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Neurosurgery Fundamentals

Nitin Agarwal, MD

Neurosurgery Resident

Enfolded Spine Surgery Fellow

Department of Neurological Surgery

University of Pittsburgh Medical Center

Pittsburgh, Pennsylvania

301 illustrations

Thieme

New York • Stuttgart • Delhi • Rio de Janeiro

Acquisitions Editor: Timothy Hiscock

Managing Editor: Gaurav Prabhu

Director, Editorial Services: Mary Jo Casey

Production Editor: Shivika

International Production Director: Andreas Schabert

Editorial Director: Sue Hodgson

International Marketing Director: Fiona Henderson

International Sales Director: Louisa Turrell

Senior Vice President and Chief Operating

Ofﬁcer: Sarah Vanderbilt

President: Brian D. Scanlan

Library of Congress Cataloging-in-Publication Data

Names: Agarwal, Nitin, 1989editor.

Title: Neurosurgery fundamentals / [edited by] Nitin Agarwal.

Description: New York : Thieme, [2019] | Includes bibliographical references and index. |

Identifiers: LCCN 2018027440 (print) | LCCN 2018027970 (ebook) | ISBN 9781626238251

| ISBN 9781626238220 | ISBN 9781626238251 (eISBN)

LC record available at https://lccn.loc.gov/ 2018027440

333 Seventh Avenue, New York, NY 10001 USA

+1 800 782 3488, customerservice@thieme.com

Thieme Publishers Stuttgart

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+49 [0]711 8931 421, customerservice@thieme.de

Thieme Publishers Delhi

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+91 120 45 566 00, customerservice@thieme.in

Thieme Publishers Rio de Janeiro, Thieme Publicações Ltda.

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Rio de Janeiro 20020-906 Brasil +55 21 3172 2297

Cover design: Thieme Publishing Group

54321

Typesetting by DiTech Process Solutions, India

Printed in USA by King Printing Company, Inc.

ISBN 978-1-62623-822-0

Also available as an e-book: eISBN 978-1-62623-825-1

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book.

Every user is requested to examine carefully the manufacturers’ leaﬂets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though speciﬁc reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microﬁlms, and electro- nic data processing and storage.

To my family for the unconditional support.

To my fellow residents for helping me carry the message. To my mentors for educating me in the art of neurosurgery. To my patients for teaching me on a daily basis.

Contents

	Preface . . . . . . . . . . . . . . . . . . . . . . .	. . .	. . .	. . . . . .	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	.	xiii
	Contributors . . . . . . . . . . . . . . . . .	. . .	. . .	. . . . . .	. . . . . . . . . . . . . . . . . . . . . . . . . . . .	. .	.xv.
1	Roadmap to a Career in Neurosurgery . .			. . . . .	. . . . . . . . . . . . . . . . . . . . . . . .	. .	. 1. . . . .
	Ahmed Kashkoush, David T Fernandes Cabral, Robert M Friedlander
1. 1 .	Introduction. . . . . . . . . . . . . . . . . . . .	.	1	1. 3 .	Profiles . . . . . . . . . . . . . . . . . . . . . . . .	.	7
1. 2 .	Applications.. . . . . . . . . . . . . . . . . . . .	.	1
2	History of Neurological Surgery . .	. . .	. . .	. . . . . .	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	.	13
	Edward G Andrews, Chandranath Sen
2. 1 .	Introduction. . . . . . . . . . . . . . . . . . . .	.	13	2..4	Spinal Neurosurgery . . . . . . . . . . . . .	.	17
2..2	The Pre-Cushing Era. . . . . . . . . . . . . .	.	14	2. 5 .	Instrumentation . . . . . . . . . . . . . . . . .	.	17
2..3	The Cushing Era. . . . . . . . . . . . . . . . .	.	15
3	Neurological Examination . . . . . . .	. . .	. . . .	. . . . . .	. . . . . . . . . . . . . . . . . . . . . . . . . . . . .	.	23
	Prateek Agarwal, Daniel Y Zhang, M Sean Grady
3. 1 .	Introduction. . . . . . . . . . . . . . . . . . . .	.	23	3..6	Sensory Examination . . . . . . . . . . . . .	.	32
3..2	Mental Status. . . . . . . . . . . . . . . . . . .	.	23	3..7	Gait and Coordination . . . . . . . . . . . .	.	32
3..3	Cranial Nerves . . . . . . . . . . . . . . . . . .	.	23	3..8	Special Tests . . . . . . . . . . . . . . . . . . . .	.	34
3..4	Motor Examination . . . . . . . . . . . . . .	.	28	3..9	Top Hits .. . . . . . . . . . . . . . . . . . . . . . .	.	37
3..5	Reflex Examination . . . . . . . . . . . . . .	.	31
4	Neuroanatomy . . . . . . . . . . . . . . . .	. . .	. . . .	. . . . . .	. . . . . . . . . . . . . . . . . . . . . . . . . . . . .	.	40
	David T Fernandes Cabral, Sandip S Panesar, Joao T Alves Belo, Juan C Fernandez-Miranda
4. 1 .	Introduction. . . . . . . . . . . . . . . . . . . .	.	40	4..6	Spinal Cord. . . . . . . . . . . . . . . . . . . . .	.	57
4..2	Bones of the Skull . . . . . . . . . . . . . . .	.	40	4..7	Vertebral Column .. . . . . . . . . . . . . . .	.	60
4. 3 .	Cerebrum.. . . . . . . . . . . . . . . . . . . . . .	.	42	4..8	Vascular Anatomy . . . . . . . . . . . . . . .	.	69
4. 4 .	Brainstem. . . . . . . . . . . . . . . . . . . . . .	.	50	4..9	Top Hits .. . . . . . . . . . . . . . . . . . . . . . .	.	78
4. 5 .	Cisterns . . . . . . . . . . . . . . . . . . . . . . . .	.	57
5	Neuroradiology for the Neurosurgeon . .			. . . . .	. . . . . . . . . . . . . . . . . . . . . . . .	. . .	81. . . . .
	David R Hansberry, Kofi-Buaku Atsina, Mougnyan Cox, Adam E Flanders
5. 1 .	Introduction. . . . . . . . . . . . . . . . . . . .	.	81	5..4	Clinical Scenarios . . . . . . . . . . . . . . . .	.	85
5..2	Computed Tomography.. . . . . . . . . .	.	81	5..5	Top Hits .. . . . . . . . . . . . . . . . . . . . . . .	.	95
5..3	Magnetic Resonance . . . . . . . . . . . . .	.	82

