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Fundamentals of operative techniques in neurosurgery pdf

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Fundamentals of Operative Techniques in Neurosurgery - Connolly, E. Sander - Ebook download as PDF File .pdf), Text File .txt) or read book online. operative . Thieme congratulates Tanvir F. Choudhri on being chosen by New York magazine for its prestigious 'Best Doctors ' list. Read More. Operative. Fundamentals of Operative. Techniques in Neurosurgery. Second Edition. This document was downloaded for personal use only. Unauthorized distribution is.

Elevate the mucosa overlying the sphenoid sinus bilaterally to expose both sphenoid ostia. California Adel M. Fundamentals of Operative Techniques in Neurosurgery. Kaiser California Brian L. Prevents ischemic complications.

Ringer Carotid Test Occlusion and Deconstructive Procedures. Larsen and Gabriel Zada. Garrett, and Philip M. Merkow, and Philip M. Meyers Vertebroplasty and Kyphoplasty. Eskey, and Joshua A. Otten, Michal A. Rynkowski, and Michael B. Sisti Radiosurgery for Metastases and Gliomas. Komotar, and Michael B.

Sisti Radiosurgery for Skull Base Lesions. Kondziolka Gamma Knife Radiosurgery for Trigeminal Neuralgia. Preface In recent years, a number of large, multivolume texts on operative neurosurgery have been published.

While these texts are useful for many applications, they are often, as a result of their size and cost, inaccessible during clinical practice, particularly for neurosurgical residents. Therefore, we developed the first edition of Fundamentals of Operative Techniques in Neurosurgery to provide a concise, practical, and portable text covering the important aspects of operative neurosurgery. This second edition represents not only an updated, but also a substantially improved and more comprehensive follow-up to that original edition.

Chapters have been organized in a subspecialty-based manner to facilitate rapid localization of relevant information. Additionally, in order to maximize portability, while minimizing bulkiness, we have organized each section with surgical approaches covered first and then pathology-specific nuances covered in detailed subsequent chapters.

As the field of neurosurgery has continued to expand in scope and practice, we recognize that not all operative procedures can be covered. Perhaps most significantly, this new edition includes improved, and more numerous, figures to more clearly represent procedures and aid in understanding of subtle nuances.

Each chapter is organized in bullet point format, leading to a quick and comprehensive reference. Choudhri, MD Ricardo J. Parsa and Yang. If one does not wish to perform such a procedure. Another useful aspect of this compendium pertains to the neurosurgeon that has had no experience in performing a specific complicated procedure. Neurosurgery is. What one finds is a very fundamental and basic step-by-step approach to performing surgery on virtually all the disorders that a neurosurgeon might encounter.

For example. The text is not overly illustrated. Foreword This second edition builds on the comprehensive presentation of neurosurgical techniques provided in the first. A veritable cookbook of neurosurgical techniques.

Most patients are appreciative of this consideration. Bennett M. Important aspects are highlighted for easy reference. I would not only recommend this book for all neurosurgeons. Morcos and Kaibara. While the majority of the authors are from the Neurological Institute of New York.

This is particularly useful for the neurosurgeon starting out. Fundamentals of Operative Techniques in Neurosurgery is a firm guideline in such cases. Acknowledgments We are grateful to all of our contributors.

Arizona Arun Paul Amar. Ohio Edward S. Maryland Devin K. California Richard C. New York Hooman Azmi. Oklahoma Eli M.

Maryland Ellen L. New York Peter D. New Jersey Clinton J. California xxiii. Illinois Darric E. Pennsylvania Chetan Bettegowda. Contributors Todd A. Ohio Felipe C. Irvine Irvine. California H. Hunt Batjer. MD Michael J.

New York James E. New York Ian F. Canada Asim F. Connecticut Andrew F. Texas Chiraz Chaalala. Georgia Tanvir F. New Jersey Michael L. New York Mark G.

