NEUROSURGERY 101
David F. Antezana, MD, FAANS
The Oregon Clinic Division of Neurosurgery Physician & Surgeon
Providence Portland Medical Center Department of Neurosurgery Chairman 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