Surgical planning overview

Youmans Chapter 25

Preoperative evaluation• Patient history

– Symptom time course – onset represent central features of the suspected disease– complement a focused neurological history

– preoperative deficits will be critical to establishment of a baseline with which to compare the patient’s postoperative examination findings

• Physical examination• Patient’s laboratory • Radiographic studies

Preoperative evaluation

• Patient history– Side of hand prominence– patient’s past medical and surgical history– medications, allergies– pertinent social or familial considerations– Complete review of systems – patients currently take anticoagulant or antiplatelet agents

: stop at least 1 wk

Preoperative evaluation

• Physical examination– The physical and neurological examination – The complete neurological examination : mental status,

speech ability, cranial nerve function (including the first cranial nerve), motor and sensory function, reflexes, and cerebellar and gait testing

– sellar or suprasellar disease exists : visual field and acuity– spinal disease : Rectal examinations for tone, volition,

sensation, and the bulbocavernosus reflex

Preoperative evaluation

• Laboratory– B-HCG for woman of childbearing age– Baseline renal function and electrolyte levels– Infection : elevated WBC , positive cultures, elevated ESR,

or elevated CRP– Hematology disease(anemia, coagulopathy) : platelet

count, prothrombin time (international normalized ratio), partial thromboplastin time, and bleeding time (if necessary)

• Ss

Preoperative evaluation

• Laboratory– Blood typing and screening, or crossmatching for reserve

units and additional blood products– sellar disease : full or selective endocrine panel

• Cardiac disease– screen for angina, CHF, EHG 12 leads, plain chest film

before routine surgery– If further cardiac work-up is indicated, exercise treadmill

testing, echocardiography, nuclear medicine study, or coronary angiography may be performed to further assess the degree of cardiac risk

Preoperative evaluation

• Diabetes – Hemoglobin A1c

• Hypertensive patients– adequate blood pressure control

• Pulmonary disease– asthma and chronic obstructive pulmonary disease :

smoking history, merit special attention by the physician. A plain chest radiograph, pulmonary function tests

– perioperative medications, including steroids and beta agonists

Preoperative evaluation

• malnutrition or failure to thrive– alternative sources of nutritional intake : nasogastric

tubes, percutaneous gastric tubes, and parenteral routes of intake for nutritional supplementation.

– serum prealbumin level

• Previous surgery or radiation therapy or those receiving chronic steroid treatment may present additional wound healing concerns

Radiographic imaging

• plain films, computed tomographic imaging, magnetic resonance imaging, angiography, and a variety of additional modalities

• The images should be available to the surgeon for the duration of the procedure

• Dynamic studies such as flexion-extension views may provide insight into the responsible pathologic process.

Radiographic imaging

• Intraoperative imaging• image-guided neurosurgery• Image guidance navigation systems• Intraoperative fluoroscopy(select spine or skull

base cases)• Intraoperative magnetic resonance imaging• ntraoperative angiography and fluorescein

angiography

Anesthesia

• Review operative plan with the anesthesia team• Optimal physiologic parameters (blood pressure,

volume, temperature)• Additional methods of monitoring required during

the procedure • The proper use of ventriculostomy and lumbar

drain catheters

Anesthesia

• In pediatric cases or other cases in which the degree of bleeding is of paramount concern

• administration of anesthetic medications for induction and the duration of the case

• In certain functional and tumor cases, neuroleptic anesthesia is desired to assess the patient during the procedure

Anesthesia

• Anesthesia for awake craniotomy or deep brain stimulator placement

• The perioperative administration of medications such as antibiotics, steroids, hemostatic or anticoagulation agents, and antiepileptic drugs

• spinal stability should be noted before positioning and intubation

Selection of surgical approach

• Considerations for Cranial Procedures– surgical approach and position– devices for cranial fixation and for positioning the body or extremity support– surgical navigation : verified before surgery– neurophysiologic monitoring : somatosensory motor, or

brainstem auditory evoked responses– The method of visualization to be used for the procedure :

operating microscope, surgical loupes, endoscopic system

Selection of surgical approach

• Considerations for Cranial Procedures– placement of a ventriculostomy catheter or lumbar drain– Drill equipment– Instruments or products required for hemostasis :

monopolar and bipolar cautery, collagen sponge, Surgicel, and thrombin,

Selection of surgical approach

• Tumor Cases– Plan of biopsy procedure : stereotactic framebased

procedures, image-guided neuronavigation through a bur hole or open craniotomy, or direct open biopsy

– The surgical pathologist should be notified and on standby before the initiation of surgery

– Prepare plan before after Frozen biopy result, A surgeon should plan for a variety of scenarios, depending on the results of the biopsy : complete tumor resection, partial resection, decompression, palliation ,medically

Selection of surgical approach

• Tumor Cases– Instruments required for tumor resection : special

transsphenoidal or skull base instrument sets, endoscopic equipment and the Cavitron ultrasonic aspirator

– If the potential for a cerebrospinal fluid leak near the skull base exists, the abdomen may be prepared for a fat or fascial graft harvest.

Selection of surgical approach

• Operative Planning for Cerebrovascular Cases– an approach is selected that offers exposure of the

entire lesion and proximal vasculature– Preparation for a potential intraoperative aneurysm

rupture– Methods of proximal control include temporary

aneurysm clipping, intraoperative balloon occlusion, and exposure of proximal vessels in the neck.

Selection of surgical approach

• Operative Planning for Cerebrovascular Cases– In cases of anticipated reconstruction or bypass

procedures, preoperative studies are performed to ensure that feeder and recipient vessels are sufficient, and mapping of the vessel course with a Doppler instrument may be required.

– In cases in which no feeding vessel is accessible, a venous or arterial graft harvest site may be selected and prepared on the basis of the flow demand of the target distribution

Selection of surgical approach

• Operative Planning for Cerebrovascular Cases– A wide variety of aneurysm clips should be available to the

surgeon to treat complex aneurysms– Temporary and permanent aneurysm clips should be

readily available in the event of an intraoperative rupture– Verification of distal artery patency after aneurysm

ligation can be performed with a micro-Doppler flow probe, fluorescence or intraoperative angiography, or an endoscope

Selection of surgical approach

• Planning of Spine Procedures– selected and equipment required for positioning should

be ready– standard radiolucent surgical table or the Jackson surgical

table– Equipment to perform imaging for surgical localization,

such as plain radiography, fluoroscopy, or image-guided navigation systems

– Monitoring of somatosensory and motor evoked potentials,

Selection of surgical approach

• Planning of Spine Procedures– instrumentation for exposure, stabilization, and fusion

should be sterilized and prepared for the case– When a bone fusion is desired, the surgeon should have a

plan for use of autograft, allograft, or any number of additional fusion products available.