1. Common Neurosurgical Hospital Consult Diagnoses Jeff Crecelius Neurosurgeon Goodman Campbell Brain and Spine

2. Disclosures None really Will use word Kyphoplasty which is commercial but in widespread use No financial interest in Kyphon, but did first case in Lafayette, and received free barbecue at training course in Memphis many years ago

3. Brain Bleeds Sounds dramatic, and sometimes it is; but often not. Epidural Subdural Subarachnoid Intracerebral

4. Epidural Hematoma Relatively uncommon-only1-2% of TBI Good prognosis if “pure” i.e. isolated Lucid interval is classic, but uncommon (20%) Prompt surgery is important Usually in younger patient with relatively low energy trauma

5. Subdural Hematoma Acute in high energy injury associated with other brain involvement Acute in low energy may be tolerated if in elderly with atrophy and room to spare Subacute (from clot to red liquid) may be treated with “just” burr hole Chronic (crankcase fluid) commonly recognized in elderly weeks after minor injury

6. Subarachnoid Hemorrhage Traumatic usually from high energy injury Spontaneous from many sources – Aneurismal cause in about 75% – Others causes include AVM, tumor, vasculitis Cause usually apparent from CT pattern and history—if likely from aneurysm, we transfer to Indianapolis for evaluation

7. Intracerebral Hypertensive Ischemic Vascular Malformations (AVM, Cavernous) Amyloid Angiopathy Trauma (DTICH) Tumor THIN Blood (growing incidence of iatrogenic)—another day for that!

8. Normal Pressure Hydrocephalus Misnomer and really a spectrum of disease Triad of symptoms – Gait Disturbance=“Stuck”, but not unique – Incontinence (which is common with immobility) – Dementia Difficult diagnosis (especially in hospital otherwise ill with co morbidity) – Clinical – Imaging (CT, MR, Isotope Cisternogram) – Tap Test vs. Ambulatory Lumbar Drainage

9. Radiculopathy Common especially C6&C7, L5&S1 Red Flags – Age 50; Weight loss; Fever; Worse at rest – Cauda Equina Syndrome Rare but increasingly reported – Insurance restriction of MR>PCP staff overwhelmed>Street knowledge of incontinence as the key to cut the red tape. Uncommon to have normal reflexes and exam though

10. No Red Flag Radiculopathy Brief rest (2-3days) Walk PT if gentle (but conditioned to be Aggressive) Analgesic Muscle relaxants Education/reassurance SMT Steroids? (IV, oral, ESI)

11. Osteoporotic Thoracolumbar Compression Fractures Risk Factors – Low Weight – Cigarettes – Family History – Female (especially postmenopausal) – Alcohol – Steroids – Inactivity

12. Evaluation of Fracture X-ray – Compare if available MRI – Acuity? CT and Bone Scan – If MR contraindicated (ex. Implants like pacemaker)

13. Treatment of Fracture Non-invasive – Rest with DVT prophylaxis – Analgesics – PT – Brace Typical time course about 6 weeks Follow up x-rays about 2 week intervals – Assess progression

14. Treatment of Fracture Invasive (augmentation) Vertebroplasty Kyphoplasty Multilevel Stabilization – Rare

15. Indications for Augmentation At least 5% height loss Intractable Pain – Activity related and at fracture site Acute or Subacute on MR or Bone Scan Also may be used for hemangiomas, myeloma, or metastases (off label)

16. Contraindications to Augmentation Healed (cold on bone scan/old on MR) Coagulopathy – Evolving leniency by IR re anti-platelet agents Retropulsion Planum

17. Questions Thanks