TRAUMA-HYDROCHEPALUS-LAMINECTOMY.ppt

Traumatic brain injury
and Procedur of
Craniotomy
Dr. dr. Farhad Bal’afif, SpBS(K)
Bedah Saraf - FKUB/RSUD Dr Saiful Anwar
Malang

 ANATOMY and PHYSIOLOGY OF BRAIN
The brain is one of the largest and most
complex organs in the human body.
It is made up of more than 100 billion nerves that
communicate in trillions of connections called
synapses. The brain is made up of many
specialized areas that work together:
The cortex is the outermost layer of brain cells.
The basal ganglia are a cluster of structures in the
center of the brain

SKULL
The purpose of the bony skull is to protect the
brain from injury.
All the arteries, veins and nerves
exit the base of the skull through holes, called
foramina.
The big hole in the middle (foramen
magnum) is where the spinal cord exits.

The brain is composed of
three parts:
CEREBELLUM
CEREBRUM.
BRAINSTEM

DEEP STRUCTURES
Hypothalamus
Pituitary gland
Thalamus
Pineal gland

MENINGES
The brain and spinal cord are covered and protected
by three layers of tissue called meninges.
From the outermost layer inward they are:The Dura
mater, Arachnoid mater, and Piamater.

Ventricles and Cerebrospinal fluid
The brain has hollow fluid-filled cavities called
ventricles. Inside the ventricles is a ribbon-like structure
called the choroid plexus that makes clear
colorless cerebrospinal fluid. CSF flows within and
around the brain and spinal cord to help cushion it from
injury. This circulating fluid is constantly being
absorbed and replenished.

Nervous system
 The nervous system is divided into central and peripheral
systems.
 The central nervous system (CNS) is composed of the
brain and spinal cord.
 The peripheral nervous system(PNS) is composed of spinal
nerves.
 That branch from the spinal cord and cranial nerves that
branch from the brain.

Number Name Function
I olfactory Smell
II optic sight
III oculomotor moves eye, pupil
IV trochlear moves eye
V trigeminal face sensation
VI abducens moves eye
THE TWELVE CRANIAL NERVES

VII facial moves face, salivate
VIII vestibulocochlear hearing, balance
IX glossopharyngeal taste, swallow
X vagus heart rate, digestion
XI accessory moves head
XII hypoglossal moves tongue

Blood supply
Blood is carried to the brain by two paired
arteries, the internal carotid arteries and the
vertebral arteries. The internal carotid arteries
supply most of the cerebrum.
The vertebral arteries supply the
cerebellum, brainstem, and the underside
of the cerebrum

Head Injury
• Scalp injury
• Skull injury
• Meningeal injury
• Traumatic Brain Injury

 Epidemic in Indonesia
 Major cause of death and permanent
disability
 70% of all road fatalities
 50% of trauma death
 10-20% of head injury: death on arrival
 Degree 10% mild head injury
10% moderate head injury
80% severe head injury

 Severity of primary injury
 Intracranial complications
 Hypoxaemia
 Hypercarbia
 Hypotension
 Anaemia
 Multiple injuries, proportional to Injury
Severity Score (ISS)
 Age

 Prolonged prehospital time
 Admission to inappropriate hospital
 Delayed or inappropriate interhospital
transfer/retrieval
 Delay in definitive surgical treatment

Traumatic Brain Injury
Blunt(Closed) Penetrating
Explosion Fall GSW Stab
Blast
Fragment
Motor vehicle crashes (MVC)

1. Headache
2. Vomiting
3. Papilloedema occur in chronic condition
4. Cushing response
◦ Bradicardia
◦ Hipertension
◦ Alteration of ventilatory pattern

5. Herniation
• Uncal - ipsilateral dilated pupil
- contralateral hemiparesis
- ipsilateral hemiparesis
(Kernohan’s notch
phenomenom)
• Central - rostrocaudal sign
• Subfalcine
• Tonsiller herniation

 Mild – GCS 14-15
Patient typically mildly lethargic, disoriented
 Moderate – GCS 9-13
Patient typically sleepy or obtunded, able to follow
commands with arousal.
Confused.
 Severe – GCS 3-8
Patient comatose, unable to follow command or
perform purposeful motor activity.
Range of motor activity: localizes, withdraws,
decorticate posturing, decerebrate posturing, nil.

