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Common Neurosurgical Problems versus Urgent

Surgical Referrals

Emily D. Friedman, M.D.Pinnacle Neurocare, Inc

Scope of Practice

Ø Infants

Ø Pediatrics

Ø Adults

ØGeriatric

The ^ Neurological Exam� How do they greet you when you walk into the room?

� Speech and affect� Gait/movement patterns� Cranial nerves (II, III, VI, VII, VIII, XII)� Motor strength� Sensation

� Reflex exam

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Spinal Disorders

Ø 2nd most common reason for PCP visit

ØMajor source of disability in the U.S. – costing the taxpayer billions

Ø New initiative - “Choosing Wisely” campaign

Spine Differential Diagnosis

Ø Discogenic pain/tear –

ØHerniated discØ LumbarØ Cervical

Ø Stenosis

Ø Spondylolisthesis/Deformity

Ø Fracture

Work-up of Spinal Pain

ØHistory – characteristics, timing

Ø Exam – spasm, weakness, sensory/reflex loss,

ØDiagnostic Testing –Ø XR is the FIRST test!Ø MRI/Myelo CT for further work-up

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Cutaneous Root distribution

Cervical Root Levels

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Cervical herniated disc MRI

Lumbar Stenosis

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Lumbar Stenosiscross-section view

Spondylolisthesis

Osteoporotic Fracture

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“ Own the Bone” Quality Improvement Program

� Missed opportunity to manage Osteoporotic Fracture

� Initial fracture is a sentinel event!� 1 VF - 5 times increase in 2nd VF

� 2 VF – 12 times increase

� The program has identified 10 prevention measures, provides tools and models of a fracture liaison service to coordinate care.

Myelopathy vs Radiculopathy

ØCervical stenosis – distinguish myelopathy vsradiculopathy or combination

Ø Lumbar stenosis – radiculopathy ONLY

Ø BEWARE – over-read of MR by radiologist

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Spinal cord compression by disc

Treatment of Spinal Pain

Ø Medications – NSAIDS, analgesics, topical ointments, muscle relaxers

Ø PT – after acute phase (within first few days)Ø Dry needlingØ AcupunctureØ MassageØ Core strengthening

Ø Role of DC, DO – spinal manipulation

v Miscellaneous: inversion table, bracing, topicals, activity restrictions – home and work, weight loss

When to refer?

ü Your “gut” tells you it’s more than routine pain

ü Leg/Arm pain primary, especially if weak

üUrinary retention or incontinence (spillover)

ü L’Hermittre – “electric shock” down body

ü True gait disorder

üMR abnormal: “severe stenosis”, “Cord compression/deformity”, “root compression” “tumor”

ü INSURANCE APPROVAL

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Surgery vs Additional Treatment

� Depends on diagnosis, risk/benefit ratio, general medical health

� Neurosurgical referral does not obligate surgical treatment

� Risks of non-operative care taken into consideration

Postop 2 level cervical discectomy/fusion

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Outcomes of surgery

� Pain relief

� Functional improvement/ QOL

� Long-term effects

� Complications

Diagnostic Traps

� Diabetic Neuropathy

� Femoral Neuropathy

� Fibromyalgia

� Neurologic disorders: CMT, Cerebellar atrophy, MS, ALS

� Psychological overlay

Image of cerebral ventricular system from: https://en.wikipedia.org/wiki/Ventricular_system

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Ventricular system

Image of cerebral ventricular system:https://en.wikipedia.org/wiki/Ventricular_system

Hydrocephalus

• Pediatric• Shape of head• Change over time• Anterior fontanelle tension

• Adult• Headache• Sudden alteration of consciousness

Stroke, tumor, brain bleed

• Geriatric• Normal Pressure Hydrocephalus (NPH)

Stroke, tumor, brain bleed

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Tumor causing outflow blockage

Normal Pressure Hydrocephalus

Brain Tumor

� Benign vs. Malignant

� Symptoms� H/A – especially new onset or “different”� Neuro deficit: facial droop, speech problems, weakness

(uni-, visual loss)� Seizure

� Diagnostic Tests� MRI, CT

� Neuro/surgical treatment -

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Glioblastoma with Cerebral Edema

Outcomes

� Pediatric –� Benign vs malignant

� Adults� Meningioma, cranial nerve schwannoma� Glioma

� Geriatric� Metastatic� Malignant gliomas

Pediatric Ventricular Tumor/HC

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Cerebral Hemorrhage and Stroke

� Ischemic � Athrosclerotic� Embolic – Afib, Valvular, Fat� Infectious

� Traumatic� Epidural vs Subdural vs Intracerebral

Subdural Hematoma CT/MRI

Intracerebral Hemorrhage

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Cerebral Hemorrhage and Stroke

� Iatrogenic� Anticoagulants

� Tumor� Malignant vs AVM

� Aneurysmal

Cerebral Hemorrhage and Stroke

� Treatment� Dependent on diagnosis� Medical

� Thrombotic/Embolic – TPA (in window)

� Interventional Radiology

� Heparin anticoagulation

� Treatment for primary diagnosis

� Surgical� Burr holes/craniotomy for hemorrhage

� Craniotomy for tumor and AVM resection, aneurysm

Pharmacology - Spinal

• Medications• NSAIDS• Muscle relaxers• Steroid – oral and IM• Analgesics – non-narcotic, narcotic• Adjuncts – seizure meds, nerve “stabilizers”,

antidepressants• Topicals

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Oral Steroids

Oral Steroid Side Effects

Hypertension Headache

Moon Face/Fat deposits –neck… Acne

Weight gain Increased appetite

Insulin resistance / Poor diabetes control

GI problems/Exacerbation of pre-existing GI problems

Insomnia Skin changes

Mood changes Dry scalp

Pharmacology – Seizure Disorder

� Type of seizure may determine drug choice � First seizure – usually not treated

