2017 Boot Camp Handbook

PGY1 Boot Camp Course Reference Guide
Society of Neurological Surgeons
PGY1 Boot Camp Course
Reference Guide
Contributors:
Thomas C. Origitano, MD
Nathan R. Selden, MD, PhD
Nicholas M. Barbaro, MD, PhD
Christopher C. Getch, MD
E. Sander Connolly, Jr., MD
Timothy B. Mapstone, MD
Kim J. Burchiel, MD
The Society Of Neurological Surgeons

2017 Course Directors:
Richard W. Byrne, MD
Dan Barrow, MD
Aclan Dogan, MD
Bruce L. Ehni, MD
Richard G. Ellenbogen, MD, FACS
M. Sean Grady, MD
Carl B. Heilman, MD
Thomas C. Origitano, MD, PhD
Ali Ozturk, MD
Gustavo Pradilla, MD
Ganesh Rao, MD
Julian K. Wu, MD
SNS Officers:
President: Robert Harbaugh

President Elect: Alan R. Cohen
Vice President: Timothy Mapstone
Secretary: Nicholas Barbaro
Treasurer: M. Sean Grady
SNS Boot Camp Subcommittee:
Gregory Zipfel (Chairman)

Richard Byrne (CoRE Chairman)
Daniel Barrow, Joseph Ciacci, E. Sander Connolly,
Bruce Ehni, Richard Ellenbogen, Sean Grady, Isabele Germano
Costas Hadjipanayis, Michael Haglund, Carl Heilman, Michael Kaplitt, Alex Khalessi
Ricardo Jorge Komotar, J. Mocco, Tom Origitano, Vikram Prabhu, Jim Schuster,
Philip Steig, Chris Winfree, Julian Wu

Table of Contents page
I. Acknowledgements 1
II. Disclaimer 1
III. Preface 2
IV. Dedication 2
V. Introduction 3
VI. Statement on Conflicts of Interest 13
VII. Procedural Skills Stations 15
VIII. Operative Skills Stations 28
IX. Lectures 31
i. Professionalism, Supervision, and Pearls for the PGY1 Resident
ii. Neurological and Neuro-trauma Assessment
iii. Emergency Cranial Radiological Assessment
iv. Emergency Spinal Radiological Assessment
v. ICP Management
vi. Unstable Neurosurgical Patient: Case Scenarios
vii. Emergency Evaluation and Management of Hydrocephalus Shunt
Patients
viii. Making the Incision: Surgical Pause to Scalp Blood Supply
ix. Patient Safety and Clinical Communications

I. Acknowledgements:
This handbook was made available using an educational grant from Stryker to the
Society of Neurological Surgeons (SNS) and the Congress of Neurological Surgeons
(CNS). We thank all course sponsors, including; Stryker, Medtronic and Integra. We also
thank the administrators of the regional courses: Kim Macon, Crys Draconi, Margaret
Bearman, Jillian Jones, Susan Small, and Joshua Leitner.
We thank Shirley McCartney, Ph.D., for editorial review.
II. Disclaimer:
Medical knowledge is constantly changing. As medical knowledge, clinical experience

and research progress, changes in treatment and drug therapy may be required. The
contributors to this handbook and the SNS boot camp course directors, on behalf of the
SNS, have consulted sources believed to be reliable in their efforts to provide
information that is complete and in accord with standards accepted in the neurosurgical
profession at the time of publication. However, in view of the possibility of human error
by the above-mentioned parties and/or changing standards of care, no party involved in
the preparation of this work warrants that the information contained herein is accurate or
complete and they are not responsible for any errors or omissions or for the results
obtained from the use of such information. Trainees in Accreditation Council for
Graduate Medical Education (ACGME) accredited neurosurgical residency programs,
for whom this handbook is intended, should always practice according to the clinical,
supervisory and all other policies of their residency training program, Program Director,
faculty, home institution, and state licensing authority. Drugs should only be
administered as directed in the relevant product information sheets and/or in
consultation with a pharmacist.
The Society Of Neurological Surgeons 1

III. Preface
The Learning Tree
There is nothing new under the Sun. (Ecclesiastes 1: 9-14), and so it is with this
neurosurgery PGY-1 survival guide. Many of us still have a similar guide inherited or
created during our residencies.
It is the tradition of medicine and even more so in neurological surgery to pass down
knowledge and practice from generation to generation, from mentor to acolyte, from
faculty to resident, from branch to branch in a learning tree that constantly seeks to
grow the quality and safety of the care we deliver to our patients. This guide includes
input from a number of North American Neurological surgery residency programs and
has been compiled and edited by Program Directors and other senior neurosurgical
educators of the SNS. This is intended to be both foundational background knowledge
as well as a quick reference.
Nothing in the guide should be construed as specific medical or surgical protocols and
all decisions must be made based on the supervision and direction of your clinical
faculty and institutional policies and procedures. Nevertheless, the principles, wisdom
and experience outlined here should frame for you a general approach and set of
values and core practices that will aid you in becoming an outstanding, successful and
safe neurosurgical resident.
The changing times have made the transfer of knowledge from senior to junior
neurosurgeons more oblique. This guide hopefully serves to bridge the gap. It is a
living document. Each neurosurgery resident should feel compelled to suggest
additions and improvements to the SNS, via their Program Director. Like a tree, each
branch bends to touch the one below. It is our way, our culture and our obligation.
Pass it on.
IV. Dedication
This manual is dedicated to our past, present and future patients who have shared in
our quest for knowledge and improvement, and share credit for all that we have come to
know.

V. Introduction
As neurosurgical residents you have entered the world of the adult learner. Important
in your training is a lifelong commitment to identifying gaps and deficiencies in your own
skills and knowledge, and independently seeking to improve. Both vigorous,
independent study and mentorship in the clinical environment are critical for successful
and safe neurosurgical training. In particular, mentors can assist you in identifying what
you dont know, and guiding you on the most effective path towards knowledge, in a
way that will maintain patient safety as paramount.
In the words of one experienced neurosurgical educator:
Its all about what we know and do not know, about what we think we know.
Be prepared to abandon your preconceptions as you open mindedly approach one of

the greatest fields of human endeavor, the queen of all specialties: neurological
surgery.
General Considerations
Be prepared to fully engage in the physical, psychological, and intellectual challenges of

your professional day. A number of factors come to play in optimizing your engagement.
Work hour restrictions have been put in place to assure that you are rested and have
the stamina to meet the challenges of the day.
Rest appropriately. Your psychomotor skills may be affected even remotely by

inadequate sleep, stimulants (such as excessive caffeine), or sedatives (such as
alcohol). Neurological surgery requires adequate focus and attention to the challenges
of the clinical service, without personal distractions. The prepared, rested resident
learns and functions best.
It is uncomfortable to lack knowledge, particularly for neurosurgical trainees who

typically set high standards for themselves, and are accustomed to success. The
practice of neurological surgery is high risk, including both clinical decision-making and
procedural interventions.
Silence promotes neither learning nor a high quality clinical environment. Ask
questions until you understand. Communication is your greatest ally. Remember,
your attendings were residents once. They do know how you feel. Give them a chance
to help, teach, and advise. If not convinced, at the very least check with your senior
residents frequently for similar advice. However, remember that although responsibility
for patient care is shared, the ultimate responsibility for most patient outcomes rests
with the faculty member overseeing their care. They would rather answer your
questions than find out through negative patient outcomes what you dont know.

Supplement this survival manual with all important phone numbers, laboratory values,
angles, drug diseases and data you use daily. Add to it often; pass it on to the PGY-1
who follows you.
Obtain skull and spine models. Study them before and after surgical procedures to
deepen your understanding. Always take advantage of any opportunities for simulated
procedural and anatomical learning, whether at courses, in the cadaver laboratory, or
online. Anatomy is the foundation in which all surgical technique is built.
Finally, wear a clean laboratory coat and present yourself professionally, confidently,
but with humility. Overall appearance is a sign of professionalism and will have a great
impact on how patients and colleagues perceive you. The human aspect of your
interactions with patients, even early in your career, will shape their perception of you,
our specialty, and profession. Faced with difficult and serious illness, patients will find
your professional demeanor and appearance a source of real comfort and confidence.
The Rules
Rule 1: Hemostasis
1. The brain is a vascular organ; 15-20% of cardiac output is distributed to the brain
at any one time. Much of your neurosurgical training will be focused on how to avoid and
stop bleeding.
2. Understand the rheological milieu your patient may possess: avoiding bleeding is
easier that stopping it. Coagulation pathologies (both hyper and hypo) present
some of the most serious risks to neurosurgical patients and may result in
morbidity or mortality.
a. A partial list of drugs affecting bleeding: aspirin, plavix, Coumadin, other
non-steroidal anti-inflammation drugs, alcohol, heparin, tpa, platelet
inhibitors, and anti-cancer drugs.
It is important to remember that there are a variety of sources for
medications, which can affect bleeding, such as many over the
counter medications, i.e. cold medications, and herbal medicines
that patients may not list unless specifically asked.
b. Many medical conditions may also affect bleeding, amongst them: liver
failure, renal failure, hematological malignancies, excessive alcohol use,
low temperature, antibodies to platelets, and hematological disorders
(such as hemophilia).
c. It is very important to ask patients prior to surgery about their personal and
familial history of bleeding or clotting problems. Laboratory studies are
also critical to assess bleeding risk prior to surgery, and may include:
a. PT/INR
b. PTT
c. CBC with differential and platelet count
d. BUN creatinine

e. Liver enzymes
f. Toxicology screen
3. General Surgical Principles

a. Obtain proximal and distal control of major vessels early
b. Electrical hemostasis
Understand how the bipolar works
o Understand its opening pressure
o Understand why there are so many different sizes, shapes,
lengths, and tips
o Understand why irrigation is important
Understanding the monopolar. Why is it grounded? When is it
effective and safe to use? What is the difference between cutting
and coagulation current?
4. Mechanical hemostasis
a. Finger pressure
b. Elevation to control venous bleeding
c. Skin clips: Raney vs. Michel
d. Warm water
e. Cotton (understand why there are so many sizes and shapes of
cottonoids)
f. Contact Agents: surgical flow seal, oxycel, gel foam, etc., bone wax,
thrombin, fibrin glue, peroxide, etc.
5. Avoid and Control Bleeding in Potential Spaces

a. Epidural: tenting sutures: Why, when and where should they be used?
b. The epidural veins of the spine: positioning counts
6. Hematological Resuscitation
a. Normalize temperature (patients and fluids)
b. Correct platelets (>100K)
c. Correct ionized calcium
d. Correct PT (INR) to below 1.30 using FFP
e. Correct DIC and/or low fibrinogen (<150) with cryoprecipitate.
f. Rapid correction in life-threatening circumstances, use Factor VII
(restrictions apply and risks may be present)
g. Ask for help (senior resident/attending, anesthesia, hematology-massive
transfusion protocol team)
Rule 2: Know your left from your right and be able to extrapolate that information from
the patient to the films to the documentation. Remember all imaging can be mislabeled.
Tomographic (CT and MR) imaging studies by convention are displayed in mirror
image: right on the left side and left on the right side. By contrast, navigational systems
often display information without mirroring. However, some systems allow a choice to

be made during the initial stages of data manipulation, introducing the possibility of side
errors.
In almost all clinical settings, you are part of a team. Have a constant system of
checking facts (name, birth date, medical ID number, date of scan, type of scan,
presence or absence of contrast agent, administration of pre-operative antibiotics, etc.).
Such checks are part of the time out prior to invasive interventions in the operating
room, ICU and other settings, but should become a reflexive habit for your practice in all
clinical settings. When in a hurry, the pause may seem like an unnecessary delay in
getting a case started. It is not, but instead is a proven method of avoiding serious
complications, and of enhancing patient safety. If something does not add up, stop what
you are doing, engage other participants, and definitively answer the concern before
proceeding. Always involve your supervisors in any question of labeling, sidedness, or
inaccuracy of clinical records, images or other data. All team members are important
and the input of nurses and others should be respected; they will help you and your
team prevent errors. Occasionally, the patient can inadvertently give you
misinformation. Finally, make sure you document side, site, and patient data in the
chart.
Wrong sided/site surgery has been identified by regulators as a preventable event.

Even more importantly, it should be the personal goal of every surgeon, working as part
of a team, to do his or her utmost to prevent it.
Rule 3: Teamwork improves safety and outcomes. Communicate within the supervisory
hierarchy well.
Managing patients is a team exercise. Document pertinent information in the chart and
minimize the use of cut and paste. Inform your seniors and attendings what is
happening throughout the day with regular updates. Include what tests are being done,
or not, who is being discharged, and relate concerns or problems. Do not be afraid to
ask for help. If you cannot contact your senior, chief, or attending call another. All
training programs are designed around constructive supervision, both to improve patient
care and outcomes and to improve your education. Never hesitate to ask for help or
advice; it is in everyones interest.
Rule 4: There are only three possible general answers to any question, and they are
mutually exclusive in any individual circumstance:
1. Yes
2. No
3. I do not know
Many residents struggle not from lack of skill or intelligence but from lack of organization
and prioritization. This may not be something you have been taught in medical school.
You must be able to sort through large volumes of data, organize it, and present
accurately and to the point. Directness, accuracy and complete transparency in your

clinical communications are absolutely necessary to the best patient care and
outcomes. You will be embarrassed at some points in your career by your own errors in
judgment or knowledge. Being in error is a natural part of learning. However, candidly
informing your supervisors in a timely fashion of clinical events and before implementing
any major clinical or diagnostic decision, and communicating with complete honesty, are
necessary to insure that the best care possible is delivered in the training environment.
Details are important. The care of neurosurgical patients can be complex, and exact
understanding is necessary for good decisions. If you are not sure what details are
important, acknowledge this and seek advice. If you did not perform what you now know
is the key part of the examination to answer your attendings question, say so and go
back. This takes practice.
You must be able to identify the sickest patient on the service and prioritize that
patients care. If you feel overwhelmed with this, ask for help. Everyone you are working
with has felt that way at some time in his or her training.
Remember:
WHO: Patient name, age, handedness, gender
WHAT: Clinical presentation, co-morbidities, medications
WHEN: Patient examination, laboratories and imaging studies
WHERE: What is your proposed plan?
HOW: How are you going to execute the plan?
A neurosurgical residents most important characteristic is the reliability of his/her word

and trust. Yes means Yes and No means No. Ambiguity is not helpful to efficient team
function, safety, outcomes, or your education. As unfavorable as it may be to say I
dont know, it is more so to mislead. FIND OUT!! Do not be afraid to make a list.
Details, details, details.
Rule 5: Keep the Chief Happy
The importance of accurate and reliable communication cannot be over emphasized.

Communication up and down the chain of command is imperative to the safety of the
patient and to you.
Communication is a skill; it must be practiced.
Respect for the chain of command is essential for good communications. Those ahead
of you have earned it. Your example will serve to teach those coming after you. You
sow the seeds for your own future success as a young clinical teacher and leader. You

will sometimes be blamed for things that are not your fault. This may come from patients
who are frightened or angry or who are afraid to take out their frustration on the
attending staff. While this is frustrating and unfair, try to accept it and realize that you
will eventually move on to senior status where this is less likely to happen. If you
perceive conflict with any patient, colleague, family member or nursing staff, share that
with your supervisors and seek advice. They have experienced it and will help with this
necessary part of clinical learning and growth, too.
If asked to come to the operating room, be thoughtful of the space around you and other
team members that are listening. Before joining or interacting with the operating team,
familiarize yourself with where along the operative time line and how the operation is
going before you interrupt. If it is a priority then state it is so.
Prepare for every operative case by reviewing the relevant anatomy. Read about the
operation, its indications, risks and expected outcomes. If the attending wrote about the
approach then pay particular attention to that article. Your senior residents will be good
sources of information on how that attending likes to prepare for a procedure. Examine
the patient before surgery and review the imaging studies. A prepared resident is easier
to teach and you will learn more. Participating in neurosurgical procedures and other
aspects of patient care is a privilege. Treat it as such: Be prepared.
Rule 6: Think before you speak
Once you speak, everyone including patients and families know how much you know
and how much you do not know. Remember what you say can make a strong
impression on those around you. Be aware that the patient and family will remember not
only what you said but also how you said it. Do not be disparaging about colleagues,
nurses, facilities, and competitors even in jest. Do not be afraid to defer answers to
questions that you do not feel capable of answering accurately and inform patients of
when and from whom they can expect a definitive answer.
Junior residents frequently get into trouble by showing their frustration in front of
colleagues, especially nursing staff. This is particularly true when tired, hungry or
otherwise stressed. Try to monitor your stress level and be open to constructive
criticism in this regard. Denial will lead to more trouble.
Respond using what you actually know not what you think you may know. Be accurate,
straightforward, and always be honest. Poor or uncertain answers are apparent and
serve neither you nor your audience well . The best way to give excellent and accurate
answers is to be well informed, so read often and read for lifelong learning!
Rule 7: There are a Million Ways to Have Complications; Despite our Best Efforts,
There Will Always Be Bad Outcomes but their Occurrence Must be Minimized in Every
Way Possible
They are not always avoidable.

