1.  Common neurosurgical conditions seen in primary care Brian Jochim MSN, APRN, FNP

2. Financial Disclosures  None

3. Objectives:  Identify early potential problems with the hydrocephalus patient.  Identify signs of a tethered cord and work-up needed.  Identify signs of chiari malformation and work-up needed.  Identify and manage head bonks/trauma.

4. What’s the one thing you must know about Neurosurgery

5. Our Number (502) 583-1697

6. Normal Cerebral Flow

7. Hydrocephalus

12. Shunt Parts

13. Ventriculoperitoneal Shunt

14. Ventriculopleural Shunt

15. Ventriculoatrial Shunt

16. Things to know about your shunted hydrocephalus patient  What kind of shunt do they have?  Location? Programmable?  When was their last revision?  What were their symptoms during the last malfunction?  What is their bowel history?

17. Signs of a shunt malfunction

18. Subtle signs of shunt malfunction  Behavior changes  Decline in PT/OT  Change in grades at school

19. Tethered Cord

20.  A mechanical diagnosis: any symptoms arising from downward traction on the spinal cord  Heterogeneous etiologies, clinical and radiographic presentations  Fatty filum and/or low conus: probably from secondary neurulation  Congenital (myelomeningocele/lipomyelomeningocele) or acquired (intradural spinal tumor) structural pathologies, or associated postoperative scar tissue  Split cord malformation: tethering bony spur or fibrous band  Idiopathic: can have a structurally normal spinal cord on imaging

21. Signs and symptoms  Younger children  Delay in motor milestones  Increased muscle tone in legs  Chronic constipation  Neurocutaneous stigmata  Asymmetric gluteal fold  Hairy patch or hemangioma on back  Sacral dimple, especially if high and/or off midline

22. Signs and Symptoms  Older children  Abnormal urinary function  Incontinence  Retention  VU reflux  Frequent UTIs  Leg cramping  Axial back pain  Gait disturbance  Scoliosis

23. Tethered cord work-up  MRI lumbar without contrast  Physical Exam  Refer to urology for urodynamic studies  Refer to GI for constipation treatment

24. Surgery

25. Radiographic evidence

26. Dural Exposure

27. Fatty/Thickened Filum

28. Dural Closure

29. Post-op considerations  Incision care  Meningitis  Pseudomeningocele  Re-tethering

30. Chiari Malformation

31.  Definition  Downward herniation of the cerebellar tonsils through the foramen magnum  Can be idiopathic or acquired  Actual distance of herniation to constitute radiographic definition of Chiari is controversial  Can have large herniation with no symptoms  Can have small herniation with bad symptoms  The diagnosis is made based on a combination of clinical and radiographic findings

32. Chiari? YesNOMaybe

33. Etiology  Precise cause has not been clearly elucidated  May be related to pressure differentials in choroid plexus pulsations above and below the tentorium during development  Some familiar clustering but no known genetic factors  Associated with other conditions such as achondroplasia, Albright’s hereditary osteodystrophy, William’s syndrome  Essentially a volume discrepancy between the posterior fossa cranium and its contents

34. Pathophysiology

35. Signs and symptoms  Upper extremity weakness  Decreased / absent gag  Posterior headache

36. Work-up

37. Surgery: Bone removal

38. Duraplasty

39. Post-op considerations  PAIN  Incision care  Meningitis  Pseudomeningocele

40. Skull Fractures & Head Trauma

41. Skull fractures/Head Trauma

42. Skull Fractures/Head Trauma  Most likely accompanied by soft tissue swelling but not always.  The mechanism is important  ER for CT to R/O intracranial abnormalities such as bleeding.

43. Skull Fractures/Head Trauma  Soft tissue swelling  Birth related  NAT concern  Glasgow coma scale

44. Take home points  Don’t panic  Knowledge is power  Neurosurgery is open 24/7

45. Our Team Thomas Moriarty, MD, PhD Division Chief William Gump, MD Ian Mutchnick, MD, MS

46. Questions

47. Its Just Brain Surgery  I won’t pretend I know the answer to everything, but I’ll get the answer to anything (neurosurgical).  Email your question to me:  brian.jochim@nortonhealthcare.org