� Febrile seizure

� May require treatment if structural lesion on imaging

� Partial vs Generalized� Grand mal – more risky- 16-60% recurrence

� Acute: Valium or Versed, Cerebyx loading

� Long acting: Dilantin, valproic acid, Felbatol, topiramate, zonisamide, Lamictal, Keppra, Tegretol (carbamazepine)

Drug treatment of Status Epilepticus

� 1st line: fosphentoin in ER, IV Break Status!Ativan 2 mg, may repeat

Maintenance: Keppra(Levetiracetam)

Valproate

Dilantin

Other options: Vagus nerve stimulation

Ketogenic diet

Cannabis derivatives

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Drug treatment for mixed Seizure Disorder

� Grand mal, myoclonic, partial

� Valproic acid

� Dilantin or Tegretol as second choices

Helpful References!!

References

� Back doctors not “Choosing Wisely” when it comes to spinal imaging. (2016). Lippincott's The Back Letter, 31(5), 51,58.

� Drugs.com. (2016). Prednisone Uses, Dosage, Side Effects, Warnings - Drugs.com. Retrieved from https://www.drugs.com/prednisone.html

� The evidence on surgery for spinal stenosis: Beauty is in the eye of the beholder. (2016). Lippincott's The Back Letter, 31(5), 52.

� Ghogawala, Z., Dziura, J., Butler, W. E., Dai, F., Terrin, N., Magge, S. N., … Benzel, E. C. (2016). Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. New England Journal of Medicine, 374(15), 1424-1434. doi:10.1056/nejmoa1508788

� Mandatory consultation with a nonoperative specialist prior to fusion surgery. Effective or not? (2016). Lippincott's The Back Letter, 31(5), 49-58.

� Matz, P. G., Meagher, R., Lamer, T., Tontz, W. L., Annaswamy, T. M., Cassidy, R. C., … Witt, J. (2016). Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. The Spine Journal, 16(3), 439-448. doi:10.1016/j.spinee.2015.11.055

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References

� Medical Research Council (Great Britain), & University of Edinburgh. (1990). Aids to the examination of the peripheral nervous system. London, United Kingdom: H.M. Stationery Off.

� Musacchio, M., Lauryssen, C., Davis, R., Bae, H., Peloza, J., Guyer, R., … Leary, S. (2016). Evaluation of decompression and interlaminar stabilization compared with decompression and fusion for the treatment of lumbar spinal stenosis: 5-year follow-up of a prospective, randomized, controlled trial. Inte J Spine Surg, 10, 1-10.

� Schroeder, G. D., Kepler, C. K., Kurd, M. F., Vaccaro, A. R., Hsu, W. K., Patel, A. A., & Savage, J. W. (2015). Rationale for the surgical treatment of lumbar degenerative spondylolisthesis. Spine, 40(21), E1161-E1166. doi:10.1097/brs.0000000000001116

� Treatment of last resort. (2016). Lippincott's The Back Letter, 31(5), 49,58-59.

� Vapiwala, N. (2001). Brain Tumor, Glioblastoma Multiforme, Frontal Lobe | OncoLink. Retrieved from https://www.oncolink.org/healthcare-professionals/oncolink-university/general-oncology-courses/md2b-electronic-cases/brain-tumor-glioblastoma-multiforme-frontal-lobe

� Wikipedia. (2016). [cerebral ventricular system]. Retrieved from https://en.wikipedia.org/wiki/Ventricular_system

References� Musacchio, M., Lauryssen, C., Davis, R., Bae, H., Peloza, J., Guyer, R., … Leary, S. (2016). Evaluation of

decompression and interlaminar stabilization compared with decompression and fusion for the treatment of lumbar spinal stenosis: 5-year follow-up of a prospective, randomized, controlled trial. Inte J Spine Surg, 10, 1-10.

� Wikipedia. (2016). [cerebral ventricular system]. Retrieved from https://en.wikipedia.org/wiki/Ventricular_system.

� Dr Balaji Anvekar Neuroradiology Unit, S P Institute of Neurosciences, Solapur, Maharashtra, INDIA 2011

� Imaging in Normal Pressure Hydrocephalus Author: James A Wilson, MD, MSc, FRCPC; Chief Editor: James G Smirniotopoulos, MD

� Lumbar Intervertebral Disc Endoscopy, Ștefan Cristea1, Florin Groseanu1, Andrei Prundeanu1, DinuGartonea1, Andrei Papp1, Mihai Gavrila1 and Dorel Bratu1, [1] Clinic of Orthopaedic and Trauma Surgery, St. Pantelimon Hospital, Bucharest, Romania

� © 2004 - 2016 www.necksolutions.com

� Carette, S., & Fehlings, M. G. (2005). Cervical radiculopathy. New England Journal of Medicine, 353(4), 392-399.

References

� PortL, CenterJ, Briffa NK, Nguyen T, Cumming R, Eisman J. Osteoporotic Fracture: missed opportunity for intervention. Osteoporosis International, 2003;14(9):780-4

� Anderson P, Reitman C, Jeray K, Own the Bone: Spine Practitioners’ Opportunity in Managing Patients with Fragility Fractures. SpineLine, 2015;16(4): 12-17