They are most commonly the result of care systems that need improvement.
Care for your patients and concern for their well-being is a high principal; self-
blame and anxiety are not good ways to achieve these goals. In fact, attributing
either successful or poor outcomes entirely to your own actions is, equally, a
form of arrogance.
Learn from poor outcomes. Be respectful and prepared at morbidity and mortality
conference. You can learn a great deal from poor outcomes experienced by
others, improving the care of your own patients. Study your own outcomes (such
as infection rates from EVD and central line placement) and demand
improvement from yourself even in the earliest stages of your career.
Document complications accurately in the medical record including the time they
occurred. Even if your note is written somewhat later because of the clinical
situation, an accurate and timely note most clearly documents important clinical
events.
The fact that bad outcomes are not always avoidable does not shelter you from
their emotional or psychological impact. Be aware of the impact; find safe venues
for managing it and mentors to advise you (faculty and resident). They have been
there.
Do not underestimate the effect that negative outcomes have on your personal
life. Your friends and family may not be able or willing to communicate with you
that you are becoming emotionally isolated. Having close friends who can is
priceless.
No matter how ashamed you think you are of your performance, honesty will
save you.
Rule 8: The Enemy of Good is Perfect
Analyze and specify the goals and end points of each procedure in advance. Goals
should always be primarily oriented towards a neurologically and clinically well patient
with a durable result, rather than a perfect looking radiological result. Remember that as
you fatigue your abilities and judgment decline. Do not be afraid to ask for help at any
stage in a procedure (or any stage of your career).
Rule 9: Know the Enemy
Know the limitations of your own skill level and experience. Do not be arrogant.
If you are afraid of a second opinion, you should question your own. In the
counsel of many there is wisdom.
Understand what your patient asks.
Understand the complications that your procedure can inflict and make sure the
family understands. If they are prepared for the worst, when it happens, they will
suffer, but understand. Disappointment (which includes anger and litigation)
comes from failed expectations: set appropriate expectations.
Communicate openly with patients and families. Let them know you are on their
side, and they will support you through the worst of difficulties. (Make sure you
are on their side).

Understand your own fears. Do not let them keep you from the patients bedside.
Do not avoid the patient or family that is doing poorly. See them twice as often.
Most experienced nurses know more than you do about patient care. Ask their
advice and take it unless you are sure it is wrong (even when sure, ask a senior).
In the operating room, keep one eye on the monitors, listen to the sound of the
pulse oximeter, and ask the anesthesiologist questions about the patients
condition. Understand the limitations the pathology places on your procedures.
Try to go wi h your senior resident or attending when they talk to the family after
a procedure. You will soon become comfortable explaining difficult situations. At
first, do not try to explain things you do not understand.
Serial neurologic examinations by the same person are the most sensitive
indicator of a patients course. Always document accurately in a straight-forward
fashion.
Rule 10: Experience
Experience is extremely valuable and should be sought. The experience of your seniors
and that reflected in the literature will prevent you (and your patients) from suffering
many problems. Always read, and always ask.
You only have 6 or 7 years of protected learning, value this time and take advantage of
the mentorship and wisdom available to you. Ultimately you will train like an athlete and
like a concert level musician. You have been given time to sleep, use it, come to work,
rested and ready. Come to work educated and prepared. Optimize your service time by
optimizing your ability to participate.
Call often and call early. It is better to have called and been wrong than not to have
called and been disastrously wrong. Not asking serves neither you nor the patient. It is
the desire and requirement of every attending that they be made aware of any event or
decision that may materially affect the outcome of their patients care. Do not take away
from the attending their opportunity to decide how much they need to participate.
Errors of commission are more tolerable than errors of omission. In other words, a
caring surgeon who sees the patient at the bedside and formulates an active plan on
their behalf will achieve better results (even if their initial impression is wrong) than a
surgeon managing that patient over the telephone. The patient, family, their clinical
supervisors, and their conscience will all forgive them for imperfection if their care and
effort are sincere and real.
You will hear dozens of rules from attendings over the years. Many do not appear in
the peer-reviewed literature, but are the voice of experience nonetheless. In general
they reflect an underlying truism. Crudely put, It is the stupid things that often hurt your
patient. Here are some examples:
The drill in your hand turns faster than a jet engine, respect its power to suck and
tear.

Lasers can cause fire.

Coagulation can devitalize the skin leading to wound breakdown, infection, and
death.
Prep alcohol in the eye can cause blindness, even though you have cured the
patient of their tumor.
Do not suck the graft.
The underlying lesson from these rules is that small things may have large
consequences, in medicine, particularly in surgery, and very particularly in
neurosurgery. This is one of the challenges and joys of your adopted profession, and
also one of the great demands.
Rule 11: Nothing substitutes for seeing the patient yourself.
The nervous system is the most elegant and eloquent organ in the universe. It is also
the least tolerant organ in the human body to damage, and its injury has the most
serious and permanent, life-altering implications.
The greatest skill of the experienced neurosurgeon you will become is not technical
operative skill (although that is required), but clinical judgment to make the right
decision, in timely fashion, and choose the proper intervention to save a life.
No-one but you (or your neurosurgical superior) can know when a patient is OK, or in
trouble, and you cannot know without seeing and examining the patient. When the road
ahead is unclear, go back and re-examine the patient at intervals, no matter the time of
night or day. You will save lives. Know who the sick patients are, focus your attention on
them, listen to your gut.
Always awaken a patient to check their neurological condition. Remember that the first
sign of increased intracranial pressure is agitation. By overly sedating an agitated
patient you may take away your only reliable indicator of their condition. Never allow a
nurse or other colleague to talk you out of awakening a patient. He was so agitated and
I just got him to sleep. Please dont wake him is less important than evaluating the
patients condition. Apologize to the nurse and explain why it is important. If necessary,
after concluding the patient is OK, stay an extra minute and try to help the nurse re-
settle them.
If you are wrong, but you have examined the patient and communicated up the chain of
command, you will be forgiven (including by yourself).
Rule 12: Document well
Most junior residents consider note writing a necessary evil with little importance except
that they get into trouble if they dont complete this task. This often results in cursory
notes with many unintelligible abbreviations and a cut and paste approach from day to
day. To the contrary, notes have several important clinical functions:

1. They document your presence at a patients bedside. When called to see a

patient for declining function, the only proof that you did your job correctly is your
documentation in the medical record. I saw him a couple of times during the
night and he was OK is not enough.
2. They allow you to communicate with your colleagues what you found on
examination and what your treatment plans are. Simply copying data that anyone
can find in the medical record is not helpful. Try to synthesize the exam,
laboratory and radiology data into a treatment plan that is useful. Chart based
communication is increasingly important in the new era of duty shifts, so that
carefully documented neurological examinations may be compared across shift
changes.
3. Every note is a medico-legal document. Your note that documents a clinical

event or finding, a time of occurrence, and implementation of a treatment plan
will almost always be helpful in proving that appropriate care was provided. A
one-line note that is timed can be followed later by a more complete
documentation.
4. The phrases benefits, alternatives and risks, or procedure, alternative, risks,

questions (PARQ) are used to show that a full discussion of a planned operation
was undertaken with a patient or surrogate. A PARQ discussion is required
before any invasive procedure or other intervention. In general, PARQ
discussions (and documentation) should include consideration of the alternative
of no treatment. The fact that the attending already did this is fine. If you do it
again, the documentation will go a long way in showing that several people
explained things to the patient.
5. Notes are also used for billing purposes and to justify care to payors. Specific
documentation of complications, treatments such as transfusions, use of
antibiotics to treat infections or any reason a patient is staying in hospital will
avoid denial of payment. While th s may seem unimportant during early training,
by getting in the habit of documenting these things, you will avoid extra work to
document when payment for care is denied.

VI. Statement on Conflicts of Interest
Introduction to Conflict of Interest: Understanding the Dynamic
The Society of Neurological Surgeons thanks all of the industry contributors to the
Founda ion in Fundamental Neurosurgical Skills: Boot Camp Courses as well as the
faculty members who have voluntarily donated their time and efforts to make this course
successful. This is the first of many educational courses you will participate in over the
course of your career. Welcome to neurological surgery training and to the beginning of
a process of lifelong learning.
A conflict of interest (COI) occurs when an individual or organization is involved in

multiple interests, one of which could possibly influence the motivation for an act on
behalf of the other. An example would be considering prescribing a certain medication
because you received the gift of a book, meal or other thing of value from the
pharmaceutical company selling the medication.
This course was created by the Society of Neurological Surgeons (aka, the Senior
Society, or SNS). The SNS has as one of its most precious trusts the continued
development and execution of resident education in neurological surgery. You are
encouraged to visit and familiarize yourself with the many benefits of the SNS website,
which includes information about the Boot Camp and RUNN (Research Update in
Neuroscience for Neurosurgeons) courses, links to course lecture and operative videos,
and information about neurosurgical fellowship training.
A course like this is not free. The logistics of putting on the course include such
components as hotel, rooms, food, technical assistance, devices, disposables, travel,
transportation of the tools and equipment. The actual cost of producing this course
approaches $100,000. The expense of this course to you is zero. This is made
possible through a carefully constructed venture between industry and organized
neurological surgery, in this case the SNS and the CNS. The American Association of
Neurosurgeons (AANS) supports the online housing of lecture material from the course,
and all three organizations provide other important educational experiences for
residents throughout training. These relationships are essential for the advancement of
the art and science of neurological surgery. They also present the potential for
development of a conflict of interest related to course funding.
In this case, the conflict of interest is managed by a series of proactive measures

implemented and maintained by organized neurosurgery through the involved parent
organizations (the SNS, CNS, and AANS).
The course has multiple sponsors

The organizers and planners must fully disclose any relationship they might have
with any individual sponsor

The educational grants are managed through a code of conduct established by

the AANS and CNS for industry relationships as defined by the Accreditation
Council for Graduate Medical Education
In addition, corporate sponsors for the course follow their own ethical guidelines,
as prescribed by AdvaMed (the Advanced Medical Technology Association)
Faculty members encourage you to report to us any perception of a conflict of interest

during this course. It is each of our responsibility to uphold a professional code of
conduct, in order to keep our neurosurgical practices free from inappropriate financial
interests and maintain the highest ethical standards that characterize our profession.
As residents, you will use many corporate products throughout your training and will
continue to use some of them in your practice. Manufacturers' representatives are often
good sources of information about their products, but are not independent of their
responsibility to sell these products to hospitals and practitioners. For this reason,
many hospitals, medical schools and training programs are required to limit access to
residents by product representatives, in part because lower earning residents are felt to
be particularly vulnerable to potential conflicts of interest arising from the value of gifts.
You are encouraged as you embark on your careers to investigate and get involved
with our parent organizations. They serve as a resource for our continuing education,
the development of the art and science of our specialty, and for the promotion of the
Interest of our patients as our primary mission, guarding against any other undue
influence.

VII. Procedural Skills Stations
I. Subclavian Central and Arterial Line Placement & Sterile Technique
Ia. Subclavian Central Line Placement & Sterile Technique
Note: At this important station, in addition to the technical goals associated with line
placement, specific attention must be given to three critical components of bedside ICU
procedures in general: sterility, clinical communications, and post procedure clinical
examination for complications (radiological examination also, if relevant). These
components (marked with an *) will not be repeated in detail at the other procedural
stations. These components of practice are important parts of professionalism, and
promote patient safety. It is the professional responsibility of the neurosurgeon to not
only participate in professional communications but also to lead.
Station Goals:
1. Patient safety and clinical communications*

2. Sterile draping and technique*
3. Cannulation of the subclavian vein
4. Central venous line placement
5. Secure and dress line
6. Documentation*
Critical steps:
Assure presence of appropriate clinical supervision for the procedure*

Inform patient, family and nursing staff of planned procedure*
Consent for procedure (or document emergency)*
Consider coagulation status, other individual risks and limitations*
Consider antibiotic prophylaxis at insertion*
Gather equipment
Position patient (10 degrees Trendelenburg with towel between the shoulders)
with appropriate access to head and neck, and convenient location of sterile field
with equipment
Clip (do not shave) area as needed
Prepare all needed flushing solutions and local anesthetic injections
Sterile skin preparation and draping, surgeon sterile scrub, gowning and gloving*
PAUSE, review consent and preparations with nurse/assistant*
Inject local anesthesia
Cannulate the vessel and insert the guide wire without force
Remove the catheter over the guide wire, retaining manual control of the guide
wire at all times
Nick the skin with an 11 blade; dilate the opening

After flushing, pass the central line over the wire, retaining manual control of the
guide wire at all times
Remove the wire, assure appropriate flow of venous (non-pulsatile) blood, flush
the catheter with sterile saline
Suture in place
Apply sterile dressing*
Auscultate breath sounds and observe respiratory rate (in case of a sudden,
large pneumothorax)*
Confirm location of tip at approximately the clavo-atrial junction with portable
radiograph and check for pneumothorax: check the radiograph in timely fashion
and relay result to nurse*
Safely dispose of sharps and other waste
Document the procedure with a brief chart note*
Dictate a full procedure note*
Record procedure in ACGME case log*
Thank assistants/nurse*
Potential Complications:
Infection
Pneumothorax, hemothorax
Cardiac Arrhythmia
Arterial placement
DVT
Death
Central line removal:
Inform nurse and obtain verbal agreement/consent from patient

Position in 10 degrees Trendelenburg
Remove dressing, prep exit site
Remove line, apply pressure
Dress site
Auscultate breath sounds and observe respiratory rate (in case of a
pneumothorax)
Document the procedure with a brief chart note
Ib. Radial Arterial Line Placement
Station Goals:
1. Cannulation of the radial artery

2. Secure and dress line

Critical Steps:
Position with arm supinated and extended

Perform Allen's Test for patency of the ulnar artery
Inject local anesthesia
Insert angiocatheter needle bevel up until flash of bright red blood
Gently advance the guide wire if used (varies)
Advance catheter
Remove guide wire
Check for pulsations
Connect, flush, secure and dress
Potential complications:
Arterial spasm, dissection, or thrombosis

Distal emboli, ischemic hand, tissue loss
Infection
Catheter removal:
Communicate line removal with nurse and consider blood sample collection
before removal
Position with arm extended, prep skin, and remove dressing and catheter
Hold pressure
Place dressing
Enter a brief procedure note in the chart
II. CSF Shunt Tap
Station Goals:
1. Tap shunt valve reservoir

2. Measure pressure; drain CSF
3. Program adjustable shunt valve
Critical Steps:
Identify valve type/configuration (and setting if relevant) on radiograph or CT

scout view, or Rickham reservoir
Insert 23g or smaller butterfly needle into valve reservoir or Rickham reservoir;
observe spontaneous flow and read pressure by using tubing as manometer
(Note: proximal obstruction may falsely obscure dangerous intracranial
hypertension)
Break seal on small syringe before attaching to butterfly tubing and very gently
draw CSF sample

Label and process/transport CSF tubes as indicated for stat processing:

generally including gram stain, cell count and differential, protein and glucose
levels
Track and be responsible for timely response to CSF laboratory results
Enter a brief procedural note in the chart including the findings on tap (opening
pressure [which may be misleading in cases of restricted flow], appearance of
CSF, volume of CSF sent, and analysis ordered)
Identify different valve types and shapes, including adjustable valves
Use valve programmer to adjust valve setting
Use valve reader to confirm valve setting
Shunt infection
Precipitation of severe malfunction and sudden or worsened intracranial
hypertension
Neurological injury
Coma
Death
III. ICP Monitor Placement
Station Goals:
1. Identify cranial landmarks and ICP monitor placement site

2. Place ICP monitor bolt
3. Zero, place and secure ICP monitor fiber-optic catheter
Critical Steps:
Make sure all electrical boxes and cables are present and functional
Mark relevant cranial landmarks prior to draping and choose insertion site (1 cm
in front of the coronal suture, at the mid pupillary line = 3 cm lateral to midline,
defaulting to the non-dominant right hemisphere)
Inject local anesthetic in scalp
Make stab incision at entry site
Attach and adjust drill bit anti-plunging guard if appropriate
Drill, taking note of tough outer table, soft cancellous bone, and tough inner
table
A catch occurs as the tip of the bit begins to traverse the inner bony cortex;
advance the drill two to three turns slowly, allowing the drill to advance a mm or
two forward against reduced resistance
Hand turn the drill clockwise while withdrawing it to pull bone fragments out of the
twist hole as the bit comes out

