Surgery_Schwartz

Surgery_Schwartz. given the relatively low risk of the procedures, and the crippling social and economic effects of uncontrolled or partially controlled epilepsy.79 Patients with symptoms, imaging abnormalities, and EEG analysis compat-ible with a specific seizure focus are most likely to have good results from epilepsy surgery.Anterior Temporal Lobectomy. Medial temporal lobe struc-tural abnormalities can lead to complex partial seizures (CPS). Many patients with CPS have poor seizure control on medi-cations. Patients with CPS may have significant reduction in seizure frequency or cessation of seizures after resection of the anterior temporal lobe. The amygdala and the head of the hip-pocampus are removed as part of the lobectomy. Resection may be taken back approximately 4.5 cm from the temporal tip in the language-dominant hemisphere, and 6 cm from the temporal tip in the language nondominant hemisphere, with low risk of significant neurologic deficits.80 The two main risks of anterior temporal


Surgery_Schwartz

Surgery_Schwartz. in the language-dominant hemisphere, and 6 cm from the temporal tip in the language nondominant hemisphere, with low risk of significant neurologic deficits.80 The two main risks of anterior temporal lobectomy are memory impairment and visual loss. Removal of the hippocampus in a patient with an atrophied or nonfunctional contralateral hippocampus causes a global mem-ory deficit. Interruption of the optic radiations, which carry visual signals from the contralateral superior visual quadrants of both eyes, causes a contralateral superior quadrantanopia, known as a pie in the sky field cut.Corpus Callosotomy. Patients with generalized seizures, atonic seizures associated with drop attacks, or absence sei-zures, who are found to have bilaterally coordinated patho-logic cortical discharges on EEG and who fail AED therapy, may be candidates for corpus callosotomy. The corpus cal-losum is a large white matter tract that connects the cerebral hemispheres. Loss of consciousness requires


Surgery_Schwartz

Surgery_Schwartz. on EEG and who fail AED therapy, may be candidates for corpus callosotomy. The corpus cal-losum is a large white matter tract that connects the cerebral hemispheres. Loss of consciousness requires simultaneous seizure activity in both hemispheres. Focal or partial seizures may spread via the corpus callosum to the contralateral hemi-sphere, causing generalization and loss of consciousness. Divi-sion of the corpus callosum can interrupt this spread. Patients may have decreased numbers of seizures and/or fewer epi-sodes of lost consciousness. Usually only the anterior half or two-thirds of the corpus callosum is divided, as more extensive division increases the risk of disconnection syndrome. Patients with disconnection syndrome are unable to match objects in the opposite visual hemifields, to identify objects held in one hand with the other hemifield, and to write with the left hand or name objects held in the left hand (in left hemisphere–dominant patients).Hemispherectomy. Children


Surgery_Schwartz

Surgery_Schwartz. to identify objects held in one hand with the other hemifield, and to write with the left hand or name objects held in the left hand (in left hemisphere–dominant patients).Hemispherectomy. Children with intractable epilepsy, struc-tural anomalies in one hemisphere, and contralateral hemiple-gia, may have improved seizure control after resection of the hemisphere (anatomic hemispherectomy) or disruption of all connections to the hemisphere (functional hemispherectomy). Functional hemispherectomy often is preferred over anatomic hemispherectomy because of the high incidence of complica-tions such as hematoma formation and ventriculoperitoneal shunt dependence associated with the latter.Vagus Nerve Stimulation. Neuromodulatory treatments like vagus nerve stimulation (VNS), approved by the U.S. Food and Drug Administration (FDA) in 1997, are less invasive and offer some titratability in addition to reversibility unlike the resec-tive surgical options previously described. Since first


Surgery_Schwartz

Surgery_Schwartz. U.S. Food and Drug Administration (FDA) in 1997, are less invasive and offer some titratability in addition to reversibility unlike the resec-tive surgical options previously described. Since first reported in 1985, VNS has proven to be efficacious in certain patient populations for several disorders such as treatment-resistant major depressive disorder, bipolar disorder, and epilepsy. In VNS, a pulse generator is placed under the skin in the chest and is connected to the vagus nerve by an electrical lead. Chronic, intermittent VNS has been proven to be an effective option for patients suffering from medically refractory seizures who are not candidates for surgical resection. Although only a small minority of patients will be entirely seizure-free, three blinded, randomized-controlled trials have examined VNS and demon-strated significant clinical improvement compared to sham.81-83 Generally VNS is well-tolerated and safe, as device implantation is associated with a low rate of