 Primary Injury: Function of energy transmitted to brain
◦ Very little can be done by health care providers to influence
◦ Cerebral concussion, contusion and degeneration, Diffuse Axonal
Injury (DAI)
 Secondary Injury: Function of damage to brain from systemic
physiology
◦ Systemic
 Hypotension: Acute and easily treatable
 Hypoxia: Acute and easily treatable
 Fever and Electrolyte Imbalances
◦ Seizures
◦ Intracranial Pressure  Can Lead to Herniation

 Primary
Scalp
contusion, abrasion, laceration
Skull fracture
open, closed (note-compound base of skull fracture
without a scalp laceration), linier, depressed
Meningeal injury
dural tear
Brain injury
concussion
contussion
diffuse axonal
focal – contusion
laceration and penetration

 Secondary
Intracranial haemorrhage
Cerebral swelling
cerebral hypoxia
CSF leakage and pneumocephalus
methabolic disorders
infection
epilepsy

 Factors influencing outcome
- airway
- breathing
- control of haemorrhage
- prevention and shock treatment
- avoidance of factors ↑ ICP
• head down position
• hypoxia
• hypercarbia
• vomiting
- recognition of serious associated injury
- effective communication and transport

 Lateral position for airway control
in Px with susp spinal injury
 The face in turned slightly down words
the tongue to fall forwards
saliva and vomit will drain out

 The indication:
◦ Airway is inadequate
◦ GCS ≤ 8
◦ Herniation
◦ Rapid deterioration
Should be performed only by a competent medical
practitioner

Early management of severe trauma
The management plan is based on:
1. Primary survey
2. Resuscitation
3. Secondary survey
4. Definitive care

 Primary survey
◦ Airway with cervical spine immobilized in neutral
position
◦ Breathing pattern and adequacy
◦ Circulation and haemorrhage
◦ Disability, minineurological examination:
 GCS
 Pupils
 Motor deficit
◦ Exposure: completely expose the patient for an
adequate examination but protect against
hypothermia

 Resuscitation
◦ Airway
 Ensure patient airway
 Unconscious patient: intubated if skilled
 Note: maintain cervical spine immobilization until
radiological examination excludes spinal injury
◦ Breathing and oxygenation
 Ensure adequate ventilation
 Mechanically ventilate if intubated
 Give supplemental oxygen initially

◦ Circulation support and control
haemorrhage
 Treat shock aggressively to improve
tissue perfusion
 Control external haemorrhage
◦ Assess response to resuscitation using
physiological parameters: pulse, blood
pressure, skin colour, capilary refill and
urine output
◦ Nasogastric tube and urinary catheter
unless contraindicated

◦ Head injury alone, without scalp injury,
does not cause hypotension. If
hypotension is present, identify the cause,
e.g.:
• Hypovolaemic shock,
• spinal injury.
• Rarely, may be due to medulallary
failure.
• Blood loss from a scalp or head injury
may cause hypotension (hypovolaemic
shock) in children

 Secondary survey
◦ Special neurosurgical assessment including
Glasgow Coma Score (GCS) and external sign of
injury to the head
◦ Record the pulse, blood pressure, respiratory rate
and temperature
◦ Systematically examine each region of the body, i.e.
head-to-toe examination
◦ Connect to monitors as available
◦ Re-evaluate the GCS
◦ Radiological examination-lateral X-ray spine, chest,
pelvis, other areas as indicated, skull X-ray and CT
head scan
◦ History

 CNS examination
◦ Glasglow Coma Scale (GCS)
◦ Pupillary responses
are they equal or unequal? Were the pupils equal
at the time of the incident (report from
ambulance officer) and have they the same
response now?
◦ Motor pattern
hemiparesis, quadriparesis
flexion or extension to pain (from supraorbital,
trapezius or tendo achilles pressure)
◦ Inspection of the face and scalp
◦ Palpation of the face and scalp and any laceration
for a depressed fracture
◦ Palpation of the spine for the tenderness and
deformity

Glasgow Coma Scale (GCS)
This scale examines three areas of behaviour: eye
opening, response to voice and motor responses.
The score can be quantitative with 3 being the lowest
score and 15 normal

 Eye opening
◦ Spontaneous E4
◦ To speech 3
◦ To pain 2
◦ Nil 1
 Verbal response
◦ Orientated V5
◦ Confused conversation 4
◦ Inappropriate words 3
◦ Incomprehensible sound 2
◦ Nil 1
 Best motor response
◦ Obeys M 6
◦ Localizes 5
◦ Withdraws 4
◦ Abnormal flexion 3
◦ Extension 2
◦ Nil 1
 Coma Score (E+V+M) = 3-15

 CT head scan guidelines
◦ GCS < 15 after resuscitation
◦ Neurological deterioration, i.e 2 point or more on
the GCS, hemiparesis, squint
◦ Drowsiness or confusion (GCS 9-14 persisting>2 h)
◦ Persistent headache, vomiting
◦ Focal neurological signs
◦ Fracture – known or suspected
◦ Penetrating injury – known or suspected
◦ Age – over 50 years of age
◦ Post-operative assessment

 Skull X-ray guidelines
In rural area where a CT scan is not available or
readily accessible, a plan skull X-ray can provide
useful information. The pictures required are AP,
lateral, Towne’s view and tangential to the point of
impact for demonstrating a depressed fracture

 Indications
◦ Loss of consciousness, amnesia
◦ Persisting headache
◦ Focal neurological signs
◦ Scalp injury
◦ Suspected penetrating injury
◦ CSF or blood from nose or ear
◦ Palpable or visible skull deformity
◦ Difficulty in clinical assessment
◦ Patient with GCS 15, essntially asymptomatic but “at
risk” bacause of a defect blow or fall onto a hard
surface, etc, especially in a patient over 50 years of
age