Palpate and then puncture the dura with a spinal needle or similar sharp device;
do not use a blunt instrument that may strip the dura from the inner table of the
skull and predispose to the formation of an epidural hematoma
Screw bolt into place until firmly engaged and stable in the skull
Calibrate (zero) the fiber optic catheter and insert just past the 5 cm (double)
line, then withdraw to the double line and secure (avoiding a falsely elevated
reading due to brain recoil)
Gently but firmly tighten the securing ring and snap the covering sheath into
place
Check wave form and wave form augmentation (generally by simulating valsalva
using abdominal pressure if the patients airway is protected)
Place dressing and double secure probe against pull out
Record brief procedure note in the chart with initial pressure reading
Hemorrhage
Infection
Drift (glacial inaccuracy of ICP readings)
Displacement
Neurological injury
Coma
Death
IV. External Ventricular Drain Placement
Station goals:
1. Identify cranial landmarks and EVD placement site

2. Place EVD
3. Tunnel, secure and dress EVD
Critical steps:
Make sure insertion tray, external drain, and drainage kit are present, as well as
local anesthetic injection and ster le saline
Mark relevant cranial landmarks prior to draping and choose insertion site (1 cm
in front of the coronal suture, at the mid pupillary line = 2.5 to 3 cm lateral to
midline, defaulting to the non-dominant right hemisphere depending on imaging
findings)
Clip (do not shave) hair at the insertion site, to include a skin exit site for the
catheter approximately 5 cm posterior, to lower the risk of infection of the
indwelling catheter
Inject local anesthetic in scalp

Make small incision at entry site (consider small hockey stick shaped flap if later
ventricular shunt implantation is expected)
Attach and adjust drill bit anti-plunging guard if appropriate
Drill, taking note of tough outer table, soft cancellous bone, and tough inner
table
A catch occurs as the tip of the bit begins to traverse the inner bony cortex;
advance the drill two to three turns slowly, allowing the drill to advance a mm or
two forward against reduced resistance
Hand turn the drill clockwise while withdrawing it to pull bone fragments out of the
twist hole as the bit comes out
Irrigate, use bone wax and clear blood for a clean field before opening the dura
Palpate and then puncture the dura with a spinal needle, 11 blade or similar
sharp device; do not use a blunt instrument that may strip the dura from the inner
table of the skull and predispose to the formation of an epidural hematoma
In a full sized adult, pass the ventricular catheter according to standard trajectory,
adjusted as needed for scan findings (intersection of trajectory towards auricular
tragus cartilage and medial canthus should be perpendicular to skull)
Mentally adjust catheter trajectory to account for shift, mass lesion, or unusual
ventricular anatomy as demonstrated on axial imaging (which should be on hand
for further review during the procedure)
Carefully monitor depth markings on the catheter throughout the pass; ventricular
entry should be evident with a palpable ependymal pop and flash of CSF from
around the stylet at approximately 4 cm depth; do not pass the catheter beyond 5
to 6 cm depth without a flash of CSF
1 cm after entering the ventricle, soft pass the catheter forward off of the rigid
stylet until the total catheter depth is 6 to 6.5 cm at the outer table of the skull
If you do not cannulate the ventricle, remove the catheter and request assistance
for a subsequent pass from a supervisor
Tunnel the catheter to the planned exit site, which should be away from the
potential tract of a ventriculoperitoneal shunt should the drain later need to be
converted to a shunt
Place a 3-0 nylon purse string around the exit site to discourage CSF leak
around the outside of the catheter and infection; use the same suture in
continuity to secure the catheter firmly using repeated loops in roman sandal
fashion, tying each single loop us ng 3 to 4 knots
Attach the catheter to a male-female connector with a silk tie and then to the
sterile enclosed drainage system before taking down the sterile field.
Check flow form and flow form augmentation (generally by simulating valsalva
using abdominal pressure if the patients airway is protected)
Place dressing
Record brief procedure note in the chart with initial pressure reading
Non-ventricular placement

Hemorrhage (including hemorrhage from presenting intracranial aneurysm, AVM

or tumor, or catastrophic hemorrhage from injury to the superior sagittal sinus or
intracranial vascular structures)
Infection
Neurological injury due to hemispheric, thalamic, or brainstem injury or stroke
Occlusion (due to poor placement and/or presenting intraventricular hemorrhage)
Displacement
Coma
Death
V. Lumbar Puncture and Lumbar Drain Placement
Station goals:
1. Optimally position patient for lumbar puncture

2. Puncture the thecal sac
3. Place, secure and dress lumbar drain
Critical steps (lumbar puncture):
Review whether the patient may have intracranial hypertension or a mass lesion
that might predispose them to brain herniation and neurological deterioration as a
result of spinal tap or drainage
Position the patient in lateral decubitus position with the knees tucked in and
flexed, or possibly sitting and leaning forward for a fully conscious and
cooperative patient (in either case, an assistant is likely necessary)
Infiltrate local anesthetic into the skin and then into the dorsal (superficial)
interspinous space
Determine spinal level; the iliac crest is generally level radiographically with the
L4-5 interspace, although a finger laid atop the crest will generally exactly parallel
a finger resting in the depression between the superficial aspect of the L3 and L4
spinous processes
The L3-4 or L4-5 interspaces are appropriate for LP and for LD placement in
anatomically normal adults and children
Before inserting the needle, examine it and understand the relationship between
the catheter and needle. If there are markings on the catheter, understand what
they mean
Insert needle with a gentle caudal to cranial trajectory parallel to mental image of
interspinous processes; the bevel should be parallel with the sagittal plane so it
splits the dural fibers
The needle may glance off the bone of the deep spinous process and/or the
adjacent superior or inferior laminae, in order to enter the epidural space
A pop will be felt as the needle traverses the interspinous ligament/ligamentum
flavum complex; remove the stylet to determine if there is CSF flow
If no flow, replace the stylet and gently advance the needle 5 mm at a time

Measure the CSF opening pressure with a manometer if indicated

Use sterile technique to collect and process CSF samples (see VP shunt tap)
Drain a volume of CSF if planned and indicated
Replace stylet and remove needle; place dressing
Critical Steps (lumbar drain placement):
After thecal sac access, rotate the needle such that the bevel is now parallel to
the coronal plane and will direct the catheter toward the thoracic spine (the small
bump indicator on the needle-stylet hub should be facing toward the head)
Pass the lumbar catheter gently through the Tuohy needle; the catheter will
encounter mild resistance at 10 cm depth as it turns the corner at the end of the
needle and enters the thecal sac; keep track of the catheter depth measurements
throughout the pass
You may use the catheter with or without the available flexible stylet based on
indication and attending surgeon preference
If the catheter encounters unacceptable resistance during the pass before it is at
an adequate depth, do not pull it back through the Tuohy needle (as it may shear
and leave a fragment in the spinal canal); if this fails, remove the needle and
catheter together as a unit and begin again starting with thecal sac puncture now
with the angle of needle slightly more cranial in orientation, so that the catheter
may pass more easily in a caudal-to-cranial orientation
Introduce a minimum of 10 cm of additional catheter into the thecal sac if
possible without resistance to avoid early catheter displacement and malfunction
Remove the Tuohy needle while gently feeding the catheter forward as the
needle comes out, so the catheter is not inadvertently removed
Attach the catheter to a male-female connector with a silk tie and then to the
sterile enclosed drainage system before taking down the sterile field
Check flow
Place dressing
Venous bleeding
Epidural hemorrhage
Nerve root or spinal cord injury and neurological deficit
Catheter loss in thecal sac
Catheter pull out
Infection
Over drainage resulting in headache or cranial subdural hematoma
Coma
Death
VI. Spinal and Cranial Positioning, Cranial Fixation, Cervical Traction

Station goals:
1. Demonstrate positioning principles and complication avoidance

2. Position supine for standard supratentorial craniotomies
3. Position prone for standard midline infratentorial midline craniotomy and spinal
procedures
4. Apply 3-point cranial fixation
Positioning Principles:
Protect your patient, your nurses, and yourself against injury, including the use of
sufficient help to avoid dropping the patient or injuring OR personnel
Position as many patients as possible with senior supervisors, as it is a subtle
and sophisticated process with serious ramifications
Venous structures should be decompressed (e.g., jugular veins should not be
compressed by excessive neck flexion, causing intracranial hypertension)
The anesthetized patient in final position should appear comfortable (as they
cannot protect their tissue and musculoskeletal structure by shifting position)
The position of the intended operative field and adjacent structures (e.g.,
shoulders) should allow optimal surgical lines of sight and surgeon comfort
Intended bone or fat harvest sites should be easy to drape and access during
surgery
Positioning should take into account placement of any required
neurophysiological monitors
Intravenous and arterial lines and the airway/ET tube should be accessible to the
anesthesiologist
The age and flexibility of patient should be accounted for
The need for any intraoperative radiography should be considered (including
ability to apply arm traction to better view the distal cervical spine, the type of
table utilized and its orientation, and the body habitus of the patient
The position of the OR table in the room should be adjusted to optimize the
position of the scrub nurse and surgical assistant, the overhead operating lights,
the microscope, and other ancillary equipment
Secure (strap) the patient to the table so that table motion will not cause them to
fall
Pad all potential pressure points and points of contact with the table
The eyes should be free from any contact or pressure and protected from drying
or injury by prep liquids (in collaboration with anesthesia)
Check the following to assure there is no pressure, deformity or traction: ears,
face, lips (endotracheal tube), breast, nipples, genitals (including Foley catheter),
panniculus, brachial plexus, rotator cuffs, superficial nerves of arms and legs,
and heels; use gel wrapping, padding and protection
Respect the patients modesty and keep them warm during positioning (and
throughout the case)

Nurses are positioning and skin protection experts; work collaboratively with
them but never relinquish personal responsibility
Critical Steps (supine positioning):
Make sure the operating table is plugged in and functioning properly

Lock the table and stretcher
Align the height of the stretcher and table before transfer (on and off)
If already anesthetized, use a draw sheet to transfer patient
Use an axillary role for lateral or semi-lateral positions
Critical Steps (prone positioning):
Plan appropriate frame or system with supervisor:

o Jackson frame
o Wilson frame
o Gel rolls
Make sure appropriate head positioning device is selected, present and
functioning
Align shoulders with top edge of table
Roll patient from stretcher onto table
Critical Steps (cranial fixation/immobilization):
Identify the anatomy of the skull and landmarks for pin placement
Identify appropriate pressure (based on age and skull thickness)
For a patient with skull fractures, previous craniotomy, or thin skull (young age),
consider using a horseshoe head holder or full circle donut
For spinal surgery, caliper or halo traction is an option to maintain cervical
alignment
Orient pins to leave the site of craniotomy accessible; some supervisors will allow
placement of the single pin on non-hair bearing forehead but others will not
Stop to think about whether the patient has a shunt or other object under the skin
and be sure that the pins will not damage them
Assure adequate pin fixation and that pins have not sunk into the skull indicating
fracture or excessive penetration
Hold the pin fixation device in the desired orientation (see positioning principles),
with the intended operative field being in the most superior position, while an
assistant tightens all connections
Check all connections, including the head holder platform connection to the table
Recheck pin pressure indicator prior to draping
Skull fracture

Epidural hematoma
Scalp laceration
Pin displacement
Cervical spine injury
Brachial plexus injury
Bleeding at pin site
Critical Steps (Cranial tong fixation for cervical traction):
Arrange for fluoroscopy or serial spine films during procedure

Anesthetize the skin properly and consider using systemic analgesics
Place tongs dependent on desired traction force: neutral (above pinna), flexion
(behind pinna), or extension (in front of pinna) traction
Prepare pin sites: clip hair, prep skin, infiltrate site with local anesthetic
Tighten pins to desired pressure based on age and skull thickness
Apply traction weight in measured increments with observation using
fluoroscopy; repeat neurological examination between addition of weights
Any change in neurological examination requires immediate reduction in weight
and appropriate imaging
After successful reduction, reduce weight to no more than10-20 pounds or fixate
ring to halo vest
Verify persistent reduction
Make sure wrenches are taped to patient vest in case they are needed to release
the vest urgently
Critical Steps (Cranial halo ring fixation for cervical traction or vest application):
Consider skull thickness, frontal sinus location, fractures, lacerations, and

supraorbital/occipital nerves when choosing pin sites (4 pins in adults, additional
pins for think skull/young children)
Seat pins with eyes closed to avoid retraction on eye lids
Tighten opposite pins at the same time using torque wrench; standard torque is 6
pounds in adults
Pins should be check for pressure once, 24 hours after application
Pin loosening
Infection
Skull penetration/CSF leak
Scars
Pressure sores from vest
Critical Steps (Application of traction):

Always consider the possible presence of atlanto-occipital dislocation and Type II

or III Hangmans fractures before traction application (contraindications)
Place towels under the shoulders to enhance extension, only if needed
depending on fracture type
Obtain baseline lateral fluoroscopic image at bedside
For adult patients, apply 10 lbs initial weight
Repeat fluoroscopy
Add 5 to 10 lbs additional weight each 10 to 20 min with a neurological
examination and fluoroscopic image before and after each additional weight
application
Do not exceed 10 lbs per cervical level to the site of injury (e.g., 50 lbs maximum
for C5 injury)
After radiographically confirmed reduction, reduce weight and reconfirm with
fluoro
Iatrogenic distraction
Exacerbation of traumatic disc herniation
Neurological injury
Respiratory failure
VII. Microscope and Basic Neurosurgical Instrumentation
Station Goals:
Balance the microscope

Demonstrate ability to adjust microscope illumination for tissue safety
Name and manipulate basic neurosurgical tools safely
Demonstrate hand-eye coordination under magnification, using both the principal
and observer station oculars
Understand the differences between the primary surgeons and the assistant
surgeons view under the microscope
Microscope Principles:
Magnification versus field of view

Illumination and tissue safety (drying and heat)
Move eyes away from oculars and announce to assistant before moving
microscope
Critical Steps (microscope):
Locate side attachments, including camera and observer eye pieces appropriate
for case

Set interocular distance and focus oculars

Balance microscope
Utilize hand controls for focus, zoom, light intensity, and iris
Use forceps, scissors and needle driver under magnified vision
Basic neurosurgical instrumentation:
Scalpel use and safety

Hemostatic skin clips
Bipolar forceps
Types of suction tips and suction regulation
Scissors types and appropriate uses
Penfield dissectors
Kerrison punches
Rongeurs
Micro instruments
Retractors, hand held and fixed
VIII. Clinical Decision Making Simulator
The clinical decision making simulator utilizes a sophisticated simulated patient in a

scenario involving neurosurgical critical care. The purpose of the station is to allow you
to apply basic knowledge and decision-making skills in a realistic clinical scenario under
pressure, without risk to a live patient.
Follow these principles:
Stick to the basics

Use common sense
Behave as if you were in a real emergency department with this patient (you can
ask for things to happen and ask for the involvement of other appropriate team
members)
An educator in the simulation room will introduce the scenario. The manikin, simulated
patient is then available for taking a focused history and performing a focused physical
examination. This equipment allows verbal interchange, monitoring of vital signs, and
physical examination including cranial nerves. The status of the simulated patient will
change over time. You must respond to these changes both diagnostically and
therapeutically.
The educator will pause the scenario at certain times to ask you questions, discuss the
case, and make suggestions.

VIII. Operative Skills Stations
Work efficiently. Assist your table partner with drilling exercises, trading off so that you
both can complete each component of the exercise. There are duplicate materials for
the other exercises. A course director will announce the appropriate time to spend on
each exercise and announce the time to move on to the next exercise.
Numerous faculty members will be present in the practical laboratory, rotating between
tables. Please rely on them for advice and ask questions!
Practical Exercises
1. Overview 10 minute
2. Drilling: Bovine Scapula 40 minutes
3. Craniotomy 40 minutes
4. Dural Closure 30 minutes
5. Plating 20 minutes
6. Cranioplasty 30 minutes
7. Skin Closure 30 minutes
1. Drilling: Bovine Scapula Exercise
Introduction
Familiarize yourself with the powered hand piece, which spins faster than a jet
engine and can thus draw in bits of tissue or gauze, forming a dangerous whip
Familiarize yourself with the various drill bits
Shapes: round, match stick, acorn, wire passer/router
Finishes: cutting vs. diamond
Perforator bit (how the clutch works)
Lengths, bends, exposure of the shaft
Demonstrate using the various attachments with the proper bit
Learn how to change the hand pieces, attachments, and bits
Familiarize yourself with the sights, sounds and feel of the power tools as you
drill on and through bone
Understand fatigue for fine motor skills caused by extensive use of the drill
Bovine Scapula: Burr Holes, Bone flap and Tenting suture
Demonstrate how the clutch mechanism on the perforator bit functions

Make several burr holes with the perforator
Try and defeat the clutch, causing a dangerous plunge and thus learn how to
avoid this
Change bit to side cutting router bit and attach foot plate

Demonstrate how to angle foot plate such that the dura is safely dissected away
from the inner table of the bone
Connect the burr holes with the craniotome, creating a free bone flap
Discuss the hazards of penetrating/tearing the dura with the footplate craniotome
Switch to wire passer drill bit and place multiple holes circumferentially around
the craniotomy opening for tacking sutures
Place holes in the center of the bone flap for central tenting sutures
Place a glove under the bone defect and practice placing dural tack-up sutures
Describe the use and benefit of dural tack-up and tenting sutures
Make series of burr holes utilizing the Acorn Bit, noting the sound and feel of
chatter just as the bit penetrates the inner table of the bone, warning you to
stop drilling in order to protect the dura
Connect the holes again with a foot plated router
Utilize a diamond bit to smooth the edge of the craniotomy
Compare the diamond and cutting bits for fine bone edge removal
Note the generation of heat by the working drill bits, which can be transferred to
adjacent neurovascular structures including cranial nerves and spinal roots
Demonstrate how to irrigate during drilling to reduce heat, without spraying
irrigant into the eyes
Demonstrate how a cotton patty can be sucked into the working drill bit and
damage nearby sensitive structures; learn how to avoid this
2. Craniotomy
Using your plastic skull model, create frontal, parietal, occipital and subocciptal
(midline) craniotomy flaps
Place appropriate burr holes
Connect with footplate craniotome
Understand the confines presented by each approach to that cranial fossa based
on the size of the opening and angles involved
Draw out the associated standard incision for each craniotomy based on optimal
vascular pedicle and best cosmetic result
3. Dural Closure
Hydrate dural substitute by soaking

Using the brain model with a dural defect, cut the dural substitute slightly larger
in size than defect
Practice closing the defect using the dural substitute patch, using both
interrupted, simple running sutures, and running locked sutures
Discuss the advantages and disadvantages of each closure type
4. Bone Fixation
Re-approximate bone flaps with rigid fixation mini plates and screws

Feel the proper seating of a screw and plate in bone, using the beef scapula
Over tighten a screw to feel the loss of fixation; try to fix this by moving the plate
or using a wider or deeper screw
Place screws at a 90 degree and 45 degree angle to the bone surface; describe
the potential problems with the latter
Plate back in the craniotomy flaps on your plastic skull model using the various
shapes and sizes of plates
Dogbone plates for simple fixation
Snowflake burr hole covers for burr holes, especially in cosmetically apparent
locations (to avoid areas of scalp depression)
Squares and rectangles to reconstruct more complicates bone flaps, multiple
bone pieces, and/or fractures
Cut the zygoma at its frontal and temporal insertion points and plate it back in
place
5. Cranioplasty
Cut mesh to size and attach it to the bone edges utilizing screws
Mix up bone cement as describe on packet insert for 45 seconds
Place over mesh and shape
Allow to set
Utilize excess cement to close a burr hole on another craniotomy or to fill the
edges of a plated craniotomy (which can yield enhanced cosmetic results on the
forehead)
6. Skin Closure
Review the anatomy of the SCALP

o Skin
o Connective tissue (subcutaneous fat and fibrous tissue)
o Aponeurosis (Galea Aponeurotica)
o Loose areolar connective tissue (containing major scalp blood supply, just
below the galea)
o Pericranium
Discuss the importance of the galeal closure for homeostasis and tensile strength
Using the suture skin model kit and enclosed diagrams, practice the following
closures:
o Simple interrupted
o Simple running
o Running locked closure
o Vertical mattress

IX. Lectures
ii. Neurological and Neuro-trauma Assessment
v. ICP Management
ii. Emergency Evaluation and Management of Hydrocephalus Shunt Patients

Professional
Professionalism, Definitions
Supervision, and Pearls for Highly educated
the PGY1 Resident Impressive competence

Autonomy
A doctor
Comfortable salary
Creative and intellectually challenging work

Trust
Strict ethical and moral standards
Professional Professionalism
Ethical behavior
Confidentiality ACGME Outcome Project
A duty not to abandon because of inability to pay Six Competencies
Putting the clients interests ahead of ones own Patient Care
Medical Knowledge
Moral compass
Professionalism
Work ethic and motivation
Interpersonal and Communication Skills
Willingness to share in the transmission of Systems-based Practice
professional knowledge and values (like today)
Practice-based Learning and Improvement
Positive attitude towards the profession
Professionalism Professionalism
ACGME definition: When is it measured?

Manifested through a commitment to carrying Assessments
out professional responsibilities, adherence to Peer (360 degree) evaluations
ethical principles, and sensitivity to a diverse On the fly evaluations (clinical & operative)
patient population. By rotation
Annually
The Society of Neurological Surgeons

The essence of professionalism

How is it measured? Continuous self-improvement
Duty hour adherence and documentation
Lifelong learning and a thirst for knowledge
Nursing interactions You must read constantly
Patient interactions You must read systematically
Demeanor and dress You must master the field
Devotion to patient care You must read throughout your career
Ethical decision making You must share you own ideas with
professional colleagues by teaching, speaking
Contributions to the profession
and writing!
Bad outcomes What is expected of you?

Bad patient outcomes are sometimes Your very best effort
unavoidable Honest acceptance of results
Perfection is unobtainable Morbidity and mortality tracking, analysis and
reporting
Constant striving for improvement
Practice based learning
To care about those we care for
Professionalism Honesty
Patients know if you are on their side and Honesty even with patients after an error?
if you care about what happens to them Yes!
When you do: Involve your superiors for their experience in
They will forgive you sensitive patient communications
You will forgive yourself

Supervision Supervision
Main principles of surgical GME How is surgical training different?

Supervision Close supervision at every training level
Graduated authority and autonomy Attending staff
Senior/Chief resident staff
ACGME
Defined psychomotor goals for each training
Recognition that surgical training is fundamentally
different from non-surgical training level
Hierarchy
One size
fits all!
When does supervision apply? No surprises!

In the operating room Things your superiors want to know:
For the key portion of the procedure Patient admitted
For any portion in which you are not independently Significant change in status
competent Transfer to a different care level (e.g. ICU)
For ward and ICU procedures Operation needed
Until you are specifically cleared for independence Anything that will change the OR schedule
For decision making Angry family
Any time you dont know Anything you would want to know in their shoes
Any time you arent sure whether you know or not!
The student:
How are supervision and hierarchy
I hear and I forget; I see and I remember;
related?
I do and I understand. - Chinese
Acquisition of competence
Proverb
Cognitive and procedural
The teacher: Graduated autonomy
A teacher is one who makes himself Experience is the best teacher
progressively unnecessary. Ethical behavior
Uncompromising excellence in patient care
-Carruthers

Fatigue Fatigue
Two imperatives:
Fatigue compromises: Regulatory compliance for PGY1s
Patient safety 16 hours shift limit ABSOLUTE
Quality outcomes 80 hours per week, averaged over 4 weeks
Resident health One in 7 days off, averaged over 4 weeks
8 hour minimum inter-shift break
Direct or on-site supervision (senior resident or
faculty)
Quality and safety
Self monitoring
Ask for help, dont drive tired
Fatigue Pearls
Patient hand offs

Teamwork approach shortens shifts Its a long road Its hard work
Transfer of knowledge and responsibility is a If you dont enjoy the process, it may be
chance for dangerous errors and poor outcome difficult to finish it
Hard work without talent is a shame, but talent
What to do? without hard work is a tragedy.
Keep meticulous lists of key information, issues
- Robert Half, 20th cent.
Leave time for ordered, careful handovers at Goodness without knowledge is weak; knowledge
each shift change, without distractions without goodness is dangerous.
Leverage the electronic medical record - John Phillips, 1781
Pearls Pearls
What do we mean? You are about to enter the most exciting

You are all smart and talented profession in the world!
We are asking for How did you come to decide to be a
Neurosurgeon
Diligence Every neurosurgeon has a story
Humanity Ask your peers to tell you their stories

Pearls Pearls
Neurosurgery is a community Neurosurgery is a community

Relationships define us Chief and Program
Mentors
Colleagues
Patients
Community
Family
Pearls Pearls
Ask yourself these questions.. Its a long program

> 6 year program
How many people enjoy what they do every
Clinical Neurosurgery
day? > 36 months
How many people feel that they are making a 12 months as Chief Resident
positive contribution to the lives of other Neurology (3 months)
human beings every day? Neurointensive care
Neuroscience, Neuropathology, Neuroradiology, INR
Ask a Neurosurgeon these questions Research
The answers will be stereotypical 80 h/wk X 48 months X 3 years = 11,520 h
Almost no neurosurgeon regrets their decision Training a concert pianist: 10,000 h
Pearls Pearls
Rest Take care of yourself

When you are rested: Spend time away from the hospital
You look better Be with your family
You learn better Keep physically active
You will stay healthier

Pearls Pearls
Prioritize
Dont be afraid to ask
Who are the sickest patients?
Silence is often mistaken for understanding Emphasize their hand-offs
Ask attendings/senior residents when you Re-examine them
dont know Prioritize their care
Its OK to say I dont know Stay organized!
Particularly to patients Keep lists
Dont provide wrong information!
Be practical
Most of all, remember that sometimes you
dont know when you dont know Brain surgery is really just common sense
Pearls Pearls
Prepare for cases: Operating in a Accurate and timely communication up

protected learning environment is a and down the chain of command is critical
precious and extraordinary privilege There are 3 answers to any question: Yes,
Be rested No, or I dont know
Read about the disease Think before you speak, dont speculate
Study, understand the goals of the operation Nothing substitutes for seeing the patient
Meet the patient if you can yourself, repeatedly if indicated
Experience is critical and precious
Pearls Pearls
Always listen
You are not expected to know everything, but Dont come with problems
you are expected to learn Come with solutions
Always keep your composure
Avoid becoming argumentative with your Neurosurgery is defined by the need and
supervisors, peers or others (at any level)
Your education, and ultimately your success depends the ability to get it done
upon their willingness to share knowledge
Positive professional relationships will allow you to
excel and will help your patients The buck stops with YOU

Pearls
Pearls
Take it one day at a time!

Better is possible. It does not take genius.
It takes diligence. It takes moral clarity. It
takes ingenuity. And above all, it takes a
willingness to try.
Atul Gawande, 2007

ii. Neurological and Neurotrauma Assessment
H & P makes the diagnosis 90% of the time!
Neurological and Neuro Clinical examination still essential skill
trauma Assessment
Bootcamp
Assessment of Mental Status

6 Essential Parts of a Neurologic Exam
Level of Consciousness: (alert, somnolent,
1) Mental Status and Cognitive Function obtunded)
2) Language Orientation: (to time, place, examiner, situation)
3) Cranial Nerves Attention span
Mood and affect: (labile, apathetic, dysphoric,
4) Motor System
euphoric, anxious irritable)
5) Sensory System Disorders of thinking and perception:
6) Reflexes (hallucination, delusion, paranoia)
Cognitive Function Language
Common Knowledge Aphasias

Whos the president? Fluent (Wernickes) aphasia
Memory Nonfluent (Brocas) aphasia
Short term recall
Conduction aphasia
Name 3 common objects, then name them
again after 5 minutes Transcortical aphasias
Long term
Verifiable events from the past

Aphasias Assessment of Cranial Nerves
Aphasias Verbal Output Comprehension Repetition

Brocas Affected
Intact
Affected CN I (Olfactory Nerve)
Indications for carrying out this test include frontal
Wernickes Intact Affected Affected headache and seizures, which might be due to an olfactory
groove meningioma.
Conduction Intact Intact Affected
Smell is tested by using a nonnoxious stimulus such as
Transcortical
Affected
Intact
Intact
soap or coffee, testing each nostril individually.
Motor
Transcortical
Intact Affected Intact
Sensory
Assessment of Cranial Nerves Assessment of Cranial Nerves
CNs III, IV, and VI (Oculomotor, Trochlear, and

CN II (Optic Nerve) Abducens Nerves)
Visual acuity, visual fields, pupillary reaction to light.
Functions of these cranial nerves include pupillary
Check for an afferent pupillary defect by using the constriction and dilation, eye movements, and eyelid
swinging flashlight test. elevation.
Dysfunction of one or more of these functions produces
pupillary inequality (anisocoria), diplopia, or ptosis.
The extraocular muscles work together during the act of
conjugate gaze and convergence, which are evaluated
during the examination of these cranial nerves.
Assessment of Cranial Nerves Pupils
CNs III, IV, and VI (Oculomotor, Trochlear, and

Abducens Nerves)
Pupils. The pupils should be examined for equality. If anisocoria exists,
one must determine which pupil is abnormal.
Diplopia. The eyes should be moved into the extremes of gaze in the
six gaze directions that test individual muscles (superior rectus: up,
inferior rectus: down, lateral rectus: abduction, medial rectus:
adduction, inferior oblique: up and in, superior oblique: down and in).
Ptosis. The patient should look up for 1 to 2 minutes. Ptosis due to
myasthenia gravis usually worsens during prolonged upward gaze. The
ptosis of a Horner's syndrome is usually mild and associated with
miosis

Mydriasis Miosis
Disorder Cause Note
Disorder Cause Note

Horners syndrome Congenital, lesions of the Ptosis, depression of the
brain stem/cord. C8T2 upper lid + impaired
3rd nerve Diabetes, aneurysm, Often acute; diabetes: roots. Pancoast tumor, ipsilateral upper facial
trauma, temporal lobe, pupil usually spared carotid, cavernous sinus, sweating
herniation, tumor, cluster headache
ArgyllRobertson Syphilis, diabetes Irregular pupils
Tonic (Adies pupil) Idiopathic (? Viral) Unilateral, + arreflexia
Pontine Thrombosis, hemorrhage Small reactive

Topical drugs Scopolamine, atropine,
cocaine
Topical drugs Glaucoma drugs
Systemic drugs Anticholinergics, Systemic drugs Parasympathetic drugs
antihistamines, MAO, (neostigmine), opioids
amphetamines
Iris Surgery, trauma
CN V (Trigeminal Nerve) CN VII (Facial Nerve)

Both motor and sensory divisions of the trigeminal nerve should be
The facial nerve supplies the muscles of facial expression and carries
tested.
taste sensation from the anterior two thirds of the tongue.
The presence of wasting of a temporalis muscle suggests involvement
Have the patient smile vigorously to assess the strength of the muscles
of the motor root. Jaw deviation on opening the mouth may also be
of the lower face, have the patient wrinkle the brow, and to squeeze
present.
the eyes tightly together while the examiner attempts to pry them
The masticatory muscles should be palpated when the patient apart.
attempts to clench the jaws.
The lacrimal and salivatory glands are also innervated by
The three sensory divisions of CN V. parasympathetic fibers that are carried in the facial nerves.
CN IX and X (Glossopharyngeal and Vagus Nerves)

CN VIII (VestibularAuditory Nerve)
Cranial nerves IX and X are usually tested together. It is convenient to
Rubbing the fingers together can be compared between two sides for think of cranial nerve IX as mainly sensory and cranial nerve X as
screening. Hearing loss can be detected with a tuning fork if it is mainly motor.
severe.
Testing sensation on the posterior third of the tongue and oropharynx
The Dolls eye maneuver is performed by quickly moving the head
is examined by testing the gag reflex.
from side to side and observing the movement of the globe within the
orbit. Hoarseness is characteristic of involvement of cranial nerve X and also
occurs with lesions in the nucleus ambiguus, the origin of motor fibers
Comatose patient with intact midbrain and pons eyes will deviate
to the pharynx and larynx.
towards opposite direction of head turning.
Unilateral lesion involving CN X reveals uvula deviation.
Vestibular Caloric testing is useful in confirming the presence or
absence of brainstem function in comatose patients. Bilateral lesions of the descending corticobulbar fibers can produce
pseudobulbar palsy, in which the palate elevates poorly to saying "ah"
but briskly when a gag reflex is elicited.

CN XII (Hypoglossal Nerve)

CN XI (Spinal Accessory) The hypoglossal nerve contains only motor fibers to the ipsilateral
The spinal accessory nerve supplies the ipsilateral SCM and tongue.
trapezius muscles. Damage to the hypoglossal nucleus or its fibers leads to tongue
Weakness of head turning to opposite side atrophy, weakness, and fasciculations.
Examination should include observation for muscle atrophy, The tongue protrudes toward the side of lesion.
palpation and movement against resistance.
Hemiparesis may be associated with weakness of shoulder shrug
and weakness of turning the face toward the side of the
hemiparesis.
Assessment of Motor Function Muscle Grading

Grade Strength
American Spinal Injury Association (ASIA) Motor Key 0 Total paralysis
Root Function Muscle 1 Palpable or visible contraction
C5 Elbow flexors Biceps 2 Active movement, full range of motion, gravity eliminated
C6 Wrist extensors Extensor carpi radialis longus and 3 Active movement, full range of motion, against gravity
brevis
4 Active movement, full range of motion, against gravity and
C7 Elbow extensors Triceps provides some resistance
C8 Finger flexors Flexor digitorum profundus 5 Active movement, full range of motion, against gravity and
T1 Finger abductors Abductor digiti minimi provides normal resistance
L2 Hip flexors Iliopsoas NT Not tested
L3 Knee extensors Quadriceps

L4 Ankle dorsiflexors Tibialis anterior
L5 Long toe extensors Extensors hallucis longus
S1 Ankle plantar flexors Gastrocnemius, soleus
Assessment of Dermatomes

Deep Tendon Reflexes

Tendon Reflex Grading Scale
Examination Localization Effect
Contraction of the biceps Grade Description

Biceps Tendon C5C6 (musculocutaneous n.) muscle, Elbow flexion
0 Absent
1+ Sluggish
Brachioradialis Tendon C6 (radial n.) Elbow flexion 2+ Normal
3+ Hyperactive without clonus
Triceps Tendon C6C7 (radial n.) Elbow extension 4+ Hyperactive with clonus
Knee extension
Patellar Tendon L3L4 (femoral n)
Achilles Tendon S1S2 (tibial n.) Plantar flexion of the foot
Reflex Examination Assessment of Radiculopathy
Clonus Root Distribution of Sensory Motor Weakness Reflex Loss

Level Loss
Babinski C5 Shoulder, upper arm Shoulder abduction None
Hoffman C6 Anterior upper arm, Forearm flexion Biceps
Bulbocavernosus radial forearm, thumb
Anal wink C7 2nd , 3rd finger Forearm extension,

wrist, handgrip
Triceps
C8 4th , 5th finger Wrist extension, None

intrinsic hand muscle
L4 Anterior thigh, inner Knee extension Patellar
calf, foot
L5 Outer calf, great toe Foot, toe dorsiflexion None
S1 Outer calf, foot, Knee flexion, foot Achilles
posterior thigh flexion
Clinical Syndromes Clinical Syndromes
Central Cord Syndrome:

Conus Medullaris Syndrome:
Cervical region injury and leads to greater weakness in the
Injury to the terminal spinal cord. Early incontinence,
upper limbs than in the lower limbs, with sacral sensory
perineal numbness and preserved Knee reflex.
sparing.
Cauda Equina Syndrome:
BrownSquard syndrome:
Injury to the lumbosacral nerve roots in the spinal
Ipsilateral hemiplegia and loss of proprioceptive sensation
canal. Asymmetric lower limb weakness, leg pain,
with contralateral loss of pain and temperature sensations
numbness and absent reflexes. Delayed incontinence.
following a spinal hemisection.
Anterior Cord Syndrome:
Lesion causing variable loss of motor function and sensitivity
to pain and temperature; proprioception is preserved.

Neurotrauma Assessment Neurotrauma Assessment

Hypotension (single SBP < 90mm Hg)
Initial Survey Doubles mortality
ABCs Hypoxia (apnea or cyanosis, or PaO2 < 60mmHg
Blood Pressure on ABG)
Oxygenation Increases mortality
GCS Combination of both
Pupils Triples mortality
Motor symmetry/strength Increases the risk of bad outcome

Hypotension Neurogenic shock
Rarely attributable to head injury except: Spinal cord injury above T1
Terminal stages Interruption of sympathetics
Dysfunction of medulla Loss of vascular tone (vasoconstrictors) below level of injury
Cardiovascular collapse Incidence increases with injuries above T6
Infancy Parasympathetics relatively unopposed

Blood lost intracranially or in subgaleal space Bradycardia
Scalp wounds Lower systemic vascular resistance
Enough blood lost to cause hypovolemia Venous pooling
Neurotrauma Assessment External Examination of the Cranium

Visual inspection of the cranium:
Initial Survey Evidence of basal skull fracture
Evidence of Injury Raccoons eyes
Battle sign
Head
CSF rhino/otorrhea
Spine
Check of facial fractures
Eyes Lefort fractures
Tympanic Membranes Orbital rim fracture
CSF Leak Periorbital edema, proptosis
Craniocervical auscultation
Auscultate over globe of eye: bruits may indicate
traumatic CC fistula
Auscultate over the carotid artery


Never insert nasogastric tube into a patient with
Evidence of basal skull fractures
Raccoon's eyes suspected basilar skull fracture
Battles sign
CSF rhinorhea/ otorrhea
Hemotympanum or laceration of external
auditory canal
Clinical Findings of CSF Leak Glasgow Coma Scale (GCS): 315
Determining if rhinorrhea or otorrhea is due to Glascow Coma Scale

CSF leak: Points Eye opening Verbal Motor
Clear drainage unless CSF is infected or 6 Follow
mixed with blood commands
5 Oriented Localizes pain
Patient with rhinorrhea describes salty or
metallic taste 4 Spontaneous Confused Withdraws to
pain
Collect fluid and obtain quantitative 3 To speech Inappropriate Decorticate
glucose, beta Transferrin
2
2 To pain Incomprehensible Decerebrate
Ring sign
1 None None None

Clinical severity is graded by GCS Combine clinical cues (mechanism) with
Mild, GCS 1315
Normal to lethargic radiological findings and physical exam
Mildly disoriented History is critical
Moderate, GCS 912 Exam is localizing
Lethargic to obtunded
Follows commands with arousal Radiology is confirmatory
Confused Serial assessment is essential
Severe, GCS 38
Comatose, no eye opening or verbalization Mental status
Does not follow commands Focal findings
Motor exam: ranges from localizing to posturing

Neurotrauma Assessment Neurological Assessment

Combine clinical cues (mechanism) with
radiological findings and physical exam Learn it all
History is critical
Learn how to divide it up (focused
Exam is localizing
exam)
Radiology is confirmatory
Serial assessment is essential Never skip the important features
Mental status Document findings so others can
Focal findings understand
Radiology

Objectives
Emergency Cranial Develop method for rapid, thorough
Radiological Assessment interpretation of computed tomography (CT)
and MR imaging of the head
Identify basic intracranial structures
Identify intracranial brain shift, hemorrhage,
and fractures
The Society of Neurological Surgeons Be able to communicate accurately to the
Bootcamp chief resident or attending the important
findings that may impact clinical decision
making and emergent patient management.
Your tools Description

The CT scan is the workhorse for most Identify R L
neurosurgical emergencies
Patient name
Cranial xrays are rarely helpful except in Date of study
children with skull fractures Specific type of study

Emergent MR imaging usually supplements CT Abnormal findings
for cranial tumor, infection, or stroke cases with location
Always interpret the scans in the context of Important normal
the clinical situation and always select the findings with location
best imaging modality to the suspected Differential diagnosis
pathology
CT Scan CT Scan
Computed Axial Tomography A collection of
superimposed Xrays
CALCIFIED STRUCTURES (e.g. bone, ACUTE calcium in
BLOOD appear WHITE, or hyperdense)
Ischemic stroke does NOT show on CT until 1224
hours after it has occurred it appears DARK (or
hypodense) then
Slices are taken at plane parallel to anterior skull
base floor Bone Window Soft Tissue Window
A CT scan is the most frequently ordered study in
Neurosurgery #1 reason: To Rule Out BLEED

Suprasellar
Caudate
Interpeduncular
Ambient Internal capsule
Thalamus
Quadrideminal
Parietal Lobe
Choroid Plexus
Hematomas Epidural Hemorrhage

Epidural Hematoma (EPD) Between skull and dura, limited by
periosteal layer so stops at sutures of
Subdural Hematomas (SDH) skull and thus biconvex (lens) shaped
Subarachnoid Hemorrhage (SAH) Due to middle meningeal artery tear,
often associated with skull fracture
Intracerebral Hemorrhage (ICH) Patients can have concussion at injury,
Intraventricular Hemorrhage (IVH) then a lucid interval when theyre
awake from the concussion, and then
suddenly worsen due to blood
compressing brain
Treatment is usually emergent surgery
(unless extremely small)

Subdural Hematoma: Clot age and CT Acute SDH

Imaging Characteristics
Emergent evacuation
If symptomatic and > 1 cm
Higher morbidity and
mortality than EDH
Greater impact than EDH,
underlying brain injury
Acute Subacute Chronic 5090% mortality
Chronic SDH
Subarachnoid Hemorrhage
Avg. age ~ 63 y/o
~50% without significant
hx. of trauma
Hypodense/isodense
crescentic collection
Evacuation if:
Focal deficit, mental status
change, serial enlargement
Burr hole drainage
Looks like motor oil
55 year old male, fell off ladder,

Traumatic SAH no LOC, mild headache
Subarachnoid Hemorrhage: Pattern
Recognition
ACoA Aneurysm Perimesenchephalic Diffuse SAH

syndrome

55 year old male, fell off ladder,

Traumatic SAH no LOC, mild headache
Intracerebral Hemorrhage:
Chronic Hypertension
Repeat head CT stable, discharged next day with routine

follow up
Intracerebral Hemorrhage
IPH, IVH, Acute Hydrocephalus
Hypertensive IPH
50% in basal ganglia
15% thalamus
1015% pons
Intracerebral Hemorrhage: Lobar Intraventricular Hemorrhage

Frontal Horn Temporal Horn Lateral Ventricle
Frontal Occipital
Third Horns
Fourth

Intraventricular Hemorrhage
Aneurysmal SAH w/ IVH HTN w/ IVH
Traumatic Contusions
Coup (direct injury of brain from impact) or
contrecoup (injury due to brain hitting skull
on opposite side as skull decelerates but
brain doesnt) usually temporal/frontal
Can develop extreme amount of edema or

blossom, so must follow closely with repeat
CT scans
Surgical evacuation if excessive mass effect,

avoidance of important brain structures to
access surgically, and meaningful survival
possible

Acute Hydrocephalus Acute Hydrocephalus
EVD
Ischemic Stroke MCA Infarcts

Typically follow a vascular distribution such
as the territory of the MCA, PCA or ACA.
A stroke may take several hours before it is

apparent on a CT scan.
Typically is seen earlier on an MRI
Infarct with a Midline Shift Cerebral Edema

Loss of Grey/White Differentiation
Cisternal Effacement
Midline Shift

Cerebral Edema
Basal Cistern Effacement
Vasogenic: from
brain tumor
BBB disrupted
Responds to
steroids
Cytotoxic: from
trauma
BBB closed
NO steroids
Normal Tight Swollen Brain
Fractures Depressed Skull Fracture
Linear
Depressed
Open Depressed
Basal Skull Fracture

Reconstruction
Open
Depressed
Skull
Fracture
Recovery: Two Months Later

Open
Depressed
Skull
Fracture s/p
MVA
Foramen ovale
Foramen spinosum
Carotid canal
Jugular fossa
Mastoid air cells

Sphenoid sinus
Basilar
Skull
Fracture
Carotid canal
Basilar Skull Fracture of the Temporal

Bone Seen on Bone Windows Basic Principles of MR Imaging
Images are created based on signals returning from spinning
protons
Not based on density
Objects are described in terms of intensity (hypointense,

isointense, hyperintense)
T1 and T2 Weighted Imaging
T1 Post Contrast Enhancement
T1 Weighted Image of the Normal T2 Weighted Image of the Normal

Brain Brain

Compare the detail:

MRI: Views in different planes
CT (left) vs. MRI T1 (right)
Axial Sagittal Coronal
Compare the detail: T1 Post Gadolinium Image of a

CT (left) vs. MRI T2 (right) Brain Tumor
Magnetic Resonance Imaging: Stroke

Diffuse Axonal Injury (DAI) Diffusion Weighted Imaging:
Ischemia
Cytotoxic edema
Increase in signal as soon as 510 minutes after

stroke onset
Left: DWI
Right: ADC map

spine injury: location

Emergency
Spinal type neurologic sequelae
T
Radiological Assessment 1. cervical . . . . . . brainstem, cord or root
2. thoracic . . . . . cord or root

L
3. lumbar . . . . . . conus or root
cord injury: deficit patterns spine injury: types
1. normal (no neurologic injury) 1. muscular/ligamentous
a. contusions
b. strains + / - dislocation
2. incomplete deficit (syndromes)
c. sprains
a. central cord a. complete ligamentous disruption

b. anterior cord
c. BrownSequard 2. fractures
d. posterior cord stability:
e. conus/epiconus
1. stable
2. unstable
3. complete functional transection
spine injury: muscular/ligamentous spine injury: ligamentous
anterior longitudinal
1. contusions
posterior longitudinal
2. strains
3. sprains ligamentum flavum

4. complete
ligamentous interspinous
disruption
supraspinous

spinal Imaging after trauma indications

spine injury: facet joints
1. clinical indications
a. spineregion pain
b. neurologic deficit
(1) radicular
(2) cord
c. severe multisystem injuries
d. altered mental status
2. clinical rationale
a. prevent cord, root injury (neurologic stability)

b. prevent incapacitating deformity and pain
(mechanical instability)
Which patients need imaging of the cervical spine? Which patients need imaging of the cervical spine?
Case 1: mild/moderate trauma patient Case 2: mild/moderate trauma patient
no loss of consciousness altered mental status (patient is obtunded and/or

normal mental status (and not intoxicated) intoxicated)
no neck pain or tenderness neck pain or tenderness
no neurologic deficit neurologic symptoms or deficit
no imaging needed
Which patients need imaging of the cervical spine? spinal Imaging after trauma imaging tools
1. boney fractures/dislocations
Case 3: severe multisystem trauma patient a. Xrays AP, lateral, openmouth odontoid
b. CT scan
2. ligamentous
a. MRI scan
b. flexion extension lateral xray
3. disk injury
imaging needed a. MRI scan

b. CT/myelogram

cervical: 7
spine injury: alignment
lordotic curve
1. prevertebral fascia
thoracic: 12 1
2. anterior marginal line
kyphotic curve
3. posterior marginal line 2
3
4. spinolaminar line
lumbar: 5 5. posterior spinous line
lordotic curve
4
5
A. vertebral body width
B. spinal canal diameter
normal cervical spine normal cervical spine

occiput to T1
bone integrity
alignment: of
vertebral bodies
laminae
facets
lordotic curve
Disk, transverse foramen
subaxial cervical spine ligamentous injury without fracture
annulus nucleus instability possible even with normal CT; early MRI helpful
stabilize until neck pain resolves, assess competence of
fibrosis pulposis
ligaments with flexion/extension Xrays or MRI

unilateral facet disruption

Bilateral facet fracture/dislocation:
jumped or locked facets
subluxation +/ fracture (major facet disruption) burst fracture
cord contusion Upper Cervical Spine: C1 C2

C1 Jefferson fracture C2 odontoid fractures/subluxations
axial loading type I

often associated with
C2 fractures type II
assess transverse ligament
type III
C2 Hangmans fracture Atlantoaxial subluxation
Atlantodental interval
hyperextension/axial loading
(ADI)
bilateral C2 pars
Left: Normal ADI 3 mm
interarticularis fracture
Right: C12 subluxation

unstable when:
a. >3.5 mm subluxation of
C2 on C3
b. >11 degrees angulation
thoracic and lumbar vertebra thoracic and lumbar vertebra
minor fractures:
a. transverse process
thoracic b. spinous process
c. minimal compression
d. endplate
lumbar

Denis 3column model thoracolumbar spine AO Classification fractures
onecolumn injury usually stable

A B C
twocolumn injury usually unstable
compression distraction rotation
threecolumn injury unstable injury mechanism
Class A: vertebral body compression Burst fracture
compression fracture
Anterior column failure
Middle and posterior columns intact
Unstable if >50% compression or
>20 degrees angulation
burst fracture
Anterior and middle column failure
Retropulsion of bone into canal
Often have neurologic deficit
Unstable
flexion/distraction
Class B: distraction (+ flexion/extension) posterior ligamentous injury
Types Flexion/distraction (Chance, seat belt injury)

Hyperextension
Threecolumn injury: unstable

Class C: threecolumn injury with rotation fracturedislocation
fracturedislocation
shear injury
unstable
neurologic deficit
1. know normal anatomy
2. obtain appropriate studies

(review every level studied)
xrays
CT
MRI
flexion/extension Xrays
3. assess stability (mechanical and neurologic)

determine the integrity of the three columns
(bony and ligamentous)
recognize fracture types associated
with mechanism of injury

v. ICP Management
Objectives
ICP Management 1. MonroKellie Doctrine
2. Normal and pathological ICP
3. Indications for ICP monitoring (TBI
Guidelines)
4. Normal and pathological CPP (variation by
age)
5. ICP Management
Bootcamp
1st Tier Therapies
2nd Tier Therapies
MonroKellie Doctrine MonroKellie Doctrine

(Edinburgh, 1783) (Edinburgh, 1783)
The cranium is a "rigid box and its total CSF Blood Brain Tissue
volume remains constant.
(3 Compartments)
Increase in the volume of the cranial
compartments (brain, blood, and/or CSF) will
elevate intracranial pressure (ICP). Increased ICP may be conceived as the result of
an attempt to force excess volume into a rigid
If one of these three compartments increase
container
in volume, it must occur at the expense of
volume of the other two elements
Intracranial Pressure
Critical Recognition of ICP
Why is it important?
What would be the clinical cost of loss of
volume from each of the 3 compartments?
Look for progressive neurologic

signs
Treatable cause of neurologic decline Look at three compartments at

risk
Determine the effect of loss of

volume from each
The Society of Neurological Surgeons Bootcamp

v. ICP Management
Principles of Treatment of ICP CMRO2 = CBF X AVDO2
ABCs of resuscitation CMRO = Cerebral metabolic rate of oxygen

Maintain perfusion matched to metabolic CBF = Cerebral blood flow
need AVDO2 = Arteriovenous difference of oxygen
Avoid distortion of brain
Limit spread of brain edema
Autoregulation Autoregulation
The tendency of the brain to keep AVDO2
Metabolic constant, at any level of CMRO2 or, to keep
Higher or lower CBF proportional to demands of CBF constant when CMRO2 and AVDO2 are
brain (CMRO2) already constant. All occurs by adjusting the
Pressure diameter of resistance vessels (25 500 ).
CBF unchanged despite changes in BP, ICP or both CMRO2 = AVDO2 x CBF
Viscosity
CBF unchanged despite changes in blood viscosity
CBF= CPP/CVR
CO2 Reactivity Hyperventilation

With hypercarbia Hyperventilation -7 intravascular CO2 -7
extravascular CO2 (CO2 readily crosses BBB) -7
Hypoventilation, CO2 -7 Vasodilatation -7 pH -7 vasoconstriction (H+ ion is vasodilator)
CBF Hyperventilation remains an excellent means for rapidly
reducing high ICP
With hypocarbia Preventive hyperventilation retards recovery from severe
Hyperventilation, CO2 -7 Vasoconstriction -7 head injury
CBF Any hyperventilation is ideally accompanied by some
monitoring of cerebral oxygenation (PbtO2, SjvO2/AVDO2,
CBF, infrared spectroscopy)
In the absence of such monitoring, hyperventilation is
used as a later step in ICP control and always with
sufficient arterial blood pressure (MAP >90 mmHg, CPP
>60 mmHg)

v. ICP Management
Guidelines for the Management of

Mannitol is used Severe TBI
Developed by the American Association of Neurological
To decrease high intracranial pressure
0
Surgeons & the Brain Trauma Foundation
Updated from 1995 and 2000 editions
To decrease brain bulk during operation 0
0 In the most recent edition, Levels of Recommendation were
changed from Standard, Guideline, and Option to Level I,
To improve CBF Level II, and Level III, respectively. Recommendation Levels
Decreases viscosity -7 Increase in CBF -7 I, II, and III, are derived from Class I, II, and III evidence,
respectively.
Compensatory vasoconstriction Class I prospective randomized controlled trials (PRCT)
(Autoregulation) -7 the gold standard of clinical trials.
Class II clinical studies in which reliable data were
CBF back to baseline, CBV decreases, ICP collected prospectively and analyzed retrospectively.
decreases Class III studies based upon retrospectively collected
data, case review/report or studies, expert opinion.
Indications for Intracranial Pressure

ICP
Monitoring
Topic Level 1 Level 2 Level 3
Indications for ICP There are insufficient Intracranial pressure ICP monitoring is
Level I monitoring data (ICP) should be indicated in patients
There are insufficient data to support a treatment standard for this monitored in all with severe TBI
topic. Salvageable GCS with a normal CT scan
Level II score of 38 after if > 40 years,
resuscitation blood pressure
ICP should be monitored in all salvageable patients with a severe TBI and an abnormal CT BP <90 mm Hg.
(GCS score of 38 after resuscitation) and an abnormal computed Intracranial Pressure There are insufficient Treatment should be A combination of ICP
tomography (CT) scan. An abnormal CT scan of the head is one that Thresholds data initiated with ICP> values, and clinical and
reveals hematomas, contusions, swelling, herniation, or compressed 20 mm Hg. brain CT
basal cisterns. findings, should be
Level III used to determine the
need for treatment.
ICP monitoring is indicated in patients with severe TBI with a normal
CT scan if two or more of the following features are noted at
admission: age > 40 years, unilateral or bilateral motor posturing, or
SBP < 90 mm Hg.
Intracranial Pressure Monitoring Eye Opening

4 spontaneous
Technology 3 to speech/sound
2 to pain Glasgow Coma Scale
1 no response
Ventricular catheter connected to an external strain
gauge is the most accurate, lowcost, and reliable Verbal Response
method of monitoring intracranial pressure (ICP). It also 5 oriented
can be recalibrated in situ. 4 confused
3 inappropriate Severity GCS
ICP transduction via fiberoptic or micro strain gauge 2 incomprehensible
Mild GS 14 15
devices placed in ventricular catheters provide similar 1 none
benefits, but at a higher cost. Moderate GCS 913
Motor Response
Parenchymal ICP monitors cannot be recalibrated during 6 obeys Severe GCS 38
monitoring. 5 localizes
Subarachnoid, subdural, and epidural monitors (fluid 4 withdraws from pain
coupled or pneumatic) are less accurate. 3 abnormal flexion
2 abnormal extension
1 no response

v. ICP Management
CPP=MAPICP
Guidelines for the Management of

Severe TBI
ICP management protocol
Stepwise ICP Management Stepwise ICP Management

Decompressive
Craniectomy Wide, open dura
Pentobarbital bolus then

Treatment is escalated to Barbiturates
continuous IV or Propofol
Pressor Phenylephrine
continuous IV
the next level based upon a and/or dopamine
Therapy continuous IV
33 35 C with surface/IV
goal of ICP < 20 mm Hg and Hypothermia cooling; Rewarm slowly
CPP 50 70 mm Hg Euvolemia/ Replace fluid
Hypervolemia losses; Goal CVP
> 8 10 mm Hg
PaCO2 < 35; Titrate to avoid
Hyperventilation* SjvO2 < 60 or PbtO2 <15
Hyperosmolar Mannitol or Hypertonic Saline ICP Goal ICP < 20

Therapy boluses as needed until Serum Osm > 320
Control mm Hg Treatment is escalated to the
Chemical Vecuronium continuous IV next level based upon a goal
Paralysis
of CPP 50 70 mm Hg
Morphine or Fentanyl continuous IV

Sedation + Midazolam or Propofol continuous IV
CSF Drain @ external auditory

Drainage canal as needed
* At baseline, PaCO2 is kept 40 mm Hg
1. 2.
Check for 30degree head elevation
Loosen Cervical collar if in place
Assure ET tube tape is not constricting tube
Open EVD for ICP > 20 for 10 minutes and then close and transduce ICP
* Repeat once
* If ICP > 20 keep open at 15 above midbrain, and proceed with ICP module

v. ICP Management
3. Hypothermia
Prophylactic There are There are Pooled data indicate
Hypothermia insufficient insufficient that prophylactic
data data hypothermia is
not significantly
associated with
decreased mortality
when compared with
normothermic
controls.
Hyperosmolar Therapy
4.
Hyperosmolar There are Mannitol is Restrict
Therapy insufficient data effective for Mannitol use

control of prior to ICP
raised (ICP) at monitoring to
Keep Body temperature < 37.5 doses of 0.25 patients with
gm/kg to 1 g/kg signs of

body weight. transtentorial
herniation
Hypertonic saline can lower ICP and improve

hemodynamics.
Great in patients with low BP and high ICP !!!
Hyperventilation
6. Topic Level 1 Level 2 Level 3
Hyperventilation There are Prophylactic Hyperventilation is
insufficient hyperventilation recommended as a temporizing
data (PaCO2 of 25 mm measure for the reduction of
Hg or less) is not (ICP).
recommended. Hyperventilation should be
avoided during the first 24
hours after injury when cerebral
blood flow (CBF) is often
critically reduced.
If hyperventilation is used,
jugular venous oxygen
saturation (SjO2) or brain tissue
oxygen tension (PbrO2)
measurements are
recommended to monitor
oxygen delivery.

v. ICP Management
8.
7.
9. Case Example
27 y/o patient after ATV accident
Needs to be intubated at the scene
Decompressive Does not open eyes
Hemicraniectomy no movement in his arms but
cramping extending his legs
Bilateral Frontal
Craniectomy
Injury Decompression

v. ICP Management
Case Example: Decompression Barbiturates/Coma
Seizure Prophylaxis
Antiseizure There are Anticonvulsants n/a
Prophylaxis Insufficient are indicated to
data decrease the incidence
of early PTS (within 7
days of injury).

Learning Objectives
Unstable
Neurosurgical Patient: 1. Evaluation of stupor and coma
2. Management of status epilepticus
Case Scenarios 3. Evaluation and management of hypoxia
4. Evaluation and management of sepsis
5. Expanding posterior fossa mass
6. Back pain and weakness after spine surgery
Bootcamp
7. Cerebral vasospasm after SAH
Possible Causes of Delayed Awakening After

PATIENT 1 Intracranial Surgery
Brain Injury Medication Systemic
You are called by an ICU nurse at 22:00 about Pt 1 Intracranial hemorrhage Sedatives Hypothermia
48 year old man who just underwent clipping of ruptured R MCA (intraparenchymal, Analgesics Respiratory (hypoxia,
aneurysm earlier today epidural, subdural, hypercapnia)
Neuromuscular blockers
Still comatose over an hour after arrival from the PACU, but he was subarachnoid)
following commands when left for the OR Anticonvulsants Cardiovascular
Stroke (hypotension, shock)
You ask for a CT scan Cerebral edema Metabolic/endocrine
It will take about 1015 minutes to disentangle yourself from the ED Hydrocephalus (hypo/hypernatremia,
The nurse reassures you that Pt 1 is still mechanically ventilated from hypo/hyperglycemia,
Pneumocephalus
the OR; and that airway, breathing and circulation are adequate panhypopituitarism,
Seizures (postictal state,
Per your signout sheet status, nonconvulsive adrenal insufficiency,
Pt 1 arrived earlier this morning as a H&H Gr III, Fisher Gr III with status) hypothyroidism)
moderate hydrocephalus Renal failure
Had a ventriculostomy drain placed Hepatic failure
Received 1000mg of fosphenytoin and 60 mg of nimodipine prior to
going to the OR for surgical ligation Sepsis
From Handbook of Neurocritical Care, ed. Bhardwaj, 2004.
Red Flags for Neurologic Compromise Focused Exam

NEW asymmetry in the neurologic exam Level of consciousness
Arousability
Exam not trending toward improvement Motor responses
Verbal output
Eyes
Movements
Pupillary light reflexes
Respiratory pattern
ABCs
Patterns can help indicated level of injury
More difficult to assess in intubated patients

What Causes Coma?

Consciousness is a Continuum Structural
Impairment of the ascending arousal systems in the brainstem

Levels of consciousness Ex. Trauma, brainstem stroke or hemorrhage
Awake/alert Because the ascending arousal system is near many cranial nerve nuclei,
Fully aware of self and environment therefore focal impairment of brainstem reflexes would be expected
Lethargic Or, structural damage can occur to both cerebral hemispheres
Mildly depressed consciousness, but can be easily aroused to wakefulness Ex. Bilateral subdural hematomas, large or multiple brain tumors, increased intracranial
pressure
Obtunded Metabolic
Moderately depressed consciousness, can be aroused with stimulation to
answer questions, for example, but will likely lapse back into an obtunded Both cerebral hemispheres are most commonly involved in a metabolic or toxic
state without verbal or light tactile stimuli insult that causes coma
Common causes:
Stuporous Loss of substrate of cerebral metabolism
Deeply depressed consciousness, those who can only be aroused by vigorous Hypoxia, hypoglycemia, global ischemia
and repeated stimuli and will lapse back into unresponsiveness as soon as Derangement of normal physiology
such stimuli is withdrawn
Hypo or hypernatremia, hyperglycemia, ongoing seizures, hypothyroidism
Comatose Toxins
Total absence of awareness of self and environment even when externally Drugs, hypercarbia, liver failure, renal failure, sepsis, meningitis
stimulated, regardless of the stimulus used
From The Diagnosis of Stupor and Coma, 3rd ed., by Plum and Posner Kandel & Schwartz Table 451
Glasgow Coma Scale
Eyes Verbal Motor

4 spontaneous 5 oriented 6 obeys
3 voice 4 confused 5 localizes
2 pain 3 inappropriate 4 withdraws
1 no eye opening 2 incomprehensible 3 decorticate
1 none 2 decerebrate
1 none

Management of the Comatose or

Neurologically Deteriorating Patient PATIENT 2
ABCs You are called to the ICU to see a patient with
History generalized tonicclonic seizure activity. The
Physical Examination
Check your equipment
patient is a 45 y/o F status post
Fix the fixable uncomplicated resection of a right frontal
Check medications meningioma. What do you do?
Malfunctioning drains and monitors
Treat seizures
Fix abnormal lab values
Imaging
Intervention
Status Epilepticus Etiology

Seizures are hypersynchronous paroxysmal Common medical causes of seizure in the ICU are
metabolic abnormalities, sepsis, and acute drug toxicity
cortical discharges with either motor or withdrawal
(convulsive), sensory, or cognitive dysfunction Metabolic abnormalities may be responsible for up to 3035% of
seizures in critically ill patients
Status epilepticus is defined as a seizure lasting Hyponatremia, hypocalcemia, hypophosphatemia, uremia and
more than 30 minutes, or more than one seizure hypoglycemia
without a return to neurologic baseline in Patients with CNS insults are obviously at high risk for
between seizures
Highest risk factors include penetrating missile injury, acute
Epilepsy is recurrence of unprovoked seizures subdural hemorrhage, depressed skull fracture, and cerebral
contusions
Varelas Varelas
JAMA (1993) 270(7):854-859

JAMA (1993) 270(7):854-859

Which Patients Should Get Emergent EEGs? PATIENT 2
Patients who are in coma for unknown reasons WHAT ELSE?
HCT !!!
Between 830% of patients, depending on patient
population, show some form of seizure activity
Patients with being treated for status epilepticus who
meet the following criteria
Receive longacting neuromuscular paralytic agents
Have a prolonged postictal period (> 12 hours)
Are being treated for refractory SE
OR have atypical features of their seizures suggestive of pseudoseizure
Denver Gen Hosp

Acute Hypoxic Event
PATIENT 3 Increased
Cuff Leak Resistance
Replace Hand Ventilate Pass Suction
Tube FiO2 Catheter
You are called to the bedside of a patient in
the ICU who has had a sudden drop in her No

Obstruction
Obstruction
oxygen saturation. 30 y/o F, hospital day 20,

Fix Mechanical Check O2 Source
Problems Ventilator Circuit
Check Tube
DAI, ventriculostomy, paralyzed, sedated, ICP R/O Plug
high teens consistently. What are you Chest

Tube Physical Exam Obstruction
Tension
thinking? Pneumothorax
Persists
Replace
Lab / X-ray Tube
Progression Pulmonary Pulmonary Intervention

of Disease Embolism Edema or Procedures
Hypoxia Respiratory Failure

Investigations: Classic indications for mechanical ventilation
ABG Respiratory criteria
CXR Hypoxia: PaO2<70 on 40% O2/significant desaturation on
maximum supplemental O2
EKG Ventilatory failure: PaCO2>60 on ABG (unless compensated COPD);
Consider: Vital capacity < 1015 cc/kg (Can the patient count to 10 at least?);
NIF < 25cm H2O
Cardiac Enzymes Helical Chest CT

CBC ( anemia, leukocytosis)
DVT Ultrasound ( consider upper and lower ext.)
Abdominal Series

Tachypnea/respiratory distress: RR>30

Neurologic criteria
Decreased mental status
(GCS<9, or trending toward
decline), as from increasing
intracranial pressure
Cranial nerve dysfunction leading to aspiration risk

Securing the Airway Ventilator Management

Know the process in your hospital
After the initial ABG, settings can be adjusted
Airway team Increasing rate, pressure support and tidal volume
Code team will increase ventilation (decrease pCO2)
Bagmask is a viable option until help arrives, as in an LMA With ASV mode, increasing the target minute
Once the patient is intubated ventilation with increase ventilation (decrease pCO2)
Initial ventilator settings Follow ABG or ETCO2 monitor to track progress
SIMV, AC, or CMV rates ~1214
Tidal Volume ~6cc/kg of ideal body weight Increasing FiO2 and PEEP will increase pO2
Pressure Support of 10 for SIMV mode Can follow O2 sats to assess patient response
PEEP around 5
FiO2 of 100%
ASV (Adaptive support ventilation)
Minute ventilation ~120150% (combination of rate, TV/PS)
Peep around 5, FiO2 of 100%
ABG in 3060 minutes
PATIENT 4 Sepsis
You are called to the bedside of a critically ill Systemic Inflammatory Response Syndrome
patient with multiple injuries which include (SIRS)
DAI, pulmonary contusions, pelvic fracture, Multiple Organ Dysfunction Syndrome
bilateral femur fractures, status post (MODS)
exploratory celiotomy for ruptured abdominal Sepsis SIRS plus infection
viscus. The nurse is concerned because the
Severe Sepsis Sepsis plus MODS
patient, who is a 40 yo m, looks septic.
Define what this means and what are you Septic Shock Severe Sepsis with Hypotension
going to do?
Sepsis Management of Sepsis
Infection Leukocytosis Resuscitation * Blood products *