Maryland Anne G. MD Bennett M. New York E. Maryland Haroon F. MD Co-Director. Ohio Paul T. Virginia John A. Sander Connolly. New Hampshire. PC Ridgewood. Tennessee Gavin W. MD Neurosurgeon St. Illinois James Frazier. California Christopher C. Newark Newark. New York Zoher Ghogawala. New Jersey Matthew C. Illinois xxv Saadi Ghatan. California Jorge Gonzalez-Martinez.

Maryland Chirag D. Maryland Robert M. Fernando Gonzalez. New York Richard G. New York David Gordon. New York. Connecticut L. Contributors Neil A. Ohio Robert R. Pennsylvania Nestor R. Los Angeles Los Angeles. Massachusetts Gary L. Jenkins III. Pennsylvania Randall T. California Brian L. New York Arthur L. Maryland Joshua A.

Massachusetts Murat Gunel. New York Gregory G. Massachusetts George Jallo. Virginia Christoph Hofstetter.. Massachusetts John Jane Jr.

Florida Judy Huang. Maryland Steven W. MD Professor of Neurological Surgery. San Francisco San Francisco. New York Kevin L. Massachusetts Michael T. New York Daniel H. MD Chief Resident. Pennsylvania Donald W. New York xxvii Douglas S. New York Sean D. Texas Grace H. Washington Ricardo J. New York Andrew L. Contributors David M.. California Ilya Laufer.

New York Edward R. Massachusetts Taro Kaibara. Arizona Michael G. Tennessee Michael Lim. Ohio William J. Pennsylvania Khan Li. PC Vancouver. California Adel M. Canada Paul G. Biomedical Engineering. Alabama Steve J. PhD Director. Virginia David Mathieu. Wisconsin Peter D. Pennsylvania Andre Machado. Massachusetts Christopher E. New York Paul C. Washington Max C. Maryland Christopher M. DHC Hon. Departments of Neurosciences.

California Marcus M. MD Neurosurgical Associates Nashville. Pennsylvania Scott A. Florida Jennifer Moliterno. New York J Mocco. New York Maxwell B. Contributors Guy M. Connecticut Jacques J.

Florida xxix Praveen V. Massachusetts Marc L. New York Andrew T. California Sean J. New York Philip M. Maryland Christopher S.

Ohio Richard B. New Jersey Pablo F. Maryland Ali R. New York Gustavo Pradilla. Michigan Peter A. Maryland Russell Reid. Ohio Sharad Rajpal. Anderson Cancer Center Houston. Maryland Daniel K. Illinois Violette Renard Recinos. New York Ganesh Rao. Florida Dimitris G. Ohio David Pincus.

Texas Rakesh Patel. Maryland Charles J. Wisconsin Alfredo Quinones-Hinojosa. Wisconsin Charles J. MD Chairman of Neurosurgery St. Massachusetts Amer F. Washington Harshpal Singh. Belgium R. Maryland Michal A. Georgia Andrew C. Texas Johannes Schramm. New York Nader Sanai. Florida Daniel L.

Techniques fundamentals of neurosurgery pdf in operative

Michael Scott. Germany Thomas C. Ohio Gerald E. MD Spine Surgeon. California David I. MD Assistant Professor of Neurosurgery. Contributors Howard A. Long Hospital Atlanta. Orthopedic Surgery. Pennsylvania Chandranath Sen.

New York Andrew J. FACS President. Virginia Theodore H. New York Guy Rosenthal. Texas xxxi Raymond Sawaya. MD Arthur A. California Daniel Sciubba. New York B. Minnesota Robert M. California Phillip B. Virginia Michael E. MD Professor of Neurosurgery. New York Arien Smith. Boston Boston. Virginia Michael P. Pennsylvania Brian R. Massachusetts Volker K. Arizona Robert J. Gregory Thompson. Pennsylvania Shirley I.

California Omar N. Michigan Luis M. Ohio Michael F. Radiation Oncology. Texas Nirit Weiss. Washington K. New York Christopher J. California Hasan Zaidi. California Kevin Walter. Michael Webb. California James Waldron. Wisconsin Mario Zuccarello. California Albert J. Massachusetts Gabriel Zada.