Criteria for admission to hospital with head injury:
• Confusion or any other decreased level of consciousness
• Neurological symtoms or sign – including persistent
headache, vomiting
• Difficulty in clinical assessment, e.g. alcohol, epilepsy
• Other medical condition, e.g. coagulation defects, diabetes
mellitus
• Skull fracture
• Abnormal CT brain scan
• Responsible observation not available outside the hospital
• Age – patients over 50 years of age
• Children under 5 years of age

 Criteria for admission in Minor head injury
◦ A minor head injury is defined as one where the Glasgow
Coma Score is 14-15
◦ Admit and observe the patient if:
a). There has been loss of consciousness or a period of
post-traumatic amnesia
b). The patient remains confused
c). The patient is under 5 years of age or over 50 years of
age
d). Presence or development of focal neurological signs
e). Severe headache with or without vomiting

 Discharge of minor head injury patient
◦ Orientated in time and place
◦ No focal neurological signs
◦ No skull fracture
◦ A responsible person is available to continue observation of
the patient
◦ Discharge check list – advise to report back to hospital
immediately if there is:
a) Vomiting
b) Complains of severe headache or dizziness
c) Becomes restless, drowsy or unconscious
d) Had a convulsion or fit

 Intubate & ventilate with GCS<9
 the goal: PaO2=100mmHg, PaCO2 35mmHg, O2 sat
96%,
 hyperventilation (PaCO2< 30mmHg) should be avoided
 Cerebral perfusion
 the goal: CPP>70mmHg, MAP>90mmHg
 hypotension (systolic BP<90mmHg) must be avoided
 Intravenous fluid electrolites
 normovolaemic is the goal,
 avoid dehydration on or ever hydration
 normal serum electrolyte should be maintaned
 Head posture: should be elevated to 20-30°
 Corticosteroid: are not recommended
 Transfer to CT and / or neurosurgical unit

 Active treatment of intracranial pressure
Only be under taken of there is evidence of
- rapid neurological deterioration
- signs of uncal herniation
- ↑ ICP from the ICP monitoring
- modality (should be decided by neurosurgeon)
• CSF drainage
• intravenous mannitol
• hyperventilation
• barbiturate
• mild hypothermia
• decompressive craniectomy

Restlessness and analgesia
o Before prescribing analgesia, it is important to
determine the cause of restlestness, e.g.:
 cerebral hypoxia from airway inadequacy or poor ventilation
or poor perfusion,
raised intracranial pressure,
pain,
alcohol intoxication or a
full bladder.
oDrugs other than paracetamol or codeine
phosphate require neurosurgical consultation

 Post traumatic epilepsy
 The risk factors for epilepsy are:
 intradural haematomas,
 dural laceration with cortical injury,
 depressed fractures,
 a post-traumatic amnesia period of 24 h early post
traumatic epilepsy
 The indication for prophylactic anti-convulsant therapy is
controversial. A neurosurgical consultation is indicated both
for the cause of the epilepsy and for consideration for anti-
convulsant therapy.

 Admit to ICU
 S/P TBI
 Cond: critical
 Vitals q1hr w/ neuro checks (if on Propofol, stop and check q4 hrs)
 Bedrest, HOB to 30*, loosen c-collar when patient sedated
 NPO
 IVF
◦ ½ NS w/ 20 K @ 80-100 cc/hr
◦ If significant brain edema, start 3%NS @ 15/hr, increase up to 50/hr (keep serum Na at 145-155, serum osmol 300-320)
 Vent
◦ No or low PEEP
◦ Keep PaCO2 at 30-35 (see hyperventilation above)
 Meds
◦ Propofol drip or Ativan 2-10mg iv q1hr for sedation or ICP>20 for>5’
◦ MSO4 2-10 mg iv q1hr prn pain or ICP>20 for>5’
◦ Mannitol 25g iv q4hrs prn ICP>20 for>5’ (hold if serum Na >155 or osmol>320)
◦ Cerebyx 1g iv now (loading dose), then 100mg q8
◦ Pepcid 20mg iv bid
◦ Ancef 1g iv q8 if scalp wound or ICP monitor
 Nursing – per ICU routine
 Labs
◦ CBC, CMP, Dilantin level qAM
◦ Serum Na and osmol q6 if on 3% NaCl or Mannitol
 Repeat head CT in am (at least 2 CTs per patient, one on arrival and one next day)
 Call for problems

 Absence of brainstem reflexes
◦ Fixed pupils
◦ Absent corneal reflexes
◦ Absent oculovestibular reflex (cold water calorics)
◦ Absent oculocephalic reflex (not if C-spine not cleared)
◦ Absent gag and cough reflex
 No response to deep central pain
 Apnea test (last test to perform!)
 Vital signs
◦ Core temp > 32.2*C (90*F)
◦ SBP>90 mm Hg
 No drugs in the system!