Diagnosis Mechanical ventilation *
Fever Leukopenia
Antibiotics Sedation, analgesia, and
Hypothermia Bandemia paralysis *
Source control
Tachycardia CRP Glucose control
Fluid therapy
Tachypnea Procalcitonin Vasopressors * Renal replacement *
Altered mental status Hypoxemia Inotropes * Bicarbonate therapy
Edema Coagulopathy Steroids * DVT prophylaxis *
Hyperglycemia ARF Recombinant human * Stress ulcer prophylaxis *
Hypotension Ileus activated Protein C (rhAPC) Standardized protocols
Thrombocytopenia
Crit Care Med 2004 32(3): 858-873
Crit Care Med 2004 32(3): 858-873 * Supported by RCT Chest 2007 132(6):1967-1976

Diagnostic Criteria for Sepsis

Eval and Management of Sepsis
Infection, documented or suspected, plus some of
Follow the principles of EARLY GOALDIRECTED the following
THERAPY (EGDT)
Internationally accepted guidelines, often General variables
protocolized within hospitals Fever (>38.3C), hypothermia (core temp <36C), heart rate
>90, tachypnea, altered mental status, hyperglycemia in the
Dictate diagnostic and therapeutic measures absence of diabetes, etc.
within the 24 hours of recognized severe sepsis or
septic shock Inflammatory variables
Leukocytosis(WBC>12K), leukopenia (WBC<4K), etc.
Severe sepsis: acute organ dysfunction secondary to
infection Hemodynamic variables
Septic shock: severe sepsis plus hypotension not Arterial hypotension
reversed with fluid resuscitation
Organ dysfunction
Hypoxemia, oliguria, ileus, thrombocytopenia, etc.
Dellinger
EGDT: Initial Resuscitation

(first 6 hrs) EGDT: Diagnostic Studies
Begin resuscitation immediately in patients with
hypotension or elevated serum lactate (>4mmol/L) Cultures before antimicrobial therapy
Do not delay pending ICU admission At least two blood cultures, including one peripherally
Fluid resuscitation goals: and one from each vascular catheter that has been in
Central venous pressure (CVP): 812mm Hg place for <48 hours
Mean arterial pressure (MAP): 65 mm Hg
Culture other sites as appropriate (urine, sputum, CSF,
Urine output: 0.5mL/kg/hr
Central venous (superior vena cava) oxygen saturation 70% or etc.)
mixed venous O2 sat 65%
If venous O2 sat is not achieved
Perform imaging studies, if safe and needed,
Consider further fluid to confirm or sample any other potential sites
Transfuse packed RBCs, if required to hematocrit 30% and/or
Start dobutamine infusion, maximum 20 g/kg/min
EGDT: Antibiotic Therapy EGDT: Hemodynamic Support

Begin IV antibiotics as early as possible and always Fluid resuscitate using colloid or crystalloid
within the first hour of recognizing severe sepsis or Target a CVP of 8mm Hg (12mm Hg in a mechanically
septic shock ventilated patient)
Broad spectrum: one or more agents active against Use a fluid challenge technique while associated with
likely bacterial/fungal pathogens with good hemodynamic improvement
penetration into presumed source Give fluid challenges of 1000mL of crystalloids or 300
Reassess daily to optimize efficacy, prevent resistance, avoid toxicity 500mL of colloids over 30 min, watch closely for
and minimize costs improvement in hemodynamic parameters
Consider combination therapy if Pseudomonas infection is suspected More rapid and larger volumes may be required in sepsisinduced
Usually for 35 days, may be able to deescalate following susceptibility data tissue hypoperfusion
Duration of therapy typically 710 days, or longer if patient is slow
to respond, if there is an undrainable foci, or if the patient is Rate of fluid administration should be decreased if
immunocomprimised cardiac filling pressures increase without concurrent
Stop antimicrobial therapy if cause is found to be noninfectious hemodynamic improvement

EGDT: Vasopressors EGDT: Supportive Measures

Maintain MAP65 mm Hg Inotropic support
Norepinephrine and dopamine through central venous Use dobutamine in patients with myocardial dysfunction
(as evidenced by elevated cardiac filling pressures and low
access should be the initial vasopressors of choice cardiac output)
May add vasopressin 0.03 units/min to norephinephrine Steroids
Use epinephrine as the first alternative agent if BP is Consider intravenous hydrocortisone for adult septic shock
poorly responsive when hypotension responds poorly to adequate fluid
Do not use lowdose dopamine for renal protection resuscitation and vasopressors
Dose should be 300 mg/day
Patients requiring vasopressors should be monitored ACTH stimulation test is no longer recommended
with an arterial catheter Do not use hydrocortisone to treat sepsis in the absence of
shock unless warranted by an endocrine or corticosteroid
history
PATIENT 5 ABC vs. ICP

You are called to the PACU at 18:15 to see PT 5 The anesthesiologist wants to intubate immediately,
58 year old woman who is 45 minutes postop from a but you feel that the patient needs a ventriculostomy
suboccipital craniectomy for resection of a cerebellar drain while she is being bagmasked, because you
hemangioblastoma suspect increased intracranial pressure
She is having a headache, and the anesthesiologists wants And maybe her exam will return quickly if her CSF space is
you to evaluate her before escalating her pain regimen decompressed, thus she wont need to be intubated?
While examining her, she quickly looses A heated discussion ensues, but you realize that you
are going to be outnumbered in the PACU, so the
consciousness, and you notice she is apneic patient is intubated while you gather EVD equipment
You grab a nearby ambu bag and start masking Once the ventriculostomy drain is placed, you take
the patient immediately to the CT scanner
Diagnostic Studies Increased Intracranial Pressure
CT scan confirms hemorrhage into the resection bed,

which has caused compression of the fourth ventricle
and hydrocephalus, now partially relieved by the
ventriculostomy drain
The patient is emergently taken back to the OR for
hematoma resection and has significant blood loss
requiring several units of PRBCs and platelets.
She returns from the OR with the ventriculostomy
drain in place, and is hemodynamically stable, but
remains intubated
The Ultimate Compartment Syndrome!

Bedside Interventions Bedside Interventions

Immediate steps ADVANCED management to consider
ABCs Consider CSF diversion (CSFtargeted)
This often done if a ventriculostomy drain is already in place
HOB up, head midline (bloodtargeted)
Cool the patient (blood targeted)
Hyperventilate with ambu bag (bloodtargeted) Can pack in ice if a cooling blanket is not available
Osmotherapy (braintargeted) Watch for shivering!
3060cc of 23.4% saline through central line Propofol 0.050.1mg/kg bolus
250500cc of 3% saline is an alternative or 125250 mg of thiopental IV (bloodtargeted)
or 1 gm/kg of mannitol through a peripheral line Will drop the MAP/CPP, and may make it difficult to examine
the patient
This must go through a filter
If an ICP monitor is in, consider vasopressors to
Try to reverse the herniation (i.e., return pupil to normal) or support CPP unless intracerebral hemorrhage is on
ICP spike and get patient to CT scanner to look for reversible your differential diagnosis (bloodtargeted)
and/or neurosurgical causes
Expanding Posterior Fossa Mass PATIENT 6

You get called to the floor at 19:30 to see Pt 6 because he is
Management determined by etiology sleepy
Ventriculostomy 76 year old man who had just undergone an L2L5 laminectomy for
spinal stenosis
Caution with possible upward herniation As you are walking to the patients room, you read your sign
out sheet
Craniectomy History of HTN and 90 packyears of tobacco smoking
Decompress the posterior fossa and evacuate mass Underwent the laminectomy because of low back pain that he treated
with NSAIDs
When you arrive, you find out from his nurse that CD had
received several doses of morphine, both in the PACU and on
Patients deteriorate quickly the floor, because he had been complaining of severe,
lancinating incisional pain postoperatively
Patients can make remarkable recoveries

CDs Exam Diagnostic Workup

Difficult to arouse, but with stimulation, will answer You order a postoperative MRI, after
some simple questions and does seem oriented assessing airway, breathing and circulation
Says his back and R leg hurt, worse than before surgery
Says his legs feel numb MRI reveals a spinal epidural hematoma, with
His motor strength is difficult to examine fully, because of compression of the dural sac
the effects of the pain medication, but he seems to be The patient is taken back to the OR
moving his arms with much more strength than his legs emergently for decompression
He still has a foley catheter in place, since his surgery just
ended a few hours ago
Spinal Epidural Hematoma (SEH) PATIENT 7

Usually asymptomatic 59 year old male
Risk factors include
Multilevel laminectomies, preoperative coagulopathies New onset focal
and vascular anomalies, preoperative NSAID use,
intraoperative blood loss of more than 1 liter, age >60
weaknesses in LUE
years old, those with Rh + blood types; intraoperative Hgb and decreased
levels less than 10 g/dL, or an INR>2 within the first 48
post operative hours levels of
Want to get an MRI to visualize the SEH as soon as it consciousness after
is suspected ruptured MCA
Early surgical exploration and evacuation gives the best
chance for recover aneurysm Clipping
Cerebral Vasospasm Diagnosing Vasospasm

Delayed narrowing of large capacitance arteries at Symptoms often start with acute or subacute
the base of the brain encephalopathy
Often associated with radiographic or cerebral blood Focal neurologic deficits can follow, depending on
flow evidence of diminished perfusion in the distal which arteries are in spasm
territory of the affected artery Fever and leukocytosis may occur
Typical temporal course Rule out infection!
Onset 3 to 5 days after the hemorrhage TCD is recommended for the diagnosis and
Maximal narrowing at 5 to 14 days monitoring of vasospasm, although cerebral
Gradual resolution over 2 to 4 weeks angiography may be required for definitive diagnosis
And has the added benefit of potential treatment

Management of Cerebral Vasospasm Cerebral Vasospasm

Oral nimodipine (60mg q 4hrs) from the time of admission
until PBD #21 reduces poor outcome related to SAH Triple H Therapy
Treatment of cerebral vasospasm begins with early Hypervolemia (Albumin; Hetastarch)
management of the ruptured aneurysm, and in most cases,
maintaining normal circulating blood volume/avoiding Target CVP 812 cm H2O
hypovolemia Hypertension
One reasonable approach to symptomatic cerebral vasospasm
is hypertensive, hypervolemic therapy (add hemodilution to SBP up to 180220 mmHg
get tripleH therapy)
Hemodilution
Cerebral angioplasty and/or selective intraarterial vasodilator
therapy may be reasonable after, together with, or in the Target Hct <33%
place of tripleH therapy, depending on the clinical scenario Transfuse for Hct >25%
Consider angiogram for angioplasty if there is a focal
deficit
Bederson
Vasospasm Treatment
Pt 7 is already on nimodipine 60 mg per NGT
q4 hrs
Bolus 1 liter NS, increase IV fluid rate
Use vasopressors (such as phenylephrine) to
increase MAP goal to 100120 mm Hg
Notify interventional neuroradiology team,
especially if above efforts do not quickly
reverse focal neurologic deficit, to consider
cerebral angioplasty

vii. Emergency Evaluation of Hydrocephalus Shunt Patients
Emergency Evaluation of The average adult brain produces

between 450 and 600 cc of CSF every day
Hydrocephalus Shunt or about 20 cc/hr
Patients At any given moment, there is ~150 cc of

CSF present in the average adult; of this,
only ~25 cc is within the brain ventricles
Bootcamp CSF volume turns over 34 times every
day
Communicating vs Obstructive
Communicating Hydrocephalus
Hydrocephalus
Communicating Hydrocephalus
All 4 ventricles are enlarged
Enlargement of lateral, 3rd, and 4th ventricles
Causes: IVH of prematurity (grade III/IV), adult IVH, aneurysmal SAH,
meningitis
Note sulcal effacement, temp horns, rounded 3rd,
May do lumbar puncture and enlarged 4th
Obstructive Hydrocephalus
Dilatation of lateral and third ventricles with small, compressed or
normal size 4th ventricle
Asymmetry or enlargement of lateral ventricle when obstruction is at
Foramen of Monro ( e.g. colloid cyst)
Posterior fossa mass lesions (tumor, ICH, cyst), intraventricular mass
lesions (tumor, IVH, cyst), aqueductal stenosis
Do NOT do lumbar puncture
Obstructive Hydrocephalus Shunt System

Aqueductal stenosis
Note enlarged frontal horns, temporal tip dilation,
rounded 3rd but small or normal 4th ventricle
The Society Of Neurological Surgeons Bootcamp

Shunt Technology CSF Shunt Malfunction:

Pressure differential valves Clinical Presentation
Antisiphon valves Raised Intracranial Pressure
Flow regulated valves Headache (frontal,
Programmable valves dependent)
Nausea, vomiting
Papilledema
Altered level of consciousness
Bradycardia
OSV Brainstem dysfunction
DEATH
CSF Shunt Malfunction: CSF Shunt Malfunction:

Infants Children
Progressive macrocephaly
Developmental delay
Tense anterior fontanelle
Decline in school
Sutural splaying performance (esp.
Downgaze, lid retraction verbal IQ)
Esotropia (VIth nerve palsy) Visual loss
CSF Shunt Malfunction:

Myelomeningocele Radiology
Compare ventricul ar
Suboccipital/spinal pain size to well bas eline
Pain/swelling at MM closure Infants: Trans
Decreased grip strength fontanelle ultras ound
Lower extremity dysfunction CT
Bladder spasticity/infections MRI
Progressive scoliosis Shunt xray series
Ventricles may not change Disconnection or
fracture of tubing

Invasive Studies CSF Shunt Infection
CSF shunt tap Early

Presentation
Assess flow and pressure (although proximal High fever
obstruction may commonly interfere with accuracy) Fever Peripheral
Send CSF for GS/Cx, Glu/Pro, cell counts if infection CSF: leukocytosis
suspected WBC:RBC > 1:700
Erythematous
Relieve pressure if obstructed distally + Gram Stain/Culture
incisions
Radionuclide shuntogram Abdominal
Late
pseudocyst
Assess proximal and distal flow
Low grade fever
Ventricular reflux and outflow each correlate with +/-Ventriculomegaly
Normal peripheral
appropriate function (but test is imperfect)
WBC count
Intracranial pressure monitoring
Anorexia
Differential Diagnosis of Shunt

CSF Shunt Infection Infection
Gastroenteritis
Often associated with sick contacts, diarrhea
Organisms Therapy
Staph. Epi (40%) Externalize shunt
Staph. Aureus Change hardware Otitis
(20%) Antibiotics May often be detected on physical examination
Gram Negatives Consider LP
Diptheroids Urinary tract infection
Yeast Important to differentiate from colonization in
spina bifida patients
CSF Shunt Complications: CSF Shunt Complications:

Mechanical Failure Mechanical Failure
Blockage Distal failure

Choroid plexus Kinked tubing
Ependyma Malabsorption
Fracture Pleural effusion
Cor pulmonale
Disconnection
Shunt nephritis
Valve failure

CSF Shunt Complications: CSF Shunt Complications:

Abdominal failure Overdrainage
Umbilical hernia Postural (Low

Extraperitoneal pressure) headache
catheter Subdural hygroma
Bowel perforation Craniostenosis
CSF Shunt Complications: Shunt Evaluation Protocol in the

Hemorrhage Emergency Room
Parenchymal damage
ED Management Labs
Raised ICP
NPO CBC with differential
IVH: Valve obstruction IV If indicated:
Ependymal adhesions a nd Cardiorespiratory Anticonvulsant levels
multicompartmental monitor Coagulation parameters
Electrolytes
hydrocephalus Physical examination

Urinalysis
Obtain imaging
studies
Shunt Evaluation Protocol: Shunt Evaluation Protocol:

History Examination
History Current Symptoms

Neurological Medical Examination
Hydrocephalus Headache
etiology Severity/location
Examination Vital Signs
Mental status Heart rate
Exact date of last tap Positional
Cranial nerves Temperature
or revision Morning
Mental status changes Fundi Pharynx
Symptoms of last
failure Fever Valve Chest auscultation
Seizure disorder? Shuntalgia Shunt incisions Tympanic membranes
Latex allergy? Nausea/vomiting Abdomen

