+worsening)

1. Spine INSTABILITY (→ neuro worsening)
2. COMPRESSION: spinal cord / root
3. OPEN Wound (CSF fistula)

1. Open → clean, hemostasis, suture
1. gunshut through abdomen? → sepetic risk
2. gunshot through ST → only eplore if surgery indication
2. C1-C2 lesion ⇒ Surgery within first 6 weeks!
1. Jefferson (C1) → ligament intact?
1. intact → occipto-cervical fusion 📷
2. Øintact → Halo vest 📷
2. Odontoid (Dens C2)
1. post. aproach → fusion C1-C3
2. ant aproach→ screw C2 body + dens 📷
3. luxation? → ablation + C1-C3 fusion
3. C3-C7 lesion

⇒ Ant. / post. or combined(complex) approach

⇒ depends on largest lesion! (i.e. ant →ant. approach)

4. Thoracolumbar lesion (esp. compression of nerves)
1. > 75% height → Corset
2. 50-75% → Vertebroplasty / kyphoplasty 📷
3. <50% Distraction + Fusion 📷 +/- vertebroplasty
‣
💬

1. Nerve damage
2. CSF fistulas
3. fusion system malfunction / instability
4. General complication: bleeding, infection

• Disc protrusion: protrusion of the nucleus pulposus through the annulus fibrosus
• Disc herniation/extrusion/prolapse: complete herniation of the nucleus pulposus through a tear in the annulus fibrosus
• Disc sequestration: extrusion of the nucleus pulposus and separation of fragments

• trauma
• occupational
• weight distribution problem
• posture
• tall / obese
• genetic

1. Radiculopathy:
• Acute severe radicular pain (stabbing / electric shock) with radiation

→ unilat. LMN signs + sensory loss in dermatome

• Cervical:
• ↓mobility,
• torticolis,
• Spurling sign 📷 + Lhermitte

‣

💬

Spurling sign: 📷

vertex compression - ↑ radiating pain

Lhermitte signs:

The Lhermitte sign is an electric shock-like sensation that travels down the spine and into the limbs when the neck is flexed.

• L5 radioculopathy (L4-L5):
• Lumbago (vertebral syndrome) ⇒ Lasegue +
• Pain & Paresthesia in dermatome (toes 1-2 (-4))
• Fibular nerve paresis → cant walk on heels
• normal reflexes
• S1 Radiculopathy (L5-S1):
• Lumbago (vertebral syndrome) ⇒ Lasegue +
• Pain & Paresthesia in dermatome (popliteal space + toes 3-5)
• Tibial nerve paresis → cant walk on toes
• ↓/Ø Achilles t. reflex
• Cauda equina syndrome (🚑 ) (large median L2-L5)
• Paraparesis + Saddle anesthesia
• Ø Patellar + Achilles
2. Myelopathy (esp. cervical) ⇒ Spinal cord syndromes (UMN + sensory + autonomic)

MRI

(CT, myeloCT, Myelography, Xray)

1. Immobilization (+devices)
2. Pain control
3. Physio
1. Inversion therapy 📷
‣
💬

1. Refractory conservative tx
2. FND
3. severe pain
4. compressive spinal emergencies
1. Cauda equina syndrome
2. spinal cord syndrome (myelopathy)
5. Clinic + imaging concordance

cervical → ant approach 📷

lumbar → minimal invasive (endoscopic📷/ tubular📷 discectomy, microdiscectomy📷)

1. Extradural (vertebra)
2. intradural (schwannoma, meningioma)
3. Intramedullary (glial origin, non-glial)

⇒ COMPRESSION:

1. Pain (central, radicular, Lhermitte)
2. FND ⇒ LMN & UMN signs below
3. Sensory deficit below ⇒ depending on spinal cord syndrome
4. Autonomic dysfunction

Indication: Radio-resistance, Øneuro-def.

Contraindication: low life expectancy, multiple lesion, altered general status

Extra-dural (vertebral):

⇒ #1 Circumferential cord decompression (+ Reconstruction + stabilization) 📷

⇒ Vertebroplasty w/ PMMA cement injection 📷 ⇒ decompression (pain relief) + antitumoral effect

Intra-dural:

Microsurgery → total resection (post. approach w/ laminotomy/-ectomy) 📷

Intra-medullary: