COMMON NEUROSURGERY

.Common cases operated in neurosurgery 

 Tumors of central nervous system

 Brain tumors

The brain is made up of many different types of cells. Brain cancers occur when one type of cell transforms from its normal characteristics and grows and multiplies in an abnormal way. Usually they are named after the part of the brain or the type of brain cell from which they arise.

Astrocytoma: The tumor arises from star-shaped glial cells called astrocytes. In adults, astrocytomas most often arise in the cerebrum. In children, they occur in the brain stem, the cerebrum, and the cerebellum.

Brain stem glioma: The tumor occurs in the lowest part of the brain. Brain stem gliomas most often are diagnosed in young children and middle-aged adults.

Ependymoma: The tumor arises from cells that line the ventricles or the central canal of the spinal cord. They are most commonly found in children and young adults.

Oligodendroglioma: This rare tumor arises from cells that make the fatty substance that covers and protects the nerves. These tumors usually occur in the cerebrum. They grow slowly and usually do not spread into surrounding brain tissue. They are most common in middle-aged adults.

Medulloblastoma or primitive neuroectodermal tumor: This tumor usually arises in the cerebellum. Rarely do these tumors spread outside the brain. It is the most common brain tumor in children.

Meningioma: This tumor arises in the meninges and grows slowly. Meningioma are benign and do not spread from their original site. Malignant meningiomas are very rare.

Schwannoma: This tumor arises from the Schwann cells. These cells line the nerve that controls balance and hearing. This nerve is in the inner ear. The tumor is also called an acoustic neuroma. It occurs most often in adults. They are more common in people who have a genetic disease called neurofibromatosis type 2.

Craniopharyngioma: The tumor grows at the base of the brain, near the pituitary gland. This type of tumor most often occurs in children.

Hemangioblastoma: This is a rare type of tumor that develops from cells that line the blood vessels. They are benign and grow slowly

Pituitary tumors: These types of tumors develop in the pituitary gland. They are benign and are called pituitary adenomas.

Germ cell tumor of the brain: The tumor arises from a germ cell. Most germ cell tumors that arise in the brain occur in people younger than 30 years. The most common type of germ cell tumor of the brain is a germinoma.

Pineal region tumor: This rare brain tumor arises in or near the pineal gland. The pineal gland is located between the cerebrum and the cerebellum. The most common tumors are germinomas, teratomas, pineocytomas and pineoblastomas.

 Spine tumors

Tumors of the spine can be either benign or malignant. Benign tumors include schwannomas, neurofibromas and meningiomas. Malignant tumors are most commonly caused by cancers that spread from other body areas (i.e. lung, breast, kidney or skin cancer.

 Cerebrovascular disorders

Cerebral aneurysm: Is the dilation, bulging, or ballooning-out of part of the wall of an artery in the brain.

Arteriovenous malformation (AVM): An abnormal connection between the arteries and veins in the brain, usually congenital.

Cavernous angioma: Is a blood vessel abnormality characterized by large, adjacent capillaries with little or no intervening brain. The blood flow through these vessels is slow.

Cerebrospinal fluid leak :A CSF leak is an escape of the fluid that surrounds the brain and spinal cord.

Moya-Moya disease: A progressive disease of the distal internal carotid arteries and their major branches that is characterized by occlusion of these vessels.

Subarachnoid hemorrhage: Bleeding in the area between the brain and subarachnoid space.

 Movement disorders

Essential tremor: A disabling movement disorder consisting of shaking of one or both hands when the patient uses the hand to do something.

Parkinson's disease: A Neurodegenerative disorder caused by the loss of cells that produce a chemical called dopamine. The hallmark of Parkinson's disease is a resting tremor, slowness of movement (bradykinesia), and limb rigidity.

 Pain disorders

Trigeminal neuralgia: A sharp shooting lancinating pain found in the forehead, face or jaw region. The pain is usually on only one side of the face.

 Peripheral nerve disorders

Carpal tunnel syndrome: Compression of the median nerve at the wrist. This causes numbness in the hand, thumb, and fingers.

 Epilepsy

Epilepsy caused by tumors or malformations of blood vessels

Temporal and extra temporal lobe lesions

 Adult hydrocephalus

Normal pressure hydrocephalus: Dilation of the ventricles of the brain caused by an obstruction of the normal spinal fluid passage from one ventricle to other. 

 Brain injuries

Subdural hematoma: Blood clot that occurs on the surface of the brain and just below the dura (outermost covering of the brain). A subdural hematoma usually occurs from the tear of one of the veins that drain the brain of blood. 

