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Chapter 75 / Neurosurgery 739

What are the three most

1.

Thoracic

common sites?

2.

Lumbar

 

3.

Cervical

What is the most common

Staphylococcus aureus

organism?

 

 

What are the signs/

Fever; severe pain over affected area

symptoms?

and with flexion/extension of spine;

 

weakness can develop, ultimately leading

to paraplegia; 15% of patients have a back furuncle

How is the diagnosis made?

Which test is contraindicated?

What is the treatment?

What is the prognosis?

PEDIATRIC NEUROSURGERY

MRI test of choice

LP, because of the risk of seeding CSF with bacteria, causing meningitis

Surgical drainage and appropriate antibiotic coverage

Depends on preop condition; severe neurologic deficits (e.g., paraplegia) show little recovery; 15% to 20% of cases are fatal

HYDROCEPHALUS

What is it?

Abnormal condition consisting of an

 

increased volume of CSF along with

 

distension of CSF spaces

What are the three general

1.

Increased production of CSF

causes?

2.

Decreased absorption of CSF

 

3.

Obstruction of normal flow of CSF

 

 

(90% of cases)

What is the normal daily

500 mL

CSF production?

 

 

What is the normal volume

150 mL in the average adult

of CSF?

 

 

740 Section III / Subspecialty Surgery

 

Define “communicating”

Communicating—unimpaired connection

versus “noncommunicating”

of CSF pathway from lateral ventricle

hydrocephalus.

to subarachnoid space

 

Noncommunicating—complete or

 

incomplete obstruction of CSF flow

 

within or at the exit of the ventricular

 

system

What are the specific causes

Congenital malformation

of hydrocephalus?

Aqueductal stenosis

 

Myelomeningocele

 

Tumors obstructing CSF flow

 

Inflammation causing impaired

 

absorption of fluid

 

Subarachnoid hemorrhage

 

Meningitis

 

Choroid plexus papilloma causing

 

c production of CSF

What are the signs/

Signs of increased ICP: HA, nausea,

symptoms?

vomiting, ataxia, increasing head

 

circumference exceeding norms for age

How is the diagnosis made?

CT scan, MRI, measurement of head

 

circumference

What is the treatment?

1. Remove obvious offenders

 

2. Perform bypass obstruction with

 

ventriculoperitoneal shunt or

 

ventriculoatrial shunt

What is the prognosis if

50% mortality; survivors show decreased

untreated?

IQ (mean 69); neurologic sequelae:

 

ataxia, paraparesis, visual deficits

What are the possible

1. Blockage/shunt malfunction

complications of treatment?

2. Infection

What is hydrocephalus ex

Increased volume of CSF spaces from

vacuo?

brain atrophy, not from any pathology

 

in the amount of CSF absorbed or

 

produced

What is a “shunt series”?

Series of x-rays covering the entire shunt length—looking for shunt disruption/ kinking to explain malfunction of shunt

Chapter 75 / Neurosurgery 741

SPINAL DYSRAPHISM/NEURAL TUBE DEFECTS

What is the incidence?

What are the race/gender demographics?

Define spina bifida occulta.

What are the signs/ symptoms?

What is the most common clinically significant defect?

1/1000 live births in the United States

More common in white patients and female patients

Defect in the development of the posterior portion of the vertebrae

Usually asymptomatic, though it may be associated with other spinal abnormalities; usually found incidentally on x-rays

Myelomeningocele: herniation of nerve roots and spinal cord through a defect in the posterior elements of the vertebra(e); the sac surrounding the neural tissue may be intact, but more commonly is ruptured and therefore exposes the CNS to the external environment

What are the three most common anatomic sites?

What are the signs/ symptoms?

1.Lumbar region

2.Lower thoracic region

3.Upper sacral region

Variable from mild skeletal deformities to a complete motor/sensory loss; bowel/ bladder function is difficult to evaluate, but often is affected and can adversely affect survival

What is the treatment?

What is the prognosis?

Which vitamin is thought to lower the rate of neural tube defects in utero?

With open myelomeningoceles, patients are operated on immediately to prevent infection

95% survival for the first 2 years, compared with 25% in patients not undergoing surgical procedures

Folic acid

742 Section III / Subspecialty Surgery

CRANIOSYNOSTOSIS

What is it?

Premature closure of one or more of the

 

sutures between the skull plates

What is the incidence?

1/200 live births in the United States

What are the types?

Named for the suture that is fused (e.g.,

 

sagittal, coronal, lambdoid); sagittal

 

craniosynostosis accounts for 50% of all

 

cases; more than one suture can be

 

fused, and all or part of a suture may be

 

affected

How is the diagnosis made?

Physical examination can reveal ridges

 

along fused sutures and lessened suture

 

mobility; plain x-rays can show a lack of

 

lucency along the fused suture, but are

 

rarely required

What are the indications for surgery?

Most often the reasons are cosmetic, as the cranial vault will continue to deform with growth; occasionally, a child will present with increased ICP secondary to restricted brain growth

What is the timing of surgery?