Maryland Thomas A. New York Arthur A. Contributors Fernando Vinuela. Union City. Center Valley. Wilson frame Mizuho OSI. Yasargil Leyla bar attachment Aesculap. Approaches Positioning — Check operating room OR table set-up prior to transferring patient.

If you slowly run through these items and their respective role in the case when entering the OR. There are 11 elements: Ensuring that the entire OR team understands the case.

Understanding the procedure. Budde Halo Integra. FL Bipolar cautery irrigating bipolar optional Microscope Monitors for frameless stereotactic navigation Anesthetic Issues — Preoperative intravenous IV antibiotics administered within 30 minutes prior to incision — For most procedures: Gelfoam [Pfizer. Surgicel [Ethicon. Greenberg Codman. Stealth [Medtronic.

Fundamentals of Operative Techniques in Neurosurgery | Download book

CT scrub for 5 minutes — Area is dried with sterile towel. MA gauze placed in external auditory canal to prevent prep fluid accumulation — Betadine Purdue Pharma. If prone position. Woodson dissector.

Approaches — Incision is marked — DuraPrep 3M. Epidural hemostasis is achieved by controlling dural bleeding with bipolar cautery. Closure of Dura — Closure of dura proceeds after hemostasis of operative field has been ensured — The dura is reapproximated with interrupted or running 4—0 Nurolon sutures while avoiding injury to cortical vessels or draining veins — If watertight dural closure cannot be obtained: The dura is tacked up to the craniotomy edges with 4—0 Nurolon sutures Ethicon to close the epidural space and prevent epidural hematoma formation.

Two small holes are placed in bone flap in anticipation of a central dural tacking suture during closure. Holes are drilled at an angle in the native skull along the edges of the craniotomy for dural tack-up sutures.

Irrigation is performed to remove bone dust and identify sites of bone or dural bleeding. Gelfoam or FloSeal Baxter. Opening of Dura — Using fine-toothed forceps or a 4—0 Nurolon suture to lift the dura. Approaches — — — — — — — — Central dural tack-up suture is threaded through bone flap Bone flap secured with titanium miniplates and screws Central dural tack-up suture is tied to close epidural space Bone filler to obliterate bone defects is optional Subgaleal drain is optional Muscle and fascial layers are closed with 0 or 3—0 Vicryl Ethicon sutures Galea closed with inverted 3—0 Vicryl sutures Skin closed with staples.

It is important to insert the endoscope into the introducer expeditiously to prevent the rapid egress of CSF that may result in postoperative subdural hematomas. It is easiest to use written text such as the labeling on the outside of a sterile suture box or marking pen.

Introduction of Endoscope — The dura is opened and the dural leaflets are coagulated with bipolar cautery. Intraventricular Anatomy — Identify the following landmarks in the lateral ventricle: A mark at 5 cm is placed to avoid deeper penetration.

Stereotaxy can also be used to reorient oneself. Other causes include turbid CSF. In the majority of cases. If significant bleeding occurs. Aggressive ventricular drainage. Techniques — If the image is blurred look for technical problems: Management Pearls — Eyes on monitor at all times when endoscope is intracranial — Abort procedure if visualization or anatomy is impaired. In cases with continued bleeding.

This can be relieved by stopping irrigation and removing the endoscope to allow the egress of irrigation fluid and CSF. Complications — In cases of significant bleeding it is important to irrigate copiously until hemostasis is achieved.

Once hypertension and bradycardia have resolved the procedure can be resumed with more cautious irrigation. For an anterior interhemispheric approach. Burr holes spanning across the superior sagittal sinus are created at the anterior and posterior edges of the bone flap B. Opening of Dura — Dura can be opened in a cruciate manner with intersecting incisions if necessary. Prepare in advance to control bleeding from superior sagittal sinus with Gelfoam of appropriate size.

B Burr hole locations and craniotomy. A small chisel or narrow side cutting burr may be used to release the nerve if a true foramen is present. Place miniplates along the flap prior to elevation to ensure a good cosmetic closure. Approaches Surgical Approach Phase I: Frontosphenotemporal Pterional Craniotomy Fig. The muscle is separated with blunt dissection. Orbitozygomatic Osteotomy Fig. Stay above the zygomaticofacial fissure to avoid the maxillary sinus.