Epidural hematoma; Blood above dural space

Post-traumatic seizures

Spinal disorders

Degenerative spine (spondylosis and spondylolisthesis): Protrusion of one of the disc. This protrusion can cause pain or neurological symptoms.

Post-traumatic cervical instability.

Spinal arteriovenous malformation (AVM): An abnormal tangle of blood vessels on, in or near the spinal cord.

Spinal cord injuries and fractures.

Chiari Malformation: The malformation consists of a protrusion of the bottom portion of the cerebellum into the upper portion of the spinal canal. This malformation can lead to headaches, arm or leg symptoms, or problems with the nerves that supply the head and neck.

Operative procedures

1. Shunt procedures

Ventriculo Peritoneal Shunt: Ventriculoperitoneal shunt is a surgery performed to relieve intracranial pressure caused by hydrocephalus. The fluid is shunted from the ventricles of the brain into the abdominal cavity

Lumbar-peritoneal Shunt: Lumbar peritoneal (LP) shunt is a technique of cerebrospinal fluid (CSF) diversion from the lumbar thecal sac to the peritoneal cavity.

2.Endoscopic procedures

Third Ventriculostomy: Endoscopic third ventriculostomy is a surgical procedure in which an opening is created in the floor of the third ventricle using an endoscope placed within the ventricular system through a burr hole. This allows the cerebrospinal fluid to flow directly to the basal cisterns, thereby shortcutting any obstruction. It is used to treat certain forms of obstructive hydrocephalus.

Ventricular lesion Excision

Pineal region tumor Biopsies

3.Skull base surgeries

Foramen Magnum Decompression for Chiari malformation by the removal of the outer layer of the dura mater.

Pituitary adenoma resection

Excision of skull base meningiomas, Schwannomas, Chordomas

4.Stereotaxy and image guidance

Neuronavigation

Biopsies

Tumor removal

5.Movement disorder surgeries

Deep Brain Stimulation for Parkinson’s disease and essential tremors.

Thalamotomy: A stereotactic surgical technique for the discrete destruction of specific groups of cells within the thalamus primarily effective for tremors such as those associated with Parkinson's Disease.

Pallidotomy: a procedure where a tiny electrical probe is placed in the globus pallidus (one of the basal ganglia of the brain), which is then heated to 80 degrees celsius for 60 s, to destroy a small area of brain cells. Pallidotomy is used to treat dyskinesias in patients with Parkinson's disease.

6.Epilepsy surgeries

Amygdalohippocampectomy: a surgical procedure for the treatment of epilepsy which consists of the removal of the hippocampus, which has a role in memory, spatial awareness, and navigation, and the amygdalae, which have a role in the processing and memory of emotional reactions, both structures forming part of the limbic system of the brain.

Corpus callossotomy: Corpus callosotomy is an operation that severs (cuts) the corpus callosum, a band of nerve fibers located deep in the brain that connects the two hemispheres of the brain. Thus interrupting the spread of seizures from one  hemisphere to the other.

Vagal Nerve Stimulation: Vagus nerve stimulation (VNS) is an adjunctive treatment for certain types of intractable epilepsy and treatment-resistant depression It involves the implantation of a generator that stimulates the vagus nerve and thus reduces seizure activity.

Hemispherectomy: a surgical procedurewhere one cerebral hemisphere is removed or disabled. This procedure is used to treat a variety of seizure disorders where the source of the epilepsy is localized to a broad area of a single hemisphere of the brain.

Grid Placement: The grids are surgically placed, by way of an open craniotomy, over and around areas suspected to be linked to a patient’s seizures. The exact number of grids used and specific location of placement depends on the individual needs of the patient.

Selective Resection

7.Vascular procedures

Clipping of Aneurysm

STA – MCA bypass

Radial Artery bypass

AVM excision

Cavernous Angiomas

8.Spine

Excision of tumor of Spinal Cord

Spinal Instrumentation

Cranio–Vertebral Junction Instrumentation

Spinal Inter Vertebral Disc Surgeries

9.Pediatric procedures

Posterior Fossa Tumors

Primitive Neuroectodermal Tumors

Craniosynostosis

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IMPORTANT PEDIATRIC CARDIAC SUYGERY.....

  pediatric cardiac surgery 

INTRODUCTION

Although many children who have congenital heart defects do not need surgical treatment, most need some form of intervention.The treatment the child receives depends on the type and severity of his or her heart defect. Other factors include child's age, size, and general health. Some conditions need urgent surgical correction in the neonatal period. A child may need open-heart surgery if his or her heart defect can't be fixed using a catheter procedure. In most conditions full correction can be achieved by at single stage, but some diseases need a staged approach needing 2-3 or more stages.

