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07.04.2020

Class 1

Class 1

 A brief history of development of neurosurgical science and practice. Structure and organization of medical care for the neurosurgical patients. Additional methods of examination. X-ray contrast methods of investigation. PEG, VG, MG, AG, CT-SCAN, MRI, DG. Ophthalmologic, otoneurologic examination. The scheme and plan of the neurologic examination of the neurosurgical patients. Standards of examination and rendering the specialized medical aid to the patient with a neurosurgical pathology.

1. Importance of the theme: It is necessary to show students value of neurosurgery in the structure of the specialized medical aid to the population by the example of a history of development of a neurosurgical science.
2. The aims of the class:

2.1. the practical aims:

- to acquaint students with the organization of the neurosurgical care;

- the student should know the basic nosological forms of a neurosurgical pathology;

- the student should be able to examine the patient with a neurosurgical pathology, to render the urgent aid at the place of accident, during of transportation and at the reception ward.

to teach the student to make algorithm of examination of the patient with a neurosurgical pathology.

2.2. The educational aims:

- to take part in formation of principles of a deontology in students, medical ethics, the professional responsibility in general and in contact with patients with a neurosurgical pathology.

3.3. Specific goals:

- to know:

- 1. The basic nosological forms of a neurosurgical pathology.

- 2. The scheme - plan of studying the psychoneurologic status of the patient.

- 3. The basic kinds of paraclinical methods of examination.

- 4. The basic standards of examination of the patient with a neurosurgical pathology.

 

3.4. On the basis of theoretical knowledge to be able:

To examine the patient with a neurosurgical pathology.
To analyse the data of clinical methods of examination.
To estimate the data of radiological examination.
To estimate the data of X-ray contrast methods of examination.
Under the guidance of the teacher to perform a lumbar puncture.

 

4. Interdisciplinary integration.

 

3. The contents of the class (lecture). The history of development of neurosurgery in Ukraine, Kyiv. The basic clinical and paraclinical methods of examination. Algorithm of rendering the specialized medical aid to the patient with a pathology of the head and spinal cord. Indications and contra-indications to carrying out the basic neurosurgical methods of examination. Their techniques.

Contemporary neurosurgical practice relies heavily on imaging for the diagnosis and management of neurosurgical diseases. The following section describes the different imaging techniques in use in neurosurgery and some examples of their applications.

Plain X-ray. With the advent of CT and MRI, the use of radiographic images in neurosurgery has declined. However, plain x-ray is easily accessible, quick, and inexpensive, and still provides valuable information, especially in spinal disease. Although plain x ray is no longer as useful in intracranial disease as it was in previous decades, it can be helpful in evaluating the anatomy of cranial sutures, paranasal and frontal sinuses, and the sella turcica in preoperative planning.

X ray of the cervical spine. One characteristic feature of the cervical vertebrae is the presence of the transverse foramen, or foramen transversarium in each transverse process for the passage of the vertebral arteries. There are three types of vertebrae: typical or subaxial cervical vertebrae (C3-6), the atlas (C1), and the axis (C2). X ray is particularly important in the diagnosis of cervical spinal trauma and degenerative disease. Two thirds of significant spinal pathology can be detected with the cross-table lateral view (Gehweiler). It is important to visualize the cervico-thoracic junction (C7-T1) with this view since significant injury can occur at the lower cervical levels. A swimmer’s view, in which one arm is raised above the head, can be done to better visualize the lower c-spine in the patient with shoulders that obscure the cervico-thoracic junction on cross-table lateral projections. Other important projections include the open mouth odontoid view, the anteroposterior (AP) view and flexion-extension views. The lateral, AP, and odontoid views can be done with the patient supine on a backboard. Flexion and extension views are performed with the patient upright, and should only be done in cooperative patients with normal mental status after their other projections have been read as normal. Flexion-extension radiographs are important in diagnosing cervical spinal instability in patients with neck pain and no recognized bony abnormality, though patients with acute paraspinal muscle spasm may not demonstrate abnormal motion on flexion-extension x-rays.

These same projections are useful in the diagnosis of degenerative disease of the cervical spine. Oblique views may also be used for examining the intervertebral foramina when there is a question of nerve root compression. X ray of the thoracic spine. Again, understanding the anatomy of the spine is essential before one can adequately interpret a thoracic or lumbar x-ray. The unique feature of the thoracic vertebra is the presence of costal facets for articulation with the heads of the ribs.