Oblique cuts are made for cosmetically appealing reapproximation. The supraorbital nerve is easily reflected with the periorbita if a supraorbital notch is present.

Five cuts B are made in the zygomatic process. Approaches Closure — Reapproximation of the dura — Placement of pericranium with its vascular pedicle in cases of a violated frontal sinus — Gelfoam is placed over the dura. Avoid cautery so as to minimize nerve injury. Bone over the optic foramen is preserved during this portion of the procedure. B Extradural drilling of the optic strut and anterior clinoid process. Note that the subtemporal exposure at this junction will aid in the exposure of the posterior aspects of the cavernous sinus and allow for identification of the third and fourth nerves.

General Craniotomy Techniques Incision — Depending on size of craniotomy. Debulking of tumor allows rotation to cauterize choroidal arteries. Minimize intraventricular hemostatic products. Approaches Complications Perioperative — Injury to superior sagittal sinus or draining veins — Injury to sensorimotor cortex or superior parietal lobule — Injury to optic radiations Postoperative — — — — — Seizures Venous infarction Wound or flap infections Visual field deficit Parietal lobe dysfunction Management Pearls — The patient should be positioned so that the trajectory to the lesion is vertical.

Approaches Postoperative — Steroids if appropriate — Antibiotics continued for 24 hours — Compression stockings. Sterile Scrub and Prep — See Chapter 2. Access to the right lateral ventricle after inadvertent entry into the left lateral ventricle is accomplished by further lateral resection of the corpus callosum or fenestration of the septum pellucidum.

Approaches Entry into the Lateral Ventricle — The cauterized ependymal layer is opened for entry into the lateral ventricle — The brain retractor is repositioned just beyond the inferior callosal margin — Orientation of entry into either the right or left lateral ventricle is confirmed by the configuration of the choroid plexus and thalamostriate vein. Franklin Lakes. Keep them wet with Telfa strips and unstretched.

Further interhemispheric space can be obtained by microsurgical dissection of the veins along their bridging course. NJ can be prepared to rapidly stem bleeding in the event of sinus injury.

Bruce Indications — — — — — — Petroclival tumors Large. Mandigo and Jeffrey N. Holes are drilled for tenting sutures. The transverse sinus is freed and additional craniotomy is performed infratentorially if necessary. Approaches Division of the Tentorium — Retraction of temporal lobe is performed with the aid of the operating microscope using the advancement of Bicol.

Greenberg retractor blades. The division of the tentorium is carried in an anterolateral direction into the middle fossa and across the superior petrosal sinus with suture ligatures or titanium clips. Surgical Treatment of Cortical Arteriovenous Malformations. Temporal Glioma — Vascular malformation see Chapter Approaches — Dexamethasone 10 mg IV prior to incision — Mannitol 0.

Steri-Drape 3M. NC on superficial temporal artery prior to cutting it with knife — Temporalis fascia incised with knife and extended with Metzenbaum scissors. Research Triangle Park. Pterional Approach Horseshoe shaped with base over sphenoid Started at inferior extent of temporal lobe limb of incision 4—0 silk through outer leaf of dura to elevate. General Craniotomy Techniques Complications Perioperative — — — — — Cervical spine injury from excessive head turning Dural tear Cortical injury with craniotome CSF leak from inadequate waxing of anterior mastoid air cells Peripheral cranial nerve VII palsy from incision.

Drainage is from the sylvian veins into the sphenoparietal sinus. When large anterior temporal resections are undertaken. Approaches — Neurophysiologic monitoring: The flap is reflected anteriorly to the level of the external auditory canal and held in place with suture or self retaining hooks. B dural opening. The translabyrinthine approach is used if there is preoperative ipsilateral deafness. The facial canal remains protected by bone in both exposures.

In the retrolabyrinthine approach. Bony Opening — Combination of cutting and diamond burrs is used to drill the posterior petrous bone — The retrolabyrinthine approach is used if preoperative hearing is present.