Treatment
• Burr hole trephination. A hole is drilled in
the skull over the area of the subdural
hematoma, and the blood is suctioned out
through the hole.
• Craniotomy. A larger section of the skull
is removed, to allow better access to the
subdural hematoma and reduce pressure.
• Craniectomy. A section of the skull is
removed for an extended period of time,
to allow the injured brain to expand and
swell without permanent damage

craniotomy
Craniotomy is a cut that opens the
cranium.During this surgical procedure,
bone flap, is removed to access the brain
underneath.Craniotomies are often named for the
bone being removed.
Some common craniotomies include
frontotemporal, parietal, temporal,
and suboccipital.A craniotomy is cut with a
special saw called a craniotome.

STEPS OF PROCEDURE
There are 6 main steps craniotomy..
Step 1: prepare the patient
Step 2: make a skin incision.
Step 3: perform a craniotomy, open the skull
Step 4: exposure the brain

Step 5: correct the problem
Step 6: close the craniotomy

TREPANASI INSTRUMENT
Handvat mess no. 3 (Scalp blade and handle) : 2 buah
Nald voeder (Needle holder) : 2 buah
Gunting metzembaum (Metzemboum scissor) : 1 buah
Gunting benang (Surgical scissor ) : 1 buah
Gunting mayo/kasar (Surgical scissor straight) : 1 buah
Gunting duramater : 1 buah
Pincet anatomis (Tissue forceps) : 2 buah
Pinset chirurgis (Dissecting forceps) : 2 buah
Pinset bebek (Adson forceps) : 2 buah
Disinfeksi klem (washing and dressing forcep) : 1 bauh
Duk klem (towel klem) : 5 buah
Klem pean cantik (nissen) : 1 buah
Bipolar / monopolar couter : 1 set
Cannule suction : 2 buah
Langenbeck retractor : 2 buah
Sharp retractor : 2 buah
Raney scalp hemostatic clips : 15 buah
Raney aplikator removing forceps : 2 buah
Dissector : 1 buah
Elevator : 1 buah
Raspatories : 1 buah
Handle gigli saw : 2 buah
Conductor gigli saw : 1 buah
Brain spatula : 4 buah
Leyla retractor : 2 buah

CRANIOPLASTY INSTRUMENT
Langenbeck retractor : 2 buah
Sharp retractor : 2 buah
Raney scalp hemostatic clips : 15 buah
Raney aplikator removing forceps : 2 buah
Elevator : 1 buah
Raspatories : 1 buah
Kikir (bone levers) : 1 buah
Spatula : 1 buah
Screwdriver : 1 buah

Quantity Name Description Size
2 Jansen Retractor Blunt 3x3 Blades 4"
2 Weitlaner Retractor Blunt 3x4 Teeth 6-1/2"
1 Scalpel Handle #3
1 Scalpel Handle #4
1 Scalpel Handle #7
4 Solid Bar Handle For Gigli Saw Pack of 2
2 Adson (Ewald) Dressing Forceps Serrated 4-3/4"
2 Adson Tissue Forceps 1x2 Teeth 4-3/4"
12 Backhaus Towel Clamp 5-1/4"
2 Cushing Brain Forceps Delicate Serrated 7"
2 Cushing Brain Forceps Delicate 1x2 Teeth 7"
6 Ruskin Rongeur Straight 7-1/4"
6 Foerster Sponge Forceps Serrated 9-1/2"
18 Halsted Mosquito Forceps Straight 5"
18 Halsted Mosquito Forceps Curved 5"
1 Luer Bone Rongeur Curved 8mm x 10mm Bite 7"
1 Stille-Liston Bone Forceps Curved Double Action 10-1/2"
2 Mayo-Hegar Nh Serrated 7"
1 Gigli Saw Wire 12"
1 Gigli Saw Wire 20"
1 Operating Scissors Straight Sharp/Blunt 6"
1 Mayo-Stille Dissecting Scissors Straight 6-3/4"
1 Mayo-Stille Dissecting Scissors Curved 6-3/4"
1 Metzenbaum Dissecting Scissors Curved 7"
1 Taylor Dural Scissors w/ Probe Tip 5-1/2"
1 Cover for Instrument Tray

 Labs: CBC, lytes, Cr, INR/PTT
 Crossmatch (at least 2 U PRBC)
 2 physician consent
 Spinal precautions
◦ May need to log roll patient

 Scalp Wounds
1. shave at least 3 cm around the wound
2. gently palpate the laceration with a gloved
finger. This may provide information regarding
an underlying fracture
3. if a fracture is found unexpectedly, do not
remove bone fragments: contact your
neurosurgeon at once.
4. Scalp wounds may bleed profusely and cause
hypertension. Secure haemostasis by pressure or
suturing early
5. if the wound edges are badly torn, excise non –
viable scalp and where possible suture the scalp
in two layers

 Seldom used by neurosurgeons in CT era
 Position supine
 Shave entire head & drape to allow access to frontal, parietal,
& temporal areas
 Burr holes typically on side of localizing neuro findings –
ipsilateral to dilated pupil or skull fracture, contralateral to
abN motor response
◦ If no hematoma found on suspected side, other side should be
explored
 Initially burr hole placed in temporal region 2.5 cm above
zygomatic arch
 Following dx of either ASDH or EDH, 2 additional burr holes
can be appropriately placed in parietal & frontal regions
 Skin incision should be made in such a manner that if formal
craniotomy required, they can be joined to form skin flap