Types of congenital heart defects

·         Obstructive congenital heart lesions

·         Congenital heart lesions that increase pulmonary arterial blood flow

·         Congenital heart lesions that decrease pulmonary arterial blood flow

Obstructive congenital heart lesions

They impede the forward flow of blood and increases ventricular after loads. They are
a) pulmonary stenosis, b) aortic stenosis, c) coarctation of the aorta.

Pulmonary stenosis

No symptoms occur in mild or moderately severe lesions. Cyanosis is seen if there is a communication between right and left sides of the heart and right-sided heart failure occurs in patients with severe lesions. There is a high-pitched systolic ejection murmur maximal in second left intercostal space. Ejection click is often present.

Aortic stenosis

Valvular aortic stenosis, subaortic stenosis, supravalvular aortic stenosis, asymmetric septal hypertrophy (Idiopathic hypertrophic subaortic stenosis) comes under this.

Percutaneous balloon valvuloplasty is usually successful in these patients and should be considered first-line therapy. Valvotomy is preferred in the neonate, infant, and child. Valvotomy is a salvage operation in neonates and infants and has high operative risk. In older children; valvotomy is the palliative operation of choice. Replacement of the aortic valve is performed in adults and the elderly.

Coarctation of aorta

It is characterized by absent or weak femoral pulses. Systolic pressure is higher in upper extremities than in lower extremities; diastolic pressures are similar. Males are affected twice as frequently as females. 98% of all coarctations occur at the segment of aorta adjacent to ductus arteriosus. Blood flow to the lower body is maintained through collateral vessels. In the infantile form of coarctation, the blood flow to the lower body is maintained by the ductus arteriosus. Post natally, as the ductus closes, these children go for severe heart failure with no perfusion of lower body. This is a surgical emergency, child should be resuscitated with prostaglandin infusion and early surgical correction should be done

Neonate with severe failure, operation indicated at time of diagnosis. If cardiac failure or failure to thrive not present, delay 3-6 months. Increased incidence of recurrent stenosis if operated at less than 3 months. Increased incidence of HTN if coarctation is repaired beyond infancy.The operative strategy includes left anterolateral thoracotomy via the 4th ICS.Maintain proximal blood pressure high to lessen the risk of paraplegia. Maintain distal pressure of 45 mmHg. Resection and end-to-end anastomosis (ETE); subclavian flap aortoplasty (SFA); resection and extended end-to-end anastomosis and combined end-to-end anastomosis and SFA are preferred.

Congenital heart lesions that increase pulmonary arterial blood flow

·         Atrial septal defect

·         Complete atrioventricular canal defect

·         Ventricular septal defect

·         Patent ductus arteriosis (closed heart procedure )

·         Total anomalous pulmonary venous connection

·         Cor triatriatum

·         Truncus arteriosus

Atrial septal defect (ASD)

 The child can be acyanotic, asymptomatic, or can have only dyspnea on exertion. It results in right ventricular lift, with fixed, widely split second heart sound. The average life expectancy is reduced because of right ventricular failure, dysrhythmias, and pulmonary vascular disease. Surgical closure is recommended. Selected ASDs can be closed using a device in the cathlab. Surgical closure of ASD is an open-heart procedure. Closure of the defect either directly or with patch depends on the type and size of the defect.

Complete atrio-ventricular canal defect

Heart failure is common in infancy and cardiomegaly with blowing pansystolic murmur is common. Deficiencies of both atrial and ventricular septal cushions and abnormalities of both mitral and tricuspid valves seen. Partial and complete AV canal defects frequently accompany Down's syndrome. Complete AV cannal defect is often associated with severe PAH. Early surgical correction is needed. Reconstruction of the AV valves and closure of the septal defects by a single or double patch technique is done. These patients need to be in follow-up to detect any regurgitation through abnormal AV Valves.

Ventricular septal defect (VSD)

Asymptomatic, if defect is small. Heart failure with dyspnea, frequent respiratory infections, and poor growth occurs if defect is large. Pan systolic murmur maximal at the left sternal border is seen. It is often one of the components of another complex congenital heart lesion. Heart is enlarged and lung fields are over circulated.  Many of the defects will close spontaneously by age 7-8 years. Larger defects if untreated can lead to pulmonary hypertension, aortic regurgitation, cardiac failure or infective endocarditis. VSDs can be closed directly or with a patch, depending on the size of the defect. Most VSDs are closed through the right atrium across the tricuspid valve. Some VSDs are approached through the pulmonary artery, right ventricle or rarely left ventricle.