The endolymphatic sac is unroofed and preserved. CN XI Fig. Sinus pressure must be measured intraoperatively to determine the competence of the torcula prior to this maneuver. The dural closure should be augmented with fibrin glue or other dural sealant and a free fat graft obtained from the abdomen or thigh. Intradural — The lateral cerebellomedullary cistern is entered sharply for CSF drainage and brain relaxation — Sharp arachnoid dissection is performed to decrease tension on CNs during manipulation Dural Closure — Every attempt should be made to create a watertight seal.

Approaches — The distal transverse and sigmoid sinuses are skeletonized to the level of the jugular bulb — The superior petrosal sinus is skeletonized — Subtemporal. The mastoid antrum must be obliterated with bone wax with care taken not to disrupt the ossicles in a hearing preservation approach. This can only be performed in a nondominant or occluded sinus. Titanium Mesh Cranioplasty — Titanium mesh should be conformed appropriately and secured in place over the cranial defect Soft Tissue Closure — The temporalis and sternocleidomastoid muscles are reattached at their common myofascial cuff.

Sisti Indications — — — — — Progressive hearing loss or recent. CN VII. Intraoperative Monitoring — Surgical dissection and resection are assisted by electrophysiological monitoring of CN V. Approaches — After originating at the basilar artery.

This can be followed over time with serial magnetic resonance imaging. Craniotomy and bony opening A. C1 arch. The jugular process has an indentation anteriorly at the site of the jugular notch.

Approaches Complications Intraoperative — Vertebral artery: The facial nerve exits the stylomastoid foramen just lateral to the jugular foramen. Bruce Indications — Lesions of pineal region especially midline — Dorsal midbrain lesions e.. Approaches Closure — — — — — — — Hemostasis crucial. Bruce Indication — — — — Mass lesions of the occipital lobe Posterior falcine meningiomas Tentorial meningiomas with only supratentorial component Tumors of the pineal region..

Ricardo J. Approaches Special Equipment — — — — — Operating microscope optional Mayfield head holder Frameless stereotaxy Yasargil bar and Greenberg retractors Cavitron Anesthetic Issues — Communicate degree of intracranial pressure elevation to anesthesiologist — Arterial line blood pressure monitoring — Intravenous IV antibiotics with skin flora coverage oxacillin 2 g should be given 30 minutes prior to incision — Dexamethasone 10 mg IV prior to incision — Mannitol B Microscopic view following division of the falx and tentorium.

Penfield no. Burr holes should be placed over sagittal sinus to avoid craniotome injury. Approaches — In general. This is best seen on axial imaging and provides important intraoperative correlation.

All patients should be evaluated by an endocrinologist prior to surgery. Equipment — — — — Transsphenoidal tray Optional: Paul T. A narrow intercarotid aperture should prompt caution and a narrow initial dural opening.

This will be needed for the immediate postoperative visual assessment. Tumors with a significant hourglass appearance may benefit from lumbar drain insertion for air insufflation during surgery. The normal gland will enhance more brightly than the tumor and the remaining normal gland should be ipsilateral to the side of stalk deviation.

Imaging also delineates the superior and inferior limits of the sella turcica.

These should be continued postoperatively if nasal packing is placed and can be discontinued when the nasal packing is removed. No tape should be placed across the upper lip. The bridge of the nose should be parallel to the floor. Place after intubation and connect to a closed drainage system. This modality is most appropriate for repeat transsphenoidal surgery. Videofluoroscopy may also be used for an encephalogram to confirm the resection of the suprasellar tumor after instillation of air via a lumbar drain.

Anesthetic Issues — Blood pressure monitoring. The assistant oculars should be set to the left of the primary surgeon. The bed is then placed diagonally in the operating.

Do not drain cerebrospinal fluid CSF during the operation. Adult patients undergoing first time transsphenoidal surgery who have good quality nasal tissue especially acromegalics in whom a wide exposure is desired. The operating table is tilted slightly toward the surgeon. Displace the cartilaginous septum into the left nasal cavity. Cleanse the nose and mouth with chlorhexidine. Sublabial Transseptal Approach — Indications: Pediatric patients.