 Scalp Incision
◦ Large question mark incision starting
1 cm in front of tragus at zygomatic
arch & curved backward & upward
above auricle to reach midline,
carried forward to frontal region
◦ Raney clips along skin edges
◦ Bovie incision in superficial temporal
fascia & temporalis muscle down to
the bone, close to margin of skin
opening
◦ Myocutaneous flap reflected
inferiorly
 Rapid Temporal Decompression
◦ In patient who is herniated or is
deteriorating, temporal end of
incision rapidly opened & burr hole
placed
◦ Burr hole is then enlarged to form a
limited craniectomy 3 cm in diameter
◦ If hematoma in subdural space, dura
is opened in a cruciate manner &
underlying hematoma is promptly
evacuated – helps to reduce ICP
before completion of craniotomy
which can then be completed more
slowly, w/ better hemostasis

 Bone Flap
◦ Burr holes, then join burr holes to
complete craniotomy opening
◦ Medial margin 1.5~2 cm from
midline
◦ Further exposure of middle fossa
obtained using Leksell rongeurs to
remove parts of lateral sphenoid
wing & temporal bone in piecemeal
fashion, as needed for temporal tip
access
 Dural Opening
◦ Opening in U-shaped fashion & flap
towards midline to avoid damaging
parasagittal bridging veins
◦ Alternatively, cruciate opening
 Closure
◦ Meticulous hemostasis
◦ Dural tack-up sutures 2.5 cm apart
in circumferential fashion & central
tack-up suture in bone flap
◦ +/- drain

Dr. dr. Farhad Bal’afif, SpBS(K)
Bedah Saraf – FKUB / RSUD Dr Saiful Anwar
Malang

 Hydrocephalus is the medical term for a
condition that is commonly called “water on
the brain.”
 It is a combination of the Greek word “hydro,”
which means water and “cephalus” which
means head.
 However, the liquid involved in hydrocephalus
is not really water at all, it is cerebrospinal
fluid or CSF.

 CSF looks like water, but it contains
proteins, electrolytes, and nutrients that
help keep your brain healthy.
 The most important purpose of CSF is to
cushion your brain and spinal cord against
injury.
 Your brain produces about 1 pint of CSF per
day.
 It circulates through a network of tiny
passageways in your brain, and ultimately
into your blood stream where it is absorbed
by your body.

 Hydrocephalus occurs when the delicate
balance of CSF production and absorption is
disrupted and CSF builds up in the brain.
 This build-up of CSF causes the brain to
swell, and for pressure to increase inside the
skull, resulting in nerve damage.

 People who are born with hydrocephalus have a type
of hydrocephalus called congenital hydrocephalus.
 It is usually caused by a birth defect or by the brain
developing in such a way that the cerebrospinal fluid
(CSF) in the brain cannot drain properly.
 Most cases of hydrocephalus (more than 70%) occur
during pregnancy, at birth, or shortly after birth.
 Causes of congenital hydrocephalus include:
 Toxoplasmosis (an infection from eating undercooked meat,
or by coming in contact with infected soil or an infected
animal)
 Cytomegalovirus (CMV, infection by a type of herpes virus)
 Rubella (German measles)
 A genetic disorder usually passed only from mother to son

 Hydrocephalus can also develop later in life.
This type of hydrocephalus is called
acquired hydrocephalus, and it can occur
when something happens to prevent the
CSF in the brain from draining properly.
 Causes of acquired hydrocephalus include:
Blocked CSF flow
Brain tumor or cyst
Bleeding inside the brain
Head trauma
Infection (such as meningitis)

 A shunt is a piece of soft, flexible
plastic tubing that is about 1/8-
inch (3mm) in diameter.
 It allows excess cerebrospinal
fluid (CSF) that has built-up
inside the skull to drain out into
another part of the body, such as
the heart or abdomen.
 To drain excess CSF, shunts are
inserted into an opening or
pouch inside the brain called a
ventricle, just above where the
blockage is that is preventing the
CSF from flowing properly.

All shunts perform two functions.
 They allow CSF to flow in only
one direction, to where it is
meant to drain.
 They all have valves, which
regulate the amount of pressure
inside the skull.
When the pressure inside the skull
becomes too great the valve opens,
lowering the pressure by allowing
excess CSF to drain out.

A ventriculo-peritoneal (VP)
shunt drains into the abdomen
or peritoneum (belly). Most
shunts, including Sean’s, are
VP shunts.
A ventriculo-pleural shunt
drains into the space
surrounding the lung.
A ventriculo-atrial (VA) shunt
drains into the atria of the
heart.
 Shunts are named according to where they are
inserted in the brain and where they are
inserted to let the excess CSF drain out.