Patent ductus arteriosis (PDA)

Murmur is usually systolic, sometimes it may be continuous, "machinery". Poor feeding, respiratory distress, and frequent respiratory infections are seen in infants with heart failure. Physical examination and echocardiography reveals the defect. Selected PDAs can be closed percutaneously using coils or device. Surgical treatment is, by ligation, clipping, or division of the ductus and suturing. It is a closed heart procedure done under left thoracotomy, when not associated with other intra cardiac defects.

Aortopulmonary window (AP window)

It is a communication between ascending aorta and pulmonary artery.Separate aortic and pulmonary valves are present.

Total anomalous pulmonary venous connection (TAPVC)

Pulmonary veins do not make a direct connection with the left atrium. Blood reaches the left atrium only through an atrial septal defect or patent foramen ovale, presents with pulmonary congestion, tachypnea, cardiac failure, and variable cyanosis. Diagnosis is by cardiac catherization or echocardiography. Operative repair is needed in all cases. An obstructed TAPVC, in which pulmonary venous return to heart is obstructed, is a surgical emergency as there is no medical or interventional palliation.The surgical treatment aims at creating a large unobstructed connection between the pulmonary vein and the left atrium.

Cor triatriatum

Pulmonary veins enter proximal LA chamber and are separated from distal LA chamber by a diaphragm, a small hole in this diaphragm allows some communication to the distal chamber.The RV is enlarged, the fossa ovalis is patent, which allows left-to-right shunting. This interatrial connection usually communicates the proximal chamber to the RA and occasionally the distal chamber to the RA. The distal chamber contains the mitral valve and left atrial appendage.Operative techniques include left atrial approach and right atrial approach.

Truncus arteriosus

Single large vessel overrides the ventricular septum and distributes all the blood ejected from the heart. Large VSD is present. One great artery arises from the base of heart with a single semilunar "truncal" valve. This truncal artery gives origin to coronary arteries, systemic arteries and one or two pulmonary arteries. Associated anomalies are- interrupted aortic arch or coarctation with PDA in 10-20%, persistent left superior vena cava in 10%, Di-George syndrome and right aortic arch in 25-30%. Treatment is early operative intervention, palliative operations are not useful and complicate later repair.Operation is performed under deep hypothermia, circulatory arrest or hypothermia with low flow. Close VSD to right of truncal valve, truncal valve repair or replacement if necessary, is also done. Remove PA from aorta, repair aorta, RVOT is reconstructed, with a valved conduit between right ventricle and pulmonary vessels. Conduit will need to be changed as child grows but likelihood to develop pulmonary vascular disease is greatly reduced.

Congenital heart lesions that decrease pulmonary arterial blood flow

Tetralogy of Fallot, transposition of the great arteries; tricuspid atresia and Ebstein's anomaly come under this category.

Tetralogy of Fallot (TOF)

Four defects ie. pulmonary stenosis, membranous VSD; over riding of aorta and right ventricular hypertrophy comprise iv) right ventricular hypertrophy comprise TOF. Addition of ASD makes it pentalogy of Fallot. It presents with hypoxic spells, squatting, cyanosis and clubbing. The VSD and infundibular stenosis determine the pathophysiologic features. The operative technique consists of dissecting and resecting infundibular stenosis through the right atrium; closing ASD/PFO; opening and enlarging the pulmonary valve and or annulus; and closing VSD, which corrects overriding of aorta.

Transposition of the great arteries (TGA)

Connections of the great vessels are reversed; aorta arises from right ventricle, and pulmonary artery from left ventricle. Cyanosis from birth, hypoxic spells and heart failure is often present. Cardiac enlargement and diminished pulmonary artery segment on X-ray is seen. Survival beyond infancy is rare without surgical treatment. Neonates with TGA, intact ventricular septum and post saturation are first stabilized with balloon atrial septostomy to improve inter circulatory mixing.

Tricuspid atresia

Tricuspid valve is completely absent in about 2% of newborns with congenital heart disease.Blood flows from right atrium to left atrium through foramen ovale. Early cyanosis and these patients are palliated through- Fontan procedure, with bi-directional Glenn shunt as the first stage in infancy, and completion of Fontan when they are older is the treatment.