Intercurrent illness

Shunt Evaluation Protocol: Shunt Evaluation Protocol:

Diagnostic Studies Admission
Immediate intervention for:
Noncontrast head CT scan (shunt protocol) Definite, acute malfunction
Pain
or quick brain MRI
Infection
Shunt xray series Bradycardia
Abdominal ultrasound, if indicated Decreased mental and/or vision
Shunt tap, if indicated Cardiorespiratory monitoring

Formal skin preparation Frequent neurological checks
NPO except meds
25g butterfly needle: test OP and valsalva
(OP may be obscured by proximal obstruction) Antimicrobial shampoo
CSF sample for GS/Cx, Cell count, Glu/Prot Consider steroid prep for latex allergy
Conclusions Case 1
Involve experienced team members in significant
care decisions
When in doubt, keep the patient for observation History
6 y.o. with posthemorrhagic hydrocephalus

Listen to parents
3 days progressive fever and malaise
Myelomeningocele patients may have protean
Intermittent right sided headaches
forms of presentation and increased risk for
Last revision 3 years ago for obtundation
sudden deterioration
Remember that, above all, shunt malfunction is a
clinical diagnosis, supported by imaging studies
and other data
Case 1 Case 2
History Physical Examination
Physical Examination Imaging 10 y.o. with Alert

Irritable Axial imaging: ventricles myelomeningocele and Baseline
Neurological exam hydrocephalus No papilledema
unchanged from last
nonfocal well scan One week of
Temperature 102.5 F. progressive frontal
Shunt xrays without headaches and neck Radiology
Inflamed right disconnection pain
tympanic membrane Axial imaging
with effusion One day of vomiting unchanged from well
Diagnosis Mother states these baseline (small
are typical malfunction ventricles)
Otitis media symptoms Shunt xrays without
No surgical intervention Last revision distant disconnection

Case 2 Case 3
Diagnosis History Physical Examination

VP shunt malfunction 10 y.o. brought to E.R. Unresponsive
Total proximal shunt obstruction was observed at by ambulance, RR 15, labored
surgery obtunded
HR 70
EMT: Has a shunt for
Pupils 4 mm, sluggish
hydrocephalus; had
headaches at home for Frontal valvereservoir
last few days palpable
Case 3 Case 4
Diagnosis Treatment History Physical Examination
15 y.o. with congenital Malaise, but normal

Severe ventricular Neurosurgeon hydrocephalus neurological exam
shunt malfunction attempts to drain CSF;
Occasional mild Temp 100.2 F.
shunt tap is dry
headaches, low grade Incisions wellhealed;
1 gram/kg mannitol is fevers for 3 weeks no inflammation
given
Anorexia Abdomen slightly
Last revision 5 months distended, nontender
E.R. Course ago for severe headache
Intubated and vomiting
During CT, heart rate Mother: very different
drops to 40 from typical
malfunction symptoms
Case 4 Case 4
Further Studies Treatment

Diagnostic Studies Abdominal ultrasound: Shunt removed and
Axial imaging: no change vs. very subtle ventricular positive for pseudocyst replaced with EVD at
enlargement from well baseline Initial CSF culture presentation
Shunt xrays: no disconnection (special request for 7
7 days IV Abx and
day hold) grows rare
Shunt tap: Proprionobacter 5 days external drainage
Opening pressure = 14 cm H2O; good flow later Repeat ultrasound:
RBC = 1, WBC = 9 pseudocyst resolved
Gram stain and preliminary culture negative
CSF WBC = 2
New shunt inserted

The Operating Room: Orientation and

Surgical Environment
Personnel: surgeons, anesthetist, nurses, techs,
Making the Incision: Surgical
neurophysiology, students, lawyers
Equipment and tools
Pause to Scalp Blood Supply Noise generation
Ongoing communication, respect.
Understanding what is going on around you
Be prepared when you arrive. The prepared mind is the
teachable mind.
When assisting, think if you were the surgeon, what would
you want done to aid you.
POSTIONING THE PATIENT IS AN ART FORM. It takes years to
learn to do correctly. You and your patient will suffer if you do
not learn to do it correctly.
The surgical environment

Right Craniotomy Concepts in Positioning
Line of sight
Patient Comfort
Venous outflow
Brain relaxation and auto retraction
Surgeon Comfort
If you do not position correctly, you cannot get there from here
Padding pressure points
Checking the pressure points: ie foley, breasts, elbows, knees, eyes
Remember harvest sites
Consider central venous access sites
Anatomical Considerations for pin placement
Work with anesthesia so they have access
Neurophysiology access
Turning the table and not making spaghetti
Cooperation: if everyone is comfortable the case will be more efficient
Rhoton AL; Neurosurgery. 2003,53(4):90734
Mayfield head holder
Yasargil MG. In: Microneurosurgery IVb, 1996, Thieme Medical Publishers

Positioning
Surgical Pause: the TIME OUT
Stop and Pay attention
Anyone in the room can pull the stop cord
There is zero tolerance to not doing it
Frontal approach Pterional approach Retrossigmoid approach
Do it correctly, or do it over.
Do it respectfully
After it is done, there is time to review with
the team the steps and flow of the operation.
Midline suboccipital approach
Rhoton AL; Neurosurgery. 2003,53(4):90734
The Surgical Pause Time Out Hair and Neurosurgery: know what the
Confirm: attending wants and the patient expects
Confirm patient identity
Confirm length, type of procedure and surgical Most neurosurgeons prefer to shave hair on
site (left/right; spinal levels) the incision site.
Confirm use of Foley catheter, prophylactic Hair sparing craniotomies are getting
antibiotics, steroids, Mannitol, Dilantin, etc
common.
Confirm availability of equipment (microscope,
CUSA, carm, retractors, implants, etc) Hair needs to be prepared and draped with
Confirm availability of blood and blood standard sterile technique.
products No difference in the incidence of infection.
Confirm availability of ICU, frozen section Tokimura H, et a. J Craniomaxillofac Surg. 2009 Dec;37(8):47780. (632 patients)
Dvilevicius AE, et al. Arq Neuropsiquiatr. 2004 Mar;62(1):1037. (640 patients)
Bekar A, et al. Acta Neurochir (Wien). 2001;143(6):5336 (1038 patients)
Winston KR. Neurosurgery. 1992 Aug;31(2):3209. (303 patients)
Prepping and Draping Principles Aseptic technique

Inside to out Scrub the skin with betadine or
Prep wide, drape narrow chlorhexidine solution for at least 5
Let dry: most agents are active on contact minutes.
REMEMBER ALCOHOL IS FLAMMABLE
Know each attendings RITUALS Avoid contact with eyes.
Your Personal Scrub is an important part of the Cost of infection is high
prepping and draping
Consider changing scrubs between cases to avoid Expensive implants (DBS, spinal
cross contamination especially in cases of infection. instrumentation)

The anatomical basis of scalp incisions:

The Scalp
basic principles
S = Skin Access to lesion
C = Subcutaneous Remember the adjuvant treatments to come and the possibility of re
operation
tissue Wound healing issues: systemic diseases, chemotherapy, radiation,
steroids, reoperations
A = Aponeurosis The closure starts with the opening
L = Loose areolar Blood Supply: 5 major arteries and a rich anastomosis
tissue The incision is a door: It rotates on its hinges
Innervation: to block, to make a numb skull or to cause paralysis and
P = Pericranium atrophy
Know the boney anatomy of the skull including: the number and location
of each bone; geometric shape and orientation; sutures; and muscular
attachments
Get a skull and study it.
Yasargil MG. In: Microneurosurgery IVb, 1996,
Thieme Medical Publishers
The Scalp Arterial Supply

Innervation
* Supratrochlear nerve and the supraorbital

nerve from the ophthalmic division of the
trigeminal nerve
* Greater occipital nerve (C2) posteriorly up
to the vertex
* Lesser occipital nerve (C2) behind the ear
* Zygomaticotemporal nerve from the
maxillary division of the trigeminal nerve
supplying the hairless temple
* Auriculotemporal nerve from the
mandibular division of the trigeminal nerve
d reconstruction of scalp and calvarial defects.

Vol 5., 199217, 1996.
The Frontalis Branch of the Facial Nerve

(Confusing nomenclature)
Standard craniotomies
Agarwal CA, et al. Plast. Reconstr. Surg. 125: 532 537, 2010

Galea plus loose areolar tissue

Galea
Temporalis fascia
Incisions Types Curvilinear

Curvilinear
Bicoronal
Straight lazy S
Reversed question mark
U shaped
Base of flap wider than height
Bicoronal Lazy S Reversed Question Mark

U Shaped
Trauma Flap

Neurological Surgery Residents

Represent your Service and Attendings
Patient Safety and Clinical Are elite and held at the highest standards
Communications Are called on to manage the terror
Must remember the burden of their patients
and families
The Society of Neurological Surgeons Must carry themselves with the utmost
respect for patient, family, coworkers and
Bootcamp
staff
Communication and Documentation

Purpose and Importance Considerations
Share information with other healthcare providers: provide In Neurological Surgery we may never have the opportunity to
talk with our patient
continuity
Communication with the family is also our responsibility
Living history of patients illness
Understand whom is the legal voice of the family
Medical legal document: any thing you write can and will be Elicit the level of the patient or families understanding of the
used in a court of law and public opinion situation
Billing and coding Ask if you are understood and if there are any questions
Part of teamwork Be patient
Primary patient safety issue Do not be afraid to say, I do not know.
Single most important aspect of communication is to stop, Remember to summarize and reinforce your discussion:
focus, and listen. There is no multitasking in communication. families and patients under stress may be distracted.
Patients whom are having difficulties need more
communication not less
Key Elements of Documentation and Types of and people with whom we

Communication communicate: How we do it determines
Timing and Timeliness our success
Critical events and values
Accurate, detailed, and concise.
Verbal
Do not use abbreviations: i.e. perrla Nonverbal
Never alter a medical record unless stating that you are Written
correcting an error Nurses/Allied Health providers
Read before you countersign
Patient: expectations
Minimize copy and paste
No derogatory statements, chart wars, subjective remarks, or
Family: expectations
nonpatient care information Colleagues
If it is not written, you did not do it Respect, Respect, Respect, Respect and Respect.
Billing and Coding Personnel

Types of Documents Admission/H&P

History and physicals/Admit Notes History of present illness: Include chief complaint and history
of present illness.
Consultations Review of Systems: 29 components
Consents Medications: include non prescribed medications,
supplements and holistic treatments
Operative/Procedural Reports: include time out and
Allergies: include food
sidedness Family History
Phone Interactions Social History: How does illness effect ability to work
Progress Notes Detailed Examination: 57 systems or 12 points on one
Discharge Summaries Review of Studies
Assessment
Handoff Documents and Communication Plan
Hospital and Physician Billing Documents
Consults Operative/Procedural Notes

Restate the patients clinical condition Pre and Post operative diagnosis
Summarize in detail the neurological examination Indications and consent
Summarize in detail the radiological studies Procedure: side, site, levels.
Surgeon and assistance
Clearly state the Assessment and Treatment Plan
Anesthetic type
Leave a page number of additional questions
Blood loss and fluid replacements
Answer the Question
Findings
Contact the service asking for the consult and talk with them Surgeons presence
specifically making sure you have answered the question.
Specimens
Be timely, prompt and courteous. If people ask you to see a Postoperative condition and disposition
patient it is because they are asking for your help.
Your audience: yourself, billing and coding, future surgeons
and care givers, legal review.
Consent: It is a Process Consent Consideration

Consent is a conversation: Document it Given Voluntarily and can be withdrawn
It is a timed document
Condition Should be procedurally and patient specific
Procedure Is necessary for all therapeutic and diagnostic procedures
Must be obtained by knowledgeable physicians
Alternatives The signed form is an important documentation of the
Risks informed discussion conversation. Include side, site and level.
Special issues: minors, difficult patients, emergencies,
Benefits cognitive disabilities, power of attorney,
language/cultural/religious barriers
Questions Understanding whom is an appropriate and legal interpreter
Agreement Treatment without consent can be construed legally as
battery. Failure to obtain proper informed consent can be
construed as malpractice.

Discharge Summary Handoffs

Is a major source of medical errors
Extremely Important for Continuity of Care

Are reflection of teams ability to communicate
Are a major source of malpractice claims
Include Key elements of Course of Care: Chief

Can place a patient at risk
Remember, the most sensitive test to follow a patients course is serial neurological
complaint; Diagnostic findings; therapies and
examinations by the same observer.
The Structured Hand off: SEAM
procedures; response to treatment, a) Summary, situation and/or status
b) Every Active major clinical status
disposition at discharge; appropriate dates of c) Management and planned next steps related to each major clinical issue
It is important for the clinician on the receiving the information to be able to ask
events; medications on discharge; and

questions
Call early, and Call often. Do not be afraid to Call your Chief or Attending for
discharge instructions (including followup

information and advise. Especially over the weekend the attending maybe the
person whom has the most continuity of care.
appointments) The Nurses spend 812 hour shifts at the patients bedside. They make serial
observations. When they call go see the patient.
Billing and Coding Conflict: the lack of communication

Might not seem important right now but will be vital Conflicts are inevitable, expect them.
in your future In Conflict you have a choice.
Generated off of your documentation Patient safety is our primary goal.
Has medical and legal consequences Try to see what is the benefit to the other person.
Are you going to work with this person again?
Codes: CPT, ICD9, inpatient, outpatient, procedural, Does your boss really want to hear what you said?
modifies, new vs. established
Keep the patient not your ego at the center of the discussion.
Components: History, Examination, Medical decision Some conflict is good and necessary for the long term benefit
making of the patient.
Contributing Components: Extent of counseling Conflict can hinder communication. The lack of
coordination of care with others, nature of the communication can be a patient safety issue.
presenting problem(s), complexity and time.
Summary
Communication and Documentation are part of your
professional responsibility
Accurate, timely, and pertinent documentation is crucial for

good patient care and a potent force against malpractice
Communication and Documentation play a critical role in

durable Handoffs which are crucial to good patient care and a
potent force against malpractice
Communication and Documentation is part of the ongoing

process of patient care and education between the physician,
patient, family and health care partners

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PGY1 Boot Camp Course Reference Guide

Society of Neurological Surgeons

PGY1 Boot Camp Course

Nathan R. Selden, MD, PhD

Nicholas M. Barbaro, MD, PhD

E. Sander Connolly, Jr., MD

The Society Of Neurological Surgeons

2017 Course Directors:

President: Robert Harbaugh

SNS Boot Camp Subcommittee:

Gregory Zipfel (Chairman)

The Society Of Neurological Surgeons

Table of Contents page

The Society Of Neurological Surgeons

We thank Shirley McCartney, Ph.D., for editorial review.

Medical knowledge is constantly changing. As medical knowledge, clinical experience

The Society Of Neurological Surgeons 1

The Learning Tree

The Society Of Neurological Surgeons 2

In the words of one experienced neurosurgical educator:

Be prepared to abandon your preconceptions as you open mindedly approach one of

Be prepared to fully engage in the physical, psychological, and intellectual challenges of

Rest appropriately. Your psychomotor skills may be affected even remotely by

It is uncomfortable to lack knowledge, particularly for neurosurgical trainees who

The Society Of Neurological Surgeons 3

The Society Of Neurological Surgeons 4

3. General Surgical Principles

5. Avoid and Control Bleeding in Potential Spaces

The Society Of Neurological Surgeons 5

Wrong sided/site surgery has been identified by regulators as a preventable event.

The Society Of Neurological Surgeons 6

WHO: Patient name, age, handedness, gender

WHAT: Clinical presentation, co-morbidities, medications

WHEN: Patient examination, laboratories and imaging studies

WHERE: What is your proposed plan?

HOW: How are you going to execute the plan?

A neurosurgical residents most important characteristic is the reliability of his/her word

Rule 5: Keep the Chief Happy

The importance of accurate and reliable communication cannot be over emphasized.

Communication is a skill; it must be practiced.

The Society Of Neurological Surgeons 7

Rule 6: Think before you speak

They are not always avoidable.

The Society Of Neurological Surgeons 8

Rule 8: The Enemy of Good is Perfect

Rule 9: Know the Enemy

The Society Of Neurological Surgeons 9

Rule 10: Experience

The Society Of Neurological Surgeons 10

Lasers can cause fire.

Rule 11: Nothing substitutes for seeing the patient yourself.

Rule 12: Document well

The Society Of Neurological Surgeons 11

1. They document your presence at a patients bedside. When called to see a

3. Every note is a medico-legal document. Your note that documents a clinical

4. The phrases benefits, alternatives and risks, or procedure, alternative, risks,

The Society Of Neurological Surgeons 12

VI. Statement on Conflicts of Interest

Introduction to Conflict of Interest: Understanding the Dynamic

A conflict of interest (COI) occurs when an individual or organization is involved in