Surgery_Schwartz

Surgery_Schwartz. trials have examined VNS and demon-strated significant clinical improvement compared to sham.81-83 Generally VNS is well-tolerated and safe, as device implantation is associated with a low rate of perioperative complications. Addi-tionally, the majority of side effects are stimulation-dependent and thus, reversible. For the most part, VNS is limited in its appli-cation because it can only exert its effects by altering neural activ-ity via the vagus nerve. Procedures with brain region-specificity are being investigated.Deep Brain StimulationThe following summary of deep brain stimulation (DBS) will include a review of the current FDA-approved indications, as well the expanding applications of this therapy, currently being investigated preclinically and in clinical trials. While the Brunicardi_Ch42_p1827-p1878.indd 186901/03/19 7:17 PM 1870SPECIFIC CONSIDERATIONSPART IImechanism of action of DBS continues to elude our understand-ing, it is well established that administering


Surgery_Schwartz

Surgery_Schwartz. Brunicardi_Ch42_p1827-p1878.indd 186901/03/19 7:17 PM 1870SPECIFIC CONSIDERATIONSPART IImechanism of action of DBS continues to elude our understand-ing, it is well established that administering electrical stimula-tion to a nucleus in the brain known to be involved in a given disease can disrupt the pathologic signals emanating to or from this brain region. A fine electrical lead is placed in a deep brain nucleus and connected to pulse generators placed in the chest in a manner similar to cardiac pacemakers. Connector wires travel from the generators in the subcutaneous space up the neck and in the subgaleal space in the head, to connect the pulse gen-erators to the electrical leads. Proper lead placement is accom-plished with stereotactic guidance. A frame is rigidly fixed to the patient’s head, and an MRI is obtained with the frame in place. Calculation of the coordinates of the millimeter-sized deep brain nuclei is performed in relation to the three-dimensional space defined


Surgery_Schwartz

Surgery_Schwartz. head, and an MRI is obtained with the frame in place. Calculation of the coordinates of the millimeter-sized deep brain nuclei is performed in relation to the three-dimensional space defined by the fixed frame, allowing for accurate targeting of the nucleus (Fig. 42-33). Postoperatively, the pulse generators can be interrogated and adjusted with hand-held, transcutane-ous, noninvasive devices as needed for symptom control.Essential Tremor. Essential tremor is the most common movement disorder in the western world and is characterized by action tremor (4–8 Hz rhythmic oscillations) of the hands, forearms, head, and voice. Essential tremor often starts in the third or fourth decade of life and increases in frequency and amplitude with age. β-Blockers can decrease symptoms, but patients with poor medical control and significant functional impairment significantly benefit from placement of a deep brain stimulator in the contralateral ventralis intermediate nucleus of the thalamus. In


Surgery_Schwartz

Surgery_Schwartz. with poor medical control and significant functional impairment significantly benefit from placement of a deep brain stimulator in the contralateral ventralis intermediate nucleus of the thalamus. In properly selected patients, DBS of this region of the thalamus appears to provide robust and durable symptom control.84,85Parkinson’s Disease. Parkinson’s disease is a progressive dis-order characterized by rigidity, bradykinesia, and resting tremor, due to loss of dopamine-secreting neurons in the substantia nigra. Dopaminergic agents such as levodopa/carbidopa and anticholinergic agents such as amantadine and selegiline form the basis of medical therapy. Patients with poor medical control or significant drug side effects may benefit significantly from placement of bilateral deep brain stimulators in the subthalamic nuclei. Although the globus pallidus interna has also been a widely targeted area, the subthalamic nuclei is now the most accepted target in deep brain stimulation for


Surgery_Schwartz

Surgery_Schwartz. stimulators in the subthalamic nuclei. Although the globus pallidus interna has also been a widely targeted area, the subthalamic nuclei is now the most accepted target in deep brain stimulation for Parkinson’s disease.86 Deep brain stimulation provides durable symp-tom relief with good postoperative neuropsychologic function in properly selected patients.87Recently, a large randomized controlled trial compared bilat-eral DBS (n = 121) to best medical therapy in advanced Parkin-son’s disease (n = 134).88 The DBS group did significantly better in both motor function and quality of life. While adverse events were 3.8 times more likely in the DBS group, 99% of these events had resolved by 6 months. There was a 0.8% risk of death due to the procedure, and there was no difference in risk of adverse events when comparing older (≥70 years) to younger patients (<70 years). Thus, the benefits of DBS over medical therapy are clear, especially when considering quality of life measures.Another


Surgery_Schwartz

Surgery_Schwartz. adverse events when comparing older (≥70 years) to younger patients (<70 years). Thus, the benefits of DBS over medical therapy are clear, especially when considering quality of life measures.Another recent randomized controlled trial focused on defining the optimal targets for DBS in Parkinson’s disease.89 While the subthalamic nucleus (STN) and the globus pallidus interna (GPi) have been successfully targeted in the past, a direct comparison of the two was lacking. In this study, 299 subjects were randomized to receive either bilateral STN or GPi stimula-tors and were evaluated for 2 years. The primary outcome was motor function, as assessed by part III of the Unified Parkin-son’s Disease Rating Scale (UPDRS). The study found no sig-nificant difference in motor improvement between target sites. However, a significant difference was found in a secondary outcome measuring depression. On the Beck Depression Inven-tory, the pallidal stimulation group improved slightly compared with the