 Ventricular (Upper) Catheter-
This is the top-most part of the
shunt. It is a small, narrow tube
that is inserted into the ventricle
(a small opening or pouch)
inside the brain that contains
the cerebrospinal fluid (CSF).
 Reservoir-This is where the
excess CSF is collected until it
drains into the bottom portion
of the shunt. The reservoir also
lets the doctor remove samples
of CSF for testing, and to inject
fluid into the shunt to test for
flow and to make sure the shunt
is working properly.

 Valve-This controls how
much CSF is allowed to drain
from the brain.
 The valve can be set to open
at a specific pressure (a fixed
pressure valve) or
 It can be set by the
neurosurgeon to meet the
individual needs of the person
with hydrocephalus (a
programmable valve).
 Lower Catheter-This is the
bottom-most part of the
shunt. It is a small, narrow
tube that carries the excess
CSF into the part of the body
where it will be absorbed,
such as into the abdomen or
the heart.

VP SHUNT INSTRUMENT
Pinset bebek (Adson pinset chirurgis) : 2 buah
Mosquito klem pean (baby mosquito klem pean) : 5 buah
Mosquito klem pean dengan karet pelindung : 2 buah
Bipolar couter : 1 set
Raspatorium : 1 buah
Dissektor : 1 buah
Langenbeck retraktor : 2 buah
Spreider abdomen : 1 buah
Knable tang : 1 buah
Penggaris steril : 1 buah
Spanner (Guide peritoneal cathether) : 2 buah
Bor Perforator : 1 set

 Small incisions are made on the head and in
the abdomen (in case of a VP shunt) to allow
the neurosurgeon to pass the shunt's tubing
through the fatty tissue just under the skin.
 A small hole is made in the skull, opening the
membranes between the skull and brain to
allow the upper catheter to be passed
through the brain and into the ventricle.

 The lower catheter is passed into the belly
through a small opening in the lining of the
abdomen where the excess CSF will
eventually be absorbed.
 The incisions are then closed and sterile
bandages are applied.

 It contained only the
upper portions of the
shunt:
 Ventricular Catheter
 Reservoir
 A small needle was used
to pierce the skin and
tap into the reservoir (a
plastic bulb).
 A syringe was then used
to pull excess CSF from
around the brain and
relieve pressure.
ANCHOR
to suture in place
RESERVOIR:
Needle inserted here to drain
VENTRICULAR
CATHETER

 Shunt surgery is the most effective treatment
for hydrocephalus.
 By draining excess cerebrospinal fluid (CSF)
from the brain, shunt surgery reduces
pressure inside the skull lowers the risk of
central nervous system damage, and relieves
the symptoms associated with hydrocephalus.

 Spinal cord lies within protective
covering of vertebral column.
 Begins just below foramen
magnum of the skull.
 Ends opposite 2nd lumbar vertebra.
 Below L2 continue as a leash of
nerve roots known as cauda
equina.
 Prolongation of the pia matter
forms filum terminale.

• Anterior Elements:
•Vertebral body: provide bulk
and height; Sustain
compression loads.
• Middle Elements:
• Pedicles: transfer forces
from posterior to anterior
elements.
• Posterior Elements:
•Articular processes and
facet jts, laminae, spinous
processes.
•Lock spine to prevent
forward sliding and twisting;
Insertion sites for muscle

 congenital; spinal stenosis.
 Infection; TB ,abscess.
 Trauma; vertebral body fracture
or facet joint dislocation.
 Inflammatory; Rheumatoid
arthritis.
 Disc and vertebral lesion.
 Vascular; epidural & SDH
 Tumors.

 75% of cases of
spinal stenosis
occur in the low
back ( lumbar
spine).
 Causes :
- congenital.
- degenerative.
- trauma.

 aging process (most
common cause ).
 herniated discs. (fig)
 bone and joint
enlargement.
 spondylolisthesis.
 bone spurs.

 Initial Tx in most cases is
conservative.
◦ Rest.
◦ Weight loss.
◦ Epidural steroid injections.
◦ Analgesia.
◦ Anti-inflammatory agents.
◦ Muscle relaxant -if needed-
◦ Physiotherapy.

 Spine surgery:
used when conservative treatment failed.
-laminectomy (removing bone behind the spinal
cord)
-foramenotomy (removing bone around the
spinal nerve).
-discectomy (removing the spinal disc to relieve
pressure).
Complications:
Dural tears.
Infections.
Instability of the spine.

 Epidural abscess
◦ Usually bacterial
( staphylococcus is
common).
◦ Spread through:
 hematogenous
 Adjacent focus.
 Direct inoculation.

•immunodeficiency
•AIDS.
•Alcoholism.
•Chronic renal failure.
•Diabetes mellitus.
•Intravenous drug abuse.
•Malignancy.
•Spinal procedure or surgery.
•Spinal trauma.

 Infection of spine
◦ Uncommon
◦ Either vertebral
osteomyelitis Or less
commonly intraspinal
infection.
◦ Causative organism :
(staph, Strep, E.coli, TB)
◦ Occasionally due to
unusual organisms
like:
Salmonella or brucella.