Ebstein's anomaly

Septal and posterior leaflets of the tricuspid valve are small and deformed, usually displaced toward the right ventricular apex. Most patients have an associated ASD or patent foramen ovale. Cyanosis and arrhythmias in infancy are common. Right heart failure occurs in half of patients. Tricuspid valve repair is preferred. Replace the valve if unable to repair, plicate the atrialized right ventricle, close any associated ASD, consider Maze procedure for atrial arrythmias, and interrupt accessory conduction pathways if present. Neonates with severe forms of Ebstein's are treated with closure of tricuspid valve and conversion to univentricular physiology.

Palliative operations

1) Increase pulmonary blood flow: aortopulmonary shunts

Indications

·         Tetralogy of Fallot less than 3 months of age, as patient is too small for adequate reconstruction of RVOT

·         Pulmonary atresia with or without VSD

·         Tricuspid atresia with PS

·         Single ventricle with PS

·         TGA with VSD and PS; although there is good mixing at the level of the ventricle, there is inadequate pulmonary flow.

Types

Classic Blalock-Taussig shunt: Subclavian to PA, first performed in 1940s. Constructed on opposite side from arch; orifice of subclavian artery controls flow. Subclavian artery to PA anastomosis is technically challenging.

Modified Blalock-Taussig shunt: Goretex subclavian to PA. Generally constructed on same side as arch, although either side works; orifice of subclavian or graft itself controls flow (3 mm or 5 mm PTFE is used depending on the weight of the baby). This is more reproducible, causes less PA distortion and better PA growth.

2) Decrease pulmonary artery blood flow - pulmonary artery banding

Indications

The most common general indication for banding is congestive heart failure in infancy with anticipated delayed repair. Single ventricle is the most common lesion requiring banding, as this protects the pulmonary bed for future Fontan conversion. Also indicated in unbalanced AV canal; multiple VSD's and VSD and coarctation. Single stage correction is preferred.

3) Improve mixing: atrial septectomy

Types

Blalock-Hanlon septectomy: It is a closed procedure. Clamp is placed behind right pulmonary veins and across portions of both atria. The lateral portion of the atrial septum is excised.

Rashkind balloon septostomy: It is 90% effective.

Park- blade septostomy: used for thicker septum or when larger intra-atrial communication is desired.

Open atrial septectomy: concomitant procedure, most commonly during repair of hypoplastic left heart.

4) Reduce ventricular work: Glenn shunt

Types

Bi-directional Glenn shunt: SVC to PA (end-to-side). Flow goes to both lungs, so subsequent Fontan procedure will use both lungs. Can be done as preparation for Fontan conversion or in combination with Fontan procedure. Much less likely to produce right heart failure from over circulation as aortopulmonary shunt can. Complications include decreased shunt flow over time as pulmonary vascular resistance gradually rises.

Classical Glenn: SVC to RPA (end-to-end). Divides pulmonary circulation. Results in late arterio-venous fistula, diverts all venous return to the larger right lung, so subsequent Fontan procedure can only use the smaller left lung.

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LUBIC ....LUBRICATING JELLY

LUBRICATING JELLY
WHICH IS USED IN HOSPITAL SETTINGS
WATER SOLUBLE SYNTHETIC AND VEGITABLE GUMS
ITS NOON IRRITATING
WIDELY USED IN GYNAECOLOGICAL AND HOSPITAL PROCEDURES
EXCELLENT FOR INSERTION OF CATHETERS,SCOPES,RECTAL THERMOMETERS,ENEMAS ETC
IDEAL CONTACT MATERIAL FOR ECG









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MADAVOORPARA....(senic beauty.....)..near kataikonam..trivandrum

FOR THOSE WHO LOVE NATURE AND ADVENTURE......

MADAVOORPARA...one of the nearest and good place to visit in trivandrum.

it locates near kataikonam.

few resting places are arranged on the top

one of the main attraction is bamboo bridge about 101 meters which lead to the top...view point

 bamboo bridge...

top resting place.....

for enjoying natures buety and breeze.....

view from the top....

 HOW TO REACH THERE

1.FROM SREEKARIYAM TAKE POTHENCODE - POWDIKONAM ROAD TO SHANTHINAGAR FROM THERE TURN TO RIGHT ....(for those who like adventure trip because through this route we have to climb the rock to reach the top..)

2.FROM SREEARIYAM -POTHENCODE - POWDIKONAM ROAD TO KATAIKONAM JUNCTION FROM THERE TURN RIGHT AFTER GOING FEW METERS AHEAD .VEHICLE WILL GO TO ALMOST TOP OF THE ROCK.

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