Problem Based Neurosurgery 7830tp.indd 1 12/9/10 4:55 PM This page intentionally left blank Problem Based Neurosurgery Sam Eljamel The University of Dundee, UK NEW JERSEY t LONDON t SINGAPORE t BEIJING t SHANGHAI t HONG KONG t TAIPEI t CHENNAI 7830tp.indd 2 12/9/10 4:55 PM Published by World Scientific Publishing Co. Pte. Ltd. 5 Toh Tuck Link, Singapore 596224 USA office: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601 UK office: 57 Shelton Street, Covent Garden, London WC2H 9HE British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. PROBLEM BASED NEUROSURGERY Copyright © 2011 by World Scientific Publishing Co. Pte. Ltd. All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system now known or to be invented, without written permission from the Publisher. For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission to photocopy is not required from the publisher. ISBN-13 978-981-4317-07-8 ISBN-10 981-4317-07-1 Typeset by Stallion Press Email: [email protected] Printed in Singapore. JQuek - Problem Based Neurosurgery.pmd 1 3/2/2011, 4:40 PM b1009_FM.qxd 11/12/2010 10:48 AM Page v b1009 Problem Based Neurosurgery Disclaimer The author provided a summary of information he thought rele- vant to students, doctors in training and other health care professionals learning about neurosurgical disorders. The author had made no attempt to set a standard of care and common sense should prevail. The author had made no attempt to update the information after the date of publication. The author took every precaution to accurately present the information, but errors or omissions may have occurred. Any therapeutic drug dosages or recommendations contained in this book should be verified before use and local policies, procedures, guidelines and national recommendations should be checked before use. b1009_FM.qxd 11/12/2010 10:48 AM Page vi b1009 Problem Based Neurosurgery This page intentionally left blank b1009_FM.qxd 11/12/2010 10:48 AM Page vii b1009 Problem Based Neurosurgery Dedication I dedicate this book to my wonderful family: my supportive and loving wife “Adora”, my eldest daughter “Sarah” who inspired me to do this work as she progressed through the medical course, my youngest daughter “Sana” who proof-read every word of this book on top of her busy schedule studying medicine and my son “Sam Jr” who kept me going to finish this project. To my parents who gave me the opportunity to pursue my career. To my teach- ers, my students, my colleagues and my patients who gave me the experience and wisdom that culminated in this project. b1009_FM.qxd 11/12/2010 10:48 AM Page viii b1009 Problem Based Neurosurgery This page intentionally left blank b1009_FM.qxd 11/12/2010 10:48 AM Page ix b1009 Problem Based Neurosurgery Contents Preface xiii Chapter 1: History and Physical Exam 1 Problem 1-1: How to get the patient to tell you what is wrong. 1 (The smart way of taking a succinct complete history of any illness) Problem 1-2: How to elicit neurological signs effectively, 12 demonstrate them with confidence and make a lasting impression. (The smart way of performing neurological physical examination 1) Problem 1-3: How to examine the first two cranial nerves 23 efficiently, with confidence and make a lasting impression. (The smart way of performing neurological physical examination 2) Problem 1-4: How to examine the third, fourth and sixth cranial 32 nerves efficiently, with confidence and make a lasting impression. (The smart way of performing neurological physical examination 3) Problem 1-5: How to examine the face (fifth and seventh 45 cranial nerves) efficiently, with confidence and make a lasting impression. (The smart way of performing neurological physical examination 4) Problem 1-6: How to examine the eighth, ninth & tenth cranial 57 nerves efficiently, with confidence and make a lasting impression. (The smart way of performing neurological physical examination 5) ix b1009_FM.qxd 11/12/2010 10:48 AM Page x b1009 Problem Based Neurosurgery x Contents Problem 1-7: How to examine the 11th and 12th cranial nerves 69 efficiently, with confidence and make a lasting impression. (The smart way of performing neurological physical examination 6) Problem 1-8: How to examine the motor system efficiently, 73 with confidence and make a lasting impression. (The smart way of performing neurological physical examination 7) Problem 1-9: How to examine the sensory system, coordination 96 and gait efficiently and make a lasting impression. (The smart way of performing neurological physical examination 8) Chapter 2: Neurological Investigations 109 Problem 2-1: Computerised tomographic scan (CT): How to 109 interpret CT-based images? Problem 2-2: Magnetic resonance imaging (MRI): How to 120 interpret MRI-based images? Problem 2-3: Non-radiological neuro-investigations. How to 134 interpret non-radiological neuro-investigations in a smart way? Chapter 3: Trauma (Head and Spinal Injured Patients) 145 Problem 3-1: Head injuries and head trauma. How to manage 145 a patient presenting with a head injury? Problem 3-2: Spinal trauma and traumatic spinal cord syndromes. 