vii

Contents

6	Operating Room . . . . . . . . . . . . . . .	. .	. . . .	. . . . . .	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	.	97
	Hanna Algattas, Kristopher Kimmell, G Edward Vates
6. 1 .	Introduction. . . . . . . . . . . . . . . . . . . .	.	97	6..7	Bedside Procedures . . . . . . . . . . . . .	.	101
6..2	Operating Room . . . . . . . . . . . . . . . .	.	97	6..8	Cranial Approaches . . . . . . . . . . . . . .	.	104
6..3	Cranial Positioning . . . . . . . . . . . . . . .	.	97	6..9	Spinal Approaches. . . . . . . . . . . . . . .	.	112
6..4	Spinal Positioning. . . . . . . . . . . . . . . .	.	98	6. 10.	Pediatric .......................	.	115
6..5	Positioning-Related Complications. .	.	100	6. 11.	Functional . . . . . . . . . . . . . . . . . . . . . .	.	117
6..6	Cerebral Relaxation . . . . . . . . . . . . . .	.	101	6..12	Top Hits .. . . . . . . . . . . . . . . . . . . . . . .	.	118
7	Neurocritical Care . . . . . . . . .	.	. . .	. . . .	. . . . . . . . . . . . . . . . . . . .	.	121. . . . . . . .
	Xiaoran Zhang, Lori Shutter
7. 1 .	Introduction. . . . . . . . . . . . . . . . . . . .	.	121	7..5	Cerebral Metabolism and
7..2	Respiratory Physiology	.	121		Perfusion .. . . . . . . . . . . . . . . . . . . . . .	.	125
7..2	Respiratory Physiology	.	121
7. 3 .	Shock .. . . . . . . . . . . . . . . . . . . . . . . . .	.	123	7..6	Hematology and Coagulation. . . . . .	.	126
7..4	Fluid and Electrolytes . . . . . . . . . . . .	.	124	7..7	Top Hits .. . . . . . . . . . . . . . . . . . . . . . .	.	128
8	Traumatic Brain Injury . . . . . .	.	. . . .	. . . .	. . . . . . . . . . . . . . . . . . . .	.	130. . . . . . . .
	Christine Mau, Shelly Timmons
8. 1 .	Introduction. . . . . . . . . . . . . . . . . . . .	.	130	8. 5 .	Anticoagulation.. . . . . . . . . . . . . . . . .	.	140
8..2	Classification of Head Injury. . . . . . .	.	130	8..6	Penetrating Trauma . . . . . . . . . . . . . .	.	143
8. 3 .	Monitoring.. . . . . . . . . . . . . . . . . . . . .	.	138	8..7	Top Hits . . . . . . . . . . . . . . . . . . . . . . . .	.	144
8..4	ICP Treatment .. . . . . . . . . . . . . . . . . .	.	138
9	Spinal Trauma . . . . . . . . . . . . . . . . .	. .	. . . . .	. . . . . .	. . . . . . . . . . . . . . . . . . . . . . . . . . . . .	.	150
	Katherine E Wagner, Jamie Ullman
9. 1 .	Introduction. . . . . . . . . . . . . . . . . . . .	.	150	9..10	Cervical Injuries. . . . . . . . . . . . . . . . . .	.	155
9. 2 .	Examination.. . . . . . . . . . . . . . . . . . . .	.	150	9..11	C1 Fractures . . . . . . . . . . . . . . . . . . . .	.	157
9. 3 .	Imaging .. . . . . . . . . . . . . . . . . . . . . . .	.	150	9..12	Additional Principles for Cervical
9. 4 .	Shock	.	151		Trauma.. . . . . . . . . . . . . . . . . . . . . . . .	. 162
9. 4 .	Shock	.	151
9. 5 .	Steroids . . . . . . . . . . . . . . . . . . . . . . . .	.	151	9..13	Thoracic Injuries . . . . . . . . . . . . . . . . .	.	163
9. 6 .	Immobilization . . . . . . . . . . . . . . . . . .	.	151	9..14	Thoracolumbar and Lumbar Spine		163
					Injuries . . . . . . . . . . . . . . . . . . . . . . . . .	.	163
9..7	Spinal Cord Syndromes . . . . . . . . . . .	.	152	9..15	Sacral Fractures. . . . . . . . . . . . . . . . . .	.	165
9..8	Spinal Column Model . . . . . . . . . . . .	.	153	9..16	Top Hits .. . . . . . . . . . . . . . . . . . . . . . .	.	165
9..9	Cervical Spine .. . . . . . . . . . . . . . . . . .	.	155

viii

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