Usually 3 to 4 months of age; earlier surgery increases the risk of anesthesia; later surgeries are more difficult because of the worsening deformities and decreasing malleability of the skull

What is the operative

1%

mortality?

 

MISCELLANEOUS

 

 

 

What is the most

Staphylococcus aureus (skin flora)

common bacteria causing

 

postneurosurgery meningitis?

 

What classically presents as

Spontaneous subarachnoid hemorrhage

the “worst headache of my

 

life”?

 

What classically has a “lucid

Epidural hemorrhage

interval”?

 

 

 

Chapter 76 / Urology 743

What is the most common

Putamen

location of a hypertensive

 

 

intracerebral hemorrhage?

 

 

What is Horner’s syndrome?

Cervical sympathetic chain lesion;

 

Think: “MAP”:

 

Miosis

 

Anhydrosis of ipsilateral face

 

Ptosis

What is a third-nerve palsy?

Think: Third nerve does three things:

 

1.

Diplopia

 

2.

Ptosis

 

3.

Mydriasis

What is Millard-Gubler

Pons infarction:

syndrome?

1.

VI nerve palsy

 

2.

VII nerve palsy

 

3.

Contralateral hemiplegia

What is syringomyelia?

Central pathologic cavitations of the

 

spinal cord

C h a p t e r 76

Urology

Define the following terms:

 

Cystogram

Contrast study of the bladder

Ureteral stents

Plastic tubes placed via cystoscope into

 

the ureters for stenting, identification, etc.

Cystoscope

Scope placed into the urethra and into

 

the bladder to visualize the bladder

Perc nephrostomy

Catheter placed through the skin into the

 

kidney pelvis to drain urine with distal

 

obstruction, etc.

Retrograde pyelogram

Dye injected into the ureter up into the

 

kidney, and films taken

744 Section III / Subspecialty Surgery

 

RUG

Retrograde UrethroGram (dye injected

 

into the urethra and films taken; rules out

 

urethral injury, usually in trauma patients)

Gomco clamp

Clamp used for circumcision; protects

 

penis glans

Bell clapper’s deformity

Condition of congenital absence of

 

gubernaculum attachment to scrotum

Fournier’s gangrene

Extensive tissue necrosis/infection of the

 

perineum in patients with diabetes

Foley catheter

Straight bladder catheter placed through

 

the urethra

Coudé catheter

Basically, a Foley catheter with hook on

 

the end to get around a large prostate

Suprapubic catheter

Bladder catheter placed through the skin

 

above the pubic symphysis into the bladder

Posthitis

Foreskin infection

Hydrocele

Clear fluid in the processus vaginalis

 

membrane

Communicating

Hydrocele that communicates with

hydrocele

peritoneal cavity and, thus, gets smaller

 

and larger as fluid drains and then

 

reaccumulates

 

Chapter 76 / Urology 745

Noncommunicating

Hydrocele that does not communicate

hydrocele

with the peritoneal cavity; hydrocele

 

remains the same size

Varicocele

Abnormal dilation of the pampiniform

 

plexus to the spermatic vein in the sper-

 

matic cord; described as a “bag of worms”

Spermatocele

Dilatation of epididymis or vas deferens

Epididymitis

Infection of the epididymis

Prehn’s sign

Elevation of the painful testicle that

 

reduces the pain of epididymitis

TRUS

TransRectal UltraSound

DRE

Digital Rectal Examination

Orchitis

Inflammation/infection of the testicle

Pseudohermaphroditism

Genetically one sex; partial or complete

 

opposite-sex genitalia

Urgency

Overwhelming sensation to void

 

immediately

Dysuria

Painful urination (usually burning

 

sensation)

Frequency

Urination more frequently than usual

746 Section III / Subspecialty Surgery

 

Polyuria

Urination in larger amounts than usual

Nocturia

Awakening to urinate

Hesitancy

Delay in urination

Pneumaturia

Air passed with urine via the urethra

Pyuria

WBCs in urine; UTI 10 WBCs/HPF

Cryptorchidism

Undescended testicle

IVP

IntraVenous Pyelogram (dye is injected

 

into the vein, collects in the renal

 

collecting system, and an x-ray is taken)

Hematuria

RBCs in urine

Space of Retzius

Anatomic extraperitoneal space in front

 

of the bladder

Enuresis

Involuntary urination while asleep

Incontinence

Involuntary urination

TURP

TransUrethral Resection of the Prostate

PVR

PostVoid Residual

Priapism

Prolonged, painful erection

Paraphimosis

Foreskin held (stuck) in the retracted

 

position

Phimosis

Inability to retract the foreskin

Balanitis

Inflammation/infection of the glans penis

Balanoposthitis

Inflammation/infection of the glans and

 

prepuce of the penis

UTI

Urinary Tract Infection

Peyronie’s disease

Abnormal fibrosis of the penis shaft,

 

resulting in a bend upon erection
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