X ray of the thoracic spine is not as useful as in the cervical spine because much of the anatomy is obscured by the ribs. In the trauma setting, however, plain radiographs are still important. Good quality AP and lateral views can be obtained with the patient on a backboard. Fractures, subluxation, and loss of vertebral body height should be detectable on these views.

X-ray of the lumbosacral spine The largest vertebrae are found in the lumbar region and can be distinguished by their lack of costal facets and transverse foramina, and by their large spinous processes and small transverse processes. The five sacral vertebrae are fused into a wedge shaped bone that articulates with the L5 facets and the ilia. Useful projections in the lumbosacral spine include AP, lateral, flexion-extension, and oblique views. AP and lateral views are good in the trauma setting because they can be done supine on a backboard, and can detect fractures and subluxation. Ligamentous instability can be demonstrated on flexion-extension views if there is displacement of one vertebra in relation to the adjacent vertebrae (spondylolisthesis). Oblique views can demonstrate spondylolysis, an acquired or congenital separation of the pars interarticularis, which may lead to spondylolisthesis. Again, flexion-extension x-rays can potentially demonstrate segmental instability.

Computed Tomography. The introduction of computed tomography (CT) in the mid 1970’s transformed the neurosurgeon’s ability to diagnose intracranial and spinal pathology. The different densities on CT images are related to the x-ray attenuation properties of the tissues being examined and can be quantified in Hounsfield units (Villarelli). These range from +1000 for bone to -1000 for air, with water being defined as zero Hounsfield units. Denser tissues (bone, foreign bodies) appear white on CT and less dense tissues (air or water) appear black. The addition of contrast makes tissues that enhance appear more dense or white. CT is a good imaging modality for diagnosis of acute neurosurgical lesions in the head and spine. Little preparation of the patient is needed and the scans are performed and processed within minutes. CT is able to diagnose intracranial hemorrhage, fractures, edema, mass lesions, hydrocephalus, and infarction.

Angiography. The first successful angiogram by performed by Egas Moniz in 1927. It was used in the pre-CT and pre-MRI era not only to evaluate cerebral aneurysms and arteriovenous malformations (AVMs), but also ventricular anatomy, shift, and mass effect on cerebral vasculature from mass lesions or edema. Infarction is evidenced by vessel occlusion. Advances in the use of microcatheters and digital imaging have transformed angiography from a purely diagnostic modality to one that also affords treatment. Superselective angiography with deposition of coils and balloons is now used for the definitive treatment of selected cerebral aneurysms and also in conjunction with surgery and radiosurgery of AVMs. Neurointerventionalists can also treat cerebral vasospasm after subarachnoid hemorrhage with superselective intra-arterial papaverine or balloon angioplasty.

Magnetic Resonance Imaging. A significant advance in neuroimaging has been magnetic resonance imaging (MRI) . Although a discussion of MRI physics is beyond the scope of this forum, the appearance of normal and abnormal structures on MR images depend on the differences in proton content and their spin properties (Wehrli). Three different acquisitions of MR images are important in interpreting MRI of the brain or spine, T1, T2, and proton density. Gadolinium is a non-iodinated contrast material that is hyperintense on T1 images. Normal brain tissue with an intact blood-brain barrier is impermeable to injected contrast agents. Areas with impaired (e.g. tumor, infection, vascular anomaly) or absent (e.g. pituitary) blood-brain barrier are permeable to contrast agents and, therefore, show preferential enhancement.

 

Materials of methodological maintenance of the class.

7.1. Materials of the control of the preparatory stage of the class: test tasks of the initial level (enclosed).

7.2. Materials of methodological maintenance of the basic stage of the class: an examination of the patient, the scheme of the case record.

7.3. Materials of the control of the final stage of the class: Tasks of the test tasks bank (Kroc 2)

 

8. LITERATURE

the main:

1. Иргер И.Н. Нейрохирургия, М., Медицина, 1982

2. Лебедев В.В., Быковников Л.Д. Руководство по неотложной нейрохирургии. – М.: Медицина. – 1987. – 336 с.

3.Неврология / Под ред. М.Самуэльса. – М.: Практика, 1997. – 640с.

4. Цимбалюк В., Хонда О., Третяк І., Авад М. Нейрохірургія. Курс лекцій. – Київ, 1998. – 206 с.

Additional

5. Руководство по нейротравматологии / Под ред. А.И.Арутюнова. – М.: Медицина, 1980. – Ч.11. – 392 с.

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