NEUROSURGERY 101

David F. Antezana, MD, FAANS

The Oregon Clinic Division of NeurosurgeryPhysician & Surgeon

Providence Portland Medical CenterDepartment of NeurosurgeryChairman

TEAM

NEUROSURGERY 101

How do you actually end up in the OR?

Indication!

Suitable candidate.

Show up to the hospital.

Taken to preoperative area

Then What? …………

Preoperative Area

Nurses insure patient is prepared, surgeon has entered orders, and H&P is on file.

EKG, labs, imaging may be required.

Surgeon and Anesthesiologist meet the patient.

When nursing deems the patient is ready, anesthesia takes her to the OR.

Slight variations in how different hospitals do them.

OPERATIVE THEATER

Upon entry to the OR, the patient’s identity is verified.

Surgical Safety Checklist is employed.

Verification of supplies and personnel.

Checklist

Procedure verified

Laterality confirmed (L vs R)

Site marked

Allergies addressed

Antibiotics given and timed

Checklist

DVT prophylaxis (TEDs & SCDs)

Warming blanket

Blood concerns (T&C, cell saver, Aquamantys, ANH)

Anesthetic concerns (BP, fluids, IV access)

GETA

Anesthesiologist induces the patient.

Intubation

Central line

Arterial line

Positioning

Supine

Prone

Lateral or Park Bench

Sitting

Get drawings of each

Positioning

Ulnar nerve

Peroneal nerve

Shoulders

Chest wall

Breasts

Genitals

Prep & Drape

Prep: Iodine, Chlorhexidine

Drape

Additional Time Out

Local anesthetic

INCISION!! ---------------- NOT YET!!!

THE TEAM

Surgeon

Physician Assistant

Anesthesiologist

Surgical Technician

Circulating Nurse

THE TEAM

Co-Surgeon

Radiology technician

Neuro-navigation technician

Neurophysiology

Industry representative

Perfusionist

Anesthesia technician

Instruments

Operative Microscope

Drill

Endoscope

Stereotactic equipment

Flouroscopy

Instruments

Cutting: Knife and Bovie cautery

Sharp dissection: Micro tray and Cobb

Blunt dissection: Penfields

Retractors

Bipolar and Kerrosens

Instruments

SPONDYLOLISTHESIS

High-Grade

Slip of one VB on another (anterolisthesis)

Usually L4-5 or L5-S1.

Grade 1-4 or spondyloptosis (0-100%)

Back pain due to instability

Radicular leg pain due to nerve root compression

SPONDYLOLISTHESIS

Why?

Big surgery concentrated on a relatively small area

Many moving parts

Lots of team members are required.

SPONDYLOLISTHESIS

SPONDYLOLISTHESIS

SPONDYLOLISTHESIS

SPONDYLOLISTHESIS

THE TEAM

Anesthesiologist (anesthesia tech & perfusionist)

Surgical Tech & Circulating Nurse.

General Vascular surgery & Physician Assistant

Industry Rep/Consultant

Radiology & Neuro-navigation

Neurophysiology

Anesthesiologist

Maintenance of Anesthesia

Vital Signs & Anesthesia Sheet

Anesthesia adjustments for monitoring

Surgical Technician & Circulating Nurse

CST – Particularly challenging. Extensive equipment and hardware to keep track of and employ. Common to use two CSTs.

Circulating Nurse - Spends a great deal of time procuring necessary equipment not in the OR and charting the myriad of implants required.

General Vascular Surgeon & Physician Assistant

Surgeon quarterbacks the abdominal approach to the spine.

Muscle-splitting NOT cutting retroperitoneal approach

Iliac vessels and lymphatics along spine

Physician assistant assists on posterior approach and as necessary on anterior approach.

An experienced PA is worth his/her weight in gold.

Industry Rep/Consultant

Reviews case with surgeon pre-operatively

Delivers and consults on all hardware.

His/her job is to make the CST look good!

Runs software that assists surgeon

Interacts with practically all staff

Facilitate the case

Radiology & Neuronavigation

Fluoroscopic images

From localization to placement of hardware to interbody work to highly complex osteotomy performance

O-arm employment and use for all of the above + Navigation and CT quality images.

Neurophysiology

Monitoring of multiple modalities:

Somatosensory Evoked Potentials

Motor Evoked Potentials

Electromyography; pedicle screw testing

Electroencephalography, phase-reversal, motor mapping, language mapping

Awake craniotomies, Deep Brain Stimulation, Functional Neurosurgery

FINALE

Closure

Hemostasis: Drains

Infection: Vancomycin & Bacitracin saliine

Dressing

Awaken from General Anesthesia

Recovery Room

ICU or Floor