The document provides an overview of preoperative evaluation and surgical planning for various neurosurgical procedures. It discusses evaluating the patient history and examination, ordering relevant labs and imaging, reviewing the procedure with anesthesia, selecting the appropriate surgical approach, and ensuring necessary equipment and staff are available. The goal is to thoroughly prepare for any scenario that may occur during surgery.

1. Surgical planning overview
Youmans Chapter 25

2. Preoperative evaluation
• Patient history
– Symptom time course
– onset represent central features of the suspected
disease
– complement a focused neurological history
– preoperative deficits will be critical to
establishment of a baseline with which to
compare the patient’s postoperative
examination findings
• Physical examination

3. Preoperative evaluation
• Patient history
– Side of hand prominence
– patient’s past medical and surgical history
– medications, allergies
– pertinent social or familial considerations
– Complete review of systems
– patients currently take anticoagulant or antiplatelet
agents : stop at least 1 wk

4. Preoperative evaluation
• Physical examination
– The physical and neurological examination
– The complete neurological examination : mental status,
speech ability, cranial nerve function (including the first
cranial nerve), motor and sensory function, reflexes, and
cerebellar and gait testing
– sellar or suprasellar disease exists : visual field and acuity
– spinal disease : Rectal examinations for tone, volition,
sensation, and the bulbocavernosus reflex

5. Preoperative evaluation
• Laboratory
– B-HCG for woman of childbearing age
– Baseline renal function and electrolyte levels
– Infection : elevated WBC , positive cultures, elevated ESR,
or elevated CRP
– Hematology disease(anemia, coagulopathy) : platelet
count, prothrombin time (international normalized ratio),
partial thromboplastin time, and bleeding time (if
necessary)
• Ss

6. Preoperative evaluation
• Laboratory
– Blood typing and screening, or crossmatching for
reserve units and additional blood products
– sellar disease : full or selective endocrine panel
• Cardiac disease
– screen for angina, CHF, EHG 12 leads, plain chest film
before routine surgery
– If further cardiac work-up is indicated, exercise
treadmill testing, echocardiography, nuclear medicine
study, or coronary angiography may be performed to
further assess the degree of cardiac risk

7. Preoperative evaluation
• Diabetes
– Hemoglobin A1c
• Hypertensive patients
– adequate blood pressure control
• Pulmonary disease
– asthma and chronic obstructive pulmonary disease :
smoking history, merit special attention by the physician.
A plain chest radiograph, pulmonary function tests
– perioperative medications, including steroids and beta
agonists

8. Preoperative evaluation
• malnutrition or failure to thrive
– alternative sources of nutritional intake : nasogastric
tubes, percutaneous gastric tubes, and parenteral routes
of intake for nutritional supplementation.
– serum prealbumin level
• Previous surgery or radiation therapy or those
receiving chronic steroid treatment may present
additional wound healing concerns

9. Radiographic imaging
• plain films, computed tomographic imaging,
magnetic resonance imaging, angiography, and a
variety of additional modalities
• The images should be available to the surgeon for
the duration of the procedure
• Dynamic studies such as flexion-extension views may
provide insight into the responsible pathologic
process.

10. Radiographic imaging
• Intraoperative imaging
• image-guided neurosurgery
• Image guidance navigation systems
• Intraoperative fluoroscopy(select spine or skull
base cases)
• Intraoperative magnetic resonance imaging
• ntraoperative angiography and fluorescein
angiography

11. Anesthesia
• Review operative plan with the anesthesia team
• Optimal physiologic parameters (blood pressure,
volume, temperature)
• Additional methods of monitoring required during
the procedure
• The proper use of ventriculostomy and lumbar
drain catheters

12. Anesthesia
• In pediatric cases or other cases in which the degree
of bleeding is of paramount concern
• administration of anesthetic medications for
induction and the duration of the case
• In certain functional and tumor cases, neuroleptic
anesthesia is desired to assess the patient during the
procedure

13. Anesthesia
• Anesthesia for awake craniotomy or deep brain
stimulator placement
• The perioperative administration of medications
such as antibiotics, steroids, hemostatic or
anticoagulation agents, and antiepileptic drugs
• spinal stability should be noted before positioning
and intubation

14. Selection of surgical approach
• Considerations for Cranial Procedures
– surgical approach and position
– devices for cranial fixation and for positioning
the body or extremity support
– surgical navigation : verified before surgery
– neurophysiologic monitoring : somatosensory motor, or
brainstem auditory evoked responses
– The method of visualization to be used for the procedure :
operating microscope, surgical loupes, endoscopic system

15. Selection of surgical approach
• Considerations for Cranial Procedures
– placement of a ventriculostomy catheter or lumbar drain
– Drill equipment
– Instruments or products required for hemostasis :
monopolar and bipolar cautery, collagen sponge, Surgicel,
and thrombin,

16. Selection of surgical approach
• Tumor Cases
– Plan of biopsy procedure : stereotactic framebased
procedures, image-guided neuronavigation through a bur
hole or open craniotomy, or direct open biopsy
– The surgical pathologist should be notified and on standby
before the initiation of surgery
– Prepare plan before after Frozen biopy result, A surgeon
should plan for a variety of scenarios, depending on the
results of the biopsy : complete tumor resection, partial
resection, decompression, palliation ,medically

17. Selection of surgical approach
• Tumor Cases
– Instruments required for tumor resection : special
transsphenoidal or skull base instrument sets, endoscopic
equipment and the Cavitron ultrasonic aspirator
– If the potential for a cerebrospinal fluid leak near the skull
base exists, the abdomen may be prepared for a fat or
fascial graft harvest.

18. Selection of surgical approach
• Operative Planning for Cerebrovascular Cases
– an approach is selected that offers exposure of the
entire lesion and proximal vasculature
– Preparation for a potential intraoperative aneurysm
rupture
– Methods of proximal control include temporary
aneurysm clipping, intraoperative balloon occlusion, and
exposure of proximal vessels in the neck.

19. Selection of surgical approach
• Operative Planning for Cerebrovascular Cases
– In cases of anticipated reconstruction or bypass
procedures, preoperative studies are performed to
ensure that feeder and recipient vessels are sufficient, and
mapping of the vessel course with a Doppler instrument
may be required.
– In cases in which no feeding vessel is accessible, a
venous or arterial graft harvest site may be selected and
prepared on the basis of the flow demand of the target
distribution

20. Selection of surgical approach
• Operative Planning for Cerebrovascular Cases
– A wide variety of aneurysm clips should be available to the
surgeon to treat complex aneurysms
– Temporary and permanent aneurysm clips should be
readily available in the event of an intraoperative rupture
– Verification of distal artery patency after aneurysm
ligation can be performed with a micro-Doppler flow
probe, fluorescence or intraoperative angiography, or
an endoscope

21. Selection of surgical approach
• Planning of Spine Procedures
– selected and equipment required for positioning should
be ready
– standard radiolucent surgical table or the Jackson surgical
table
– Equipment to perform imaging for surgical localization,
such as plain radiography, fluoroscopy, or image-guided
navigation systems
– Monitoring of somatosensory and motor evoked
potentials,

22. Selection of surgical approach
• Planning of Spine Procedures
– instrumentation for exposure, stabilization, and fusion
should be sterilized and prepared for the case
– When a bone fusion is desired, the surgeon should have a
plan for use of autograft, allograft, or any number of
additional fusion products available.