 The goals of treatment are to relieve
spinal cord compression and cure the
infection.
◦ drain abscess.
◦ antibiotics or antimicrobial.
◦ corticosteroid.
◦ may need urgent surgical decompression by
laminectomy.

 Tumors are
classified into 3
types according to
their site:
-extradural ( between
the meninges and
spine bones)
-intradural
extramedullary
(within meninges)
-intramedullary (
inside the cord)

 Most spinal tumors are extradural (85%)
 They may be primary tumors originating in
the spine, or secondary tumors that are the
result of the spread of cancer from other
locations primarily the lung, breast,
prostate, kidney, or thyroid gland.
 Any type of tumor may occur in the spine,
including lymphoma, leukemic tumors,
myeloma, and others. A small percentage
of spinal tumors occur within the nerves of
the spinal cord itself, most often
consisting of ependymomas and other
gliomas.

 Plain X-rays.
 Myelography “contrast material is
injected into the thecal sac fluid
surrounding the spinal cord and
nerve root within the spinal canal”
 CT.
 MRI ( study of choice ).

The goal of treatment is to reduce or prevent
nerve damage from compression of the
spinal cord, relieve pain and maintain the
function.
- Surgical excision is the treatment for
extramedullary tumors.
- Radiation therapy for intramedullary
tumors.
The traditional treatment of intramedullary
gliomas has been biopsy followed by radiation
therapy.
Radiotherapy is clearly of value in metastatic
lesions.
- Chemotherapy can be considered in patients
with progression of disease after radiation therapy.

 The act of exerting an abnormal amount of
pressure on the spinal cord.
 Causes and risk factors :
- Traumatic injury.
- Spinal cord tumors.
- Spinal stenosis.
- Ruptured disks.
- Abscesses.
- Arteriovenous malformations.
- Degenerative diseases, such as arthritis.

Thoracic
70%
Lumbosacral
20%
Cervical
10%
Spinal Cord Compression in Three Main Areas

Symptoms vary depending on the cause of
the compression, its location, severity,
extent and rate of development but can
include:
- Back pain at the spinal site of compression.
- Pain or burning in other parts of the body.
- Difficulty breathing.
- Weakness in the arms, legs, or both.
- Numbness or tingling in the neck, shoulder, arms,
hands, or legs.
- Loss of coordination or difficulty walking.
- Loss of fine motor skills.
- Loss of sexual function.
- Loss of bladder or bowel control.
- Paralysis.

 Cauda equina syndrome;
is a serious condition caused by
compression of the nerves in the lower
portion of the spinal canal .
is considered a surgical emergency because
if left untreated it can lead to permanent
loss of bowel and bladder control and
paralysis of the legs.

 X ray.
 CT scan.
 MRI.
 Myelogram.
 Biopsy.
 Bone scan.
 Blood and spinal fluid
studies.

 Acute cord compression is a 'surgical'
emergency.
 In those with malignant disease
radiotherapy may be treatment of choice.
 In general, tumor, infection and disc disease
produces anterior compression.
 Surgical decompression should be achieved
through an anterior approach.

 Spinal cord trauma is damage to the spinal cord. It
may result from direct injury to the cord itself or
indirectly from damage to surrounding bones,
tissues, or blood vessels.
 Symptoms:
- Symptoms vary depending on the location of the
injury.
- Spinal cord injury causes weakness and sensory
loss at and below the point of the injury.
- we can divide spinal trauma into 3 levels
according to its location in the spinal cord (
cervical - thoracic – Lumbosacral ).

- When spinal cord injuries occur near the neck,
symptoms can affect both the arms and the
legs:
 Breathing difficulties (from paralysis of the breathing
muscles).
 Loss of normal bowel and bladder control (may include
constipation, incontinence, bladder spasms).
 Numbness.
 Sensory changes.
 Spasticity (increased muscle tone).
 Pain.
 Weakness, paralysis.

- When spinal injuries occur at chest level,
symptoms can affect the legs:
 Breathing difficulties (from paralysis of the breathing
muscles)
 Loss of normal bowel and bladder control (may include
constipation, incontinence, bladder spasms).
 Numbness.
 Pain.
 Weakness, paralysis.
 Injuries to the cervical or high-thoracic spinal cord may
also result in blood pressure problems, abnormal
sweating, and trouble maintaining normal body
temperature.

- When spinal injuries occur at the lower-
back level, varying degrees of symptoms
can affect the legs:
 Loss of normal bowel and bladder control (may
include constipation, incontinence, bladder
spasms).
 Numbness.
 Pain.
 Weakness and paralysis.

 A CT scan or MRI of the spine may show
the location and extent of the damage and
reveal problems such as blood clots
(hematomas).
 Myelogram (an x-ray of the spine after
injection of dye) may be necessary in rare
cases.
 Somatosensory evoked potential (SSEP)
testing or magnetic stimulation may show
if nerve signals can pass through the
spinal cord.
 Spine x-rays may show fracture or damage
to the bones of the spine.