163 How to manage a patient following spinal trauma? Chapter 4: Sudden Headache or Collapse (SAH, ICH, 185 Seizures) Problem 4-1: Sudden headache and subarachnoid haemorrhage. 185 How to manage a patient presenting with sudden headache? Problem 4-2: Collapse and sudden focal neurological deficits. 209 How to manage a patient presenting with sudden focal neurological deficit or collapse? b1009_FM.qxd 11/12/2010 10:48 AM Page xi b1009 Problem Based Neurosurgery Contents xi Problem 4-3: Collapse, seizures, fits and funny turns. How to 220 manage a patient presenting with seizure or funny turn? Chapter 5: Raised ICP (Tumours, Abscess and 233 Hydrocephalus) Problem 5-1: Raised ICP and primary malignant brain tumours. 233 How to manage a patient presenting with raised ICP due to primary malignant brain tumours (PMBT)? Problem 5-2: Raised ICP and secondary brain tumours. How to 258 manage a patient presenting with raised ICP due to secondary brain tumour (SBT)? Problem 5-3: Raised ICP, brain abscess and CNS infections. 265 How to manage a patient presenting with raised ICP due to CNS infection? Problem 5-4: Raised ICP and hydrocephalus. How to manage 281 a patient presenting with raised ICP due to hydrocephalus? Chapter 6: Visual Symptoms (Meningiomas, Pituitary 307 Adenomas) Problem 6-1: Visual failure and intracranial meningiomas. 307 How to manage a patient presenting with compressive optic neuropathy? Problem 6-2: Visual symptoms and pituitary adenomas. 324 How to manage a patient presenting with visual field defect? Chapter 7: Hearing Loss, Ataxia, Vertigo and Facial Pain 345 (CPA Lesions) Problem 7-1: Hearing loss and cerebellopontine angle (CPA) 345 lesions. How to manage a patient presenting with hearing loss? Problem 7-2: Facial pain and trigeminal neuralgia. How to 356 manage a patient presenting with facial pain? b1009_FM.qxd 11/12/2010 10:48 AM Page xii b1009 Problem Based Neurosurgery xii Contents Chapter 8: Tremor (Parkinson’s Disease and Dystonia) 369 Problem 8-1: Tremor and Parkinson’s disease. How to manage 369 a patient presenting with tremor? Problem 8-2: Movement disorders and dystonia. How to 376 manage a patient with dystonia? Chapter 9: Para-/Tetraparesis (Spinal Compression) 381 Problem 9-1: Bilateral limb paresis (malignant spinal 381 compression). How to manage suspected malignant spinal compression? Problem 9-2: Bilateral limb paresis (benign spinal compression). 396 How to manage suspected benign spinal compression? Problem 9-3: Bilateral limb paresis (spinal infections). How to 410 manage suspected spinal infection? Chapter 10: Pain, Weakness or Numbness in a Limb 421 (Radiculopathy, Myelopathy and Peripheral Nerve Pathologies) Problem 10-1: Brachalgia, myelopathy and cervical disc 421 prolapse. How to manage a patient presenting with arm pain or myelopathy? Problem 10-2: Sciatica, cauda equina and lumbar disc prolapse. 429 How to manage a patient presenting with leg pain or cauda equina? Problem 10-3: Hands and feet numbness and peripheral nerves. 443 How to manage a patient presenting with hand or foot numbness? Appendices 451 Index 473 b1009_FM.qxd 11/12/2010 10:48 AM Page xiii b1009 Problem Based Neurosurgery Preface Problem based neurosurgery is a systematic approach to diagnosis, under- standing and management of neurosurgical diseases based on symptoms and signs of disease and using common sense and the art of applying scientific knowledge to practice. In producing this book I took the common sense approach, my patients presented me with a set of symptoms and signs creating a prob- lem that needed diagnosis and management plans. My students and residents had asked me questions. It is these presentations and questions that formed the foundation problems in this book. I concentrated on core and common neurosurgical problems that constituted the majority of neu- rosurgical practice. When one’s goal is to be concise, it is not possible to include every detail in this text. I envisaged that the main users of this book will be those studying neurosurgery, and neurology and those train- ing in neurosurgery, emergency medicine, ENT, ophthalmology, general medicine, general surgery, orthopaedic surgery, and radiology and doctors in their foundation years and those practicing in the community. Thanks for using this text. Professor Sam Eljamel, MD, FRCS(Ed,Ir,NS) Consultant Neurosurgeon xiii b1009_FM.qxd 11/12/2010 10:48 AM Page xiv b1009 Problem Based Neurosurgery This page intentionally left blank b1009_Chapter-01.qxd 11/12/2010 10:48 AM Page 1 b1009 Problem Based Neurosurgery Chapter 1: History and Physical Exam Problem 1-1: How to get the patient to tell you what is wrong.