Develop bilateral inferior submucosal tunnels along the nasal floor and detach the cartilaginous septum from the anterior nasal spine. This approach provides a rapid exposure of the sphenoid sinus but is narrower than the transseptal approach. Submucosal Tunnels — Ipsilateral submucosal tunnels: Using a Cottle or Freer dissector. Inject the septal mucosa subperichondrially with 0.

Using a blade knife in the right nostril. Identify the junction of the cartilaginous and bony septum. Using the blades of the speculum. Develop a posterior submucosal tunnel along the contralateral bony septum toward the sphenoid rostrum. This bone is saved for sellar reconstruction at the end of the operation.

Avoid liberal use of Bovie cautery to prevent thermal injury to the teeth. Separate the cartilaginous septum along its attachment to the bony septum and then along the maxillary ridge. Adult patients undergoing extended microscopic skull base approaches. The trajectory is also slightly off midline and exposes more of the contralateral side of the sella. Using Knight scissors and a large pituitary rongeur. Adult patients undergoing repeat transsphenoidal surgery or first time transsphenoidal surgery in patients with poor quality nasal tissue especially patients with Cushing disease.

A cuff of mucosa must remain attached to the gingiva to permit closure at the end of the operation. Use the 4-mm outer diameter. Expose the contralateral sphenoid ostium and resect the sphenoid bone between the two ostia. This requires removal of intersphenoid sinus septae. Find the sphenoid ostium posterior to the superior turbinate.

Adult patients undergoing transsphenoidal surgery — Although this is a binasal operation. Sphenoidotomy and Sellar Exposure — If performing a transseptal approach.

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Displace the posterior septum from the sphenoid rostrum and retract the septum with both layers of mucosa attached into the contralateral nasal cavity. Obtain a videofluoroscopic image to confirm the appropriate trajectory to the sphenoid sinus. Approaches — Place a long nasal speculum in the right nostril along the middle turbinate with the tips approximated 1. Do not resect the posterior septum more anteriorly than the anterior limit of the middle turbinate.

Elevate the mucosa overlying the sphenoid sinus bilaterally to expose both sphenoid ostia. Endoscopic Binasal 3. Ensure that the posterior septectomy is complete. Reconstruct the sellar floor using either harvested septal bone or a synthetic material. Closure — Irrigate the tumor cavity with saline. Soak the tailored pieces of fat in antibiotic solution and then dab them in cotton and Avitene. Large defects in the diaphragma sellae also require obliteration of the sphenoid sinus with fat.

Initially debulk the inferior portions of the tumor. Remove a patch of dura when resecting macroadenomas so that the specimen can be sent to pathology to determine the presence of tumor invasion.

Removal of Tumor — Using a blunt nerve hook.

Neurosurgery pdf of in fundamentals operative techniques

Place the fat grafts into the tumor bed and reconstruct the sellar floor. If the intercarotid distance is narrow. Dural Opening — Prior to opening the dura. Identify the location of the normal gland if discernible and determine the intercarotid distance at the level of the cavernous sinus. Care should be taken to only traverse the dura and to not enter the gland or tumor. If a narrow interval is present. A cruciate incision is made when removing microadenomas.

Suction the stomach using the preoperatively placed orogastric tube. Greater than mL of urine output for 3 consecutive hours should prompt an evaluation. Remove the speculum and irrigate the nasal cavity. If imaging suggests overpacking. Complications Perioperative — Nasal: Anterior septal perforations. Most often not a difficult diagnosis. If persistent. May be secondary to overpacking of the sella.

Treat diabetes insipidus acutely with intravenous or subcutaneous desmopressin. Irrigate the nasal cavities and inspect around the inferolateral corners of the sphenoidotomy for bleeding. Place nasal rockets between the middle turbinates and the nasal septum.

Draw the serum cortisol level at 6 AM on postoperative day 2 and 3. If not adrenally insufficient preoperatively. No nasal rockets are required. Remove the speculum. Injury to the cavernous carotid artery or cavernous cranial nerves. Medialize the ipsilateral middle turbinate and reposition the nasal septum in the midline.

Medialize the middle turbinates bilaterally. In cases in which uncertainty persists one may perform Tau transferrin.