 ABC
 Spine Immobilization to prevent further injury to
the spinal cord.
 In cervical injuries higher than C5, intubation and
respiratory support are usually needed.
 Corticosteroids, rest, analgesics and muscle
relaxant.
 Surgery (decompression laminectomy ).
 Extensive physical therapy and other rehabilitation
interventions are often required after the acute
injury has healed.

EXTRICATION :
 GOOD WELL TRAINED TEAM WORK
 PREVENT FURTHER INJURIES
 SCOOP STRETCHER IS SAFEST
TRANSPORT :
 ONCE STABILIZED REFER TO LEVEL 1 TRAUMA
CENTRE
 TRENDELENBURG POSITION
 LONG JOURNEY CONSIDER : NGT, IV LINE, URINARY
CATETHER

THE IN-HOSPITAL MANAGEMENT
 EVALUATION OF A, B & C
 PaO2 > 100 mmHg and PaCO2 < 45 mmHg
 MAINTAIN BP > 90 mmHg
 TREAT NEUROGENIC SHOCK !

Rupture of the disc or
prolapse as it is
usually called, can
press on the spinal
cord and its nerve
roots leading to pain,
numbness and
weakness and may
also affect the control
of bowel and urinary
bladder.
Dx: X-ray, CT scan or
MRI.

 Initial Tx in most cases is
conservative.
◦ Rest.
◦ Analgesia.
◦ Anti-inflammatory agents.
◦ Muscle relaxant -if needed-.
◦ Physiotherapy.

 laminectomy, involves excision of a portion
of the lamina and removal of the protruding
disk.
 spinal fusion, may be necessary to overcome
segmental instability.
 Laminectomy and spinal fusion are
sometimes performed concurrently to stabilize
the spine.
 Microdiskectomy, can also be used to
remove fragments of nucleus pulposus.
 Chemonucleolysis: Injection of the enzyme
chymopapain into the herniated disk produces
a loss of water and proteoglycans from the
disk, thereby reducing both the disk’s size
and the pressure in the nerve root.

 Spondylolisthesis
is a condition in
which the there is a
defect in a portion
of the spine,
causing vertebra to
slip to one side of
the body.

 Non-surgical treatment may include one or
a combination of:
- NSAID’s (e.g. ibuprofen, COX-2 inhibitors)
- Oral steroids
- Physical therapy
- Manual manipulation (e.g. chiropractic
manipulation).
 Spinal fusion surgery.

 Early compression → minimal symptom / sign
 MRI is very sensitive for soft tissue
 Early Dx and Tx → better result
 Prevent secondary damage
 Suspected of spinal cord / root compression
should reffered to neurosurgeon as early as
possible

 Indications :
- compression syndrome (acute/chronic)
- progressif neurologic deficit
- instability
- debridement
 Approaches :
- anterior
- posterior
- endoscopic

 Dewasa : Hb > 10 gr %, anak2: Hb> 12 g%
 FH normal dan lab lain normal
 Daerah yg akan dioperasi harus bersih (
mandi)
 inform concent

 KULIT
 KOMBINASI DENGAN LIDOKAIN
 CARA MENYUNTIK : SUBKUTAN
 DOSIS MAKSIMAL : ADRENALIN 0,25 MG
LIDOKAIN 4 MG/KG/KALI
 CARA MEMBUAT
◦ 1 AMPUL = 1 CC = 1/1000
◦ 1 CC + 9 CC AQUA = 10 CC  1/10.000
◦ 10 CC (1/10.000)  DIAMBIL 1 CC + 9 CC AQUA =
10 CC ADRENALIN 1/100.000
◦ 5 CC LIDOKAIN 2% + 5 CC AQUA + 10 CC
ADRENALIN 1/100.000  ADR 1/200.000,
LIDOKAIN 0,5%

SPINE INSTRUMENT (LAMINECTOMY)
Disinfeksi klem (washing and dressing forcep): 1 buah
Canule suction : 2 buah
Langenbeck : 2 buah
Gelpi ( Spesial retractors) : 2 buah
Sprider (Laminectomy retractors) : 1 buah
Dissector : 2 buah
Kop / Chissel (Dissector) : 2 buah
Nerve Hook : 2 buah
Nerve root exploration : 1 buah
Caspar rongeur straight/upwards/downwards : 3 buah
Kerrison bone punch no.2/3/4 : 3 buah
Knable tang : 1 buah
Bone cutting : 1 buah

 Posisi
 Desinfeksi
 Batasi daerah operasi dengan kain steril
 Sayatan kulit sesuai lokasi
 Rawat perdarahan kulit
 Pasang peregang kulit (SPREIDER) tajam,
tumpul
 Spinosus dipisahkan dari otot
 Dilakukan laminotomi , laminectomi ,
disectomi sesuaikebutuhan
 Perdarahan dirawat
 TUTUP

 Mikrodiskektomi
 Laminotomi
 Laminektomi

 Laminectomy Vertebra Th2 – 5 + total eksisi
intradural ekstramedular tumor
 ekstradural tumor at vertebra Th3,4

SUB AXIAL CERVICAL SPINE INJURIES
CME UI ‘05

TRAUMA-HYDROCHEPALUS-LAMINECTOMY.ppt

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