Common neurosurgical conditions seen in primary care Brian

Common neurosurgical conditions seen in primary care Brian Jochim MSN, APRN, FNP S

Financial Disclosures S None

Objectives: S Identify early potential problems with the hydrocephalus patient. S Identify signs of a tethered cord and work-up needed. S Identify signs of chiari malformation and work-up needed. S Identify and manage head bonks/trauma.

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Normal Cerebral Flow

Hydrocephalus

Hydrocephalus

Hydrocephalus

Hydrocephalus

Hydrocephalus

Shunt Parts

Ventriculoperitoneal Shunt

Ventriculopleural Shunt

Ventriculoatrial Shunt

Things to know about your shunted hydrocephalus patient S What kind of shunt do they have? S Location? Programmable? S When was their last revision? S What were their symptoms during the last malfunction? S What is their bowel history?

Signs of a shunt malfunction

Subtle signs of shunt malfunction S Behavior changes S Decline in PT/OT S Change in grades at school

Tethered Cord

Tethered Cord S A mechanical diagnosis: any symptoms arising from downward traction on the spinal cord S Heterogeneous etiologies, clinical and radiographic presentations S Fatty filum and/or low conus: probably from secondary neurulation S Congenital (myelomeningocele/lipomyelomeningocele) or acquired (intradural spinal tumor) structural pathologies, or associated postoperative scar tissue S Split cord malformation: tethering bony spur or fibrous band S Idiopathic: can have a structurally normal spinal

Signs and symptoms S Younger children S Delay in motor milestones S Increased muscle tone in legs S Chronic constipation S Neurocutaneous stigmata S Asymmetric gluteal fold S Hairy patch or hemangioma on back S Sacral dimple, especially if high and/or off midline

Signs and Symptoms S Older children S Abnormal urinary function S Incontinence S Retention S VU reflux S Frequent UTIs S Leg cramping S Axial back pain S Gait disturbance S Scoliosis

Tethered cord work-up S MRI lumbar without contrast S Physical Exam S Refer to urology for urodynamic studies S Refer to GI for constipation treatment

Surgery

Radiographic evidence

Dural Exposure

Fatty/Thickened Filum

Dural Closure

Post-op considerations S Incision care S Meningitis S Pseudomeningocele S Re-tethering

Chiari Malformation

Chiari Malformation S Definition S Downward herniation of the cerebellar tonsils through the foramen magnum S Can be idiopathic or acquired S Actual distance of herniation to constitute radiographic definition of Chiari is controversial S S Can have large herniation with no symptoms Can have small herniation with bad symptoms S The diagnosis is made based on a combination of clinical and radiographic findings

Chiari? Yes NO Maybe

Etiology S Precise cause has not been clearly elucidated S May be related to pressure differentials in choroid plexus pulsations above and below the tentorium during development S Some familiar clustering but no known genetic factors S Associated with other conditions such as achondroplasia, Albright’s hereditary osteodystrophy, William’s syndrome S Essentially a volume discrepancy between the

Pathophysiology

Signs and symptoms S Upper extremity weakness S Decreased / absent gag S Posterior headache

Work-up

Surgery: Bone removal

Duraplasty

Post-op considerations S PAIN S Incision care S Meningitis S Pseudomeningocele

Skull Fractures & Head Trauma

Skull fractures/Head Trauma

Skull Fractures/Head Trauma S Most likely accompanied by soft tissue swelling but not always. S The mechanism is important S ER for CT to R/O intracranial abnormalities such as bleeding.

Skull Fractures/Head Trauma S Soft tissue swelling S Birth related S NAT concern S Glasgow coma scale

Take home points S Don’t panic S Knowledge is power S Neurosurgery is open 24/7

Our Team Thomas Moriarty, MD, Ph. D Division Chief William Gump, MD Ian Mutchnick, MD, MS

Questions

Its Just Brain Surgery S I won’t pretend I know the answer to everything, but I’ll get the answer to anything (neurosurgical). S Email your question to me: S brian. jochim@nortonhealthcare. org