Fundamentals of Operative Techniques in Neurosurgery - Connolly, E. Sander

Patients who are adrenally insufficient preoperatively should be continued on steroids postoperatively. Close the hemitransfixion incision and the sublabial incision if present using absorbable chromic suture.

Strict fluid input and output measurements. A confirmed postoperative CSF leak is effectively treated by return to the operating room for repacking of the sella and sphenoid sinus.

A thorough endocrinological evaluation should be performed prior to surgical consideration. Similar consideration should be given to access for abdominal fat. Leaving the scalp too thin will lead to wound breakdown postoperatively as well as result in excess epidural tissue compressing the brain under the cranioplasty flap.

Minimal Shave — Use electric clippers — Expose prior incision with 2-cm strip as well as any extension of prior incision — Slick hair bordering incision down with antibiotic ointment bacitracin.

Muscle and Soft Tissue Dissection — Should be approached in the same way the initial dissection was done to avoid unduly devascularizing the muscle tissue — For a cranioplasty. Opening the entire incision will give full access to the underlying bone flap and speed removal. Puncturing the dura during the dissection can cause brain injury. These sites can be best anticipated based on a careful review of a preoperative CT.

General Craniotomy Techniques Incision — In most operations. A water tight seal on the dura is critical as healing of superficial tissues may be retarded. In these cases. Expect dural defects. IN] and no. The original suture line may be used for reoperations done shortly after the original operation.

Dura Opening — The dura will be most adherent to the brain at any prior suture lines. Closure — Use 4—0 silk suture to close dura. Craniotomy — Depending on the interval between the initial craniotomy and reoperation. Often original plates may be reused safely and successfully. Areas where skull has fused to prior bone flap should be cut with a high-speed drill large or Kerrison punch small.

Synthetic graft materials are available. For reoperative craniotomies performed at an extended time after the original operation. Approaches — In cases of infection. Moving your dural opening over as little as 0. Knowing what cranial fixation system and dural closure were used initially as well as being familiar with any problems that were experienced can save a lot of time. Michael F. Continue in a large reverse question mark fashion. Course just superior to the pinna.

Dura-Guard [Synovis Surgical Innovations. General Craniotomy Techniques Scalp Incision — Shave — Identify midline and contralateral frontal burr hole for ventricular catheter or intracranial pressure ICP monitor — Incorporate scalp lacerations if feasible — Start 1 cm anterior to the tragus at the root of the zygoma.

Mayfield head holder. Approaches Skin incision Craniotomy outline Dural incision stellate Fig. A burr hole and. Muscle Dissection — Incise temporalis fascia and muscle posteriorly. Midas Rex [Medtronic] with a B1 bit with a footplate is used to cut a large free bone flap that parallels the skin incision. Dural Opening — Dural opening is curved anteriorly in a gentle C in the frontal-temporal region starting from the initial burr hole — A posteromedial triradiate incision completes the exposure and provides access to the anterior..

Surgicel and Cottonoids — For a decompressive hemicraniectomy cultures are taken from the bone flap and the flap stored in sterile fashion double bagged in the bone bank. Evacuation of Hematoma — Subdural hematoma should be removed using gentle irrigation and suction and bipolar cautery. It should allow access to the floor of the anterior and middle fossa and extend: Approaches Closure — — — — — — — — Dural closure with 4—0 Nurolon unless decompressive hemicraniectomy Surgicel over dura Epidural tack-up sutures: IV antibiotics for decompressive hemicraniectomy.

This allows muscle to be dissected off the brain when the bone flap is to be replaced usually 8 to 12 weeks later. ICP management. ICP monitor. DuraGen under pericranial or temporalis fascia flap to reduce scarring of flap to brain. This may imply that simple clipping may not be possible due to calcification of the neck. Written by authors with over 20 years of experience in the rehabilitation of patients in a persistent vegetative state, this practical text bridges a gap in the specialized literature by providing neurologists, emergency physicians, physiatrists, and internists, as well as therapists, with a new set of tools to make rapid progress in the treatment of these patients whose improvement is wholly dependent upon them.

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