Surgery_Schwartz

Surgery_Schwartz. sites. However, a significant difference was found in a secondary outcome measuring depression. On the Beck Depression Inven-tory, the pallidal stimulation group improved slightly compared with the STN group, which actually worsened slightly. Never-theless, the actual incidence of depressive episodes requiring prolonged or new hospitalization was 2.6% and 0.7% in GPi and STN, respectively, which was not significantly different. On the other hand, the STN group was found to require less adjunctive dopaminergic pharmacotherapy than the GPi group. In terms of overall severe adverse events, there was no difference between groups. The investigators concluded that both target sites are effective and that nonmotor factors such as psychiatric symp-toms may be a consideration in DBS target selection.Dystonia. The FDA humanitarian device exemption has been made for DBS for dystonia but is limited to patients ≥7 years of age with primary dystonia, including generalized and/or seg-mental


Surgery_Schwartz

Surgery_Schwartz. selection.Dystonia. The FDA humanitarian device exemption has been made for DBS for dystonia but is limited to patients ≥7 years of age with primary dystonia, including generalized and/or seg-mental dystonia, hemidystonia, or cervical dystonia (torticollis). Dystonia is characterized by sustained muscle contractions that cause repetitive movements and involuntary postures. Cognitive function is typically spared, and pharmacological therapy is fre-quently inadequate. The positive impact of DBS on Parkinson’s and essential tremor has led neurologists and neurosurgeons to direct their attention to DBS for treatment of idiopathic focal and generalized dystonia.Although the pathophysiology of idiopathic dystonia is unclear, positron emission tomography studies have shown disturbed glucose metabolism in the GPi, suggesting secondary pathologic activation of the motor cortex. Indeed, the GPi is cur-rently considered the most efficacious target for dystonia, and controlled trials indicate


Surgery_Schwartz

Surgery_Schwartz. in the GPi, suggesting secondary pathologic activation of the motor cortex. Indeed, the GPi is cur-rently considered the most efficacious target for dystonia, and controlled trials indicate approximately a 50% improvement in motor function and disability.90 Since many patients undergoing 8Figure 42-33. Fast spin echo coronal magnetic resonance imaging demonstrating position of deep brain stimulator leads in the subtha-lamic nuclei bilaterally. The electrodes appear thick and wavy due to magnetic susceptibility artifact.Brunicardi_Ch42_p1827-p1878.indd 187001/03/19 7:17 PM 1871NEUROSURGERYCHAPTER 42surgery for dystonia are children and young adults, DBS is an attractive surgical option because it can be titrated, revised, and reversed according to individual needs and growth patterns.Obsessive-Compulsive Disorder. The safety and efficacy of DBS, as well as its titratability and reversibility, that have been demonstrated for the treatment of movement disorders in the 1990s and 2000s


Surgery_Schwartz

Surgery_Schwartz. Disorder. The safety and efficacy of DBS, as well as its titratability and reversibility, that have been demonstrated for the treatment of movement disorders in the 1990s and 2000s has spawned an increasing interest and awareness of the capabilities of nonlesional surgical treatments for diseases of the brain. An obvious outgrowth of DBS for movement disorders has been the treatment of medically refrac-tory psychiatric disorders. Despite the dark history of frontal leucotomy procedures that dominated the early 20th century, nonlesional DBS for psychiatric disorders are now considered potential treatment strategies.Functional neuroimaging has implicated certain brain regions in the pathogenesis of a variety of psychiatric disorders. The FDA has approved a humanitarian device exemption for DBS targeting the ventral capsule/ventral striatum for severe obsessive-compulsive disorder (OCD). Recent case reports and pilot studies have reported remission in patients suffering from refractory


Surgery_Schwartz

Surgery_Schwartz. DBS targeting the ventral capsule/ventral striatum for severe obsessive-compulsive disorder (OCD). Recent case reports and pilot studies have reported remission in patients suffering from refractory OCD following DBS. A pilot study using a blinded, staggered-onset design found that four (66.7%) of six patients met a stringent criterion as “responders” (≥35% improvement), according to the Yale-Brown Obsessive Compulsive Scale after 12 months of stimulation.91 In this study, patients did not improve during the sham phase. Adverse events were generally mild and modifiable with setting changes, and stimulation inter-ruption led to rapid yet reversible development of depressive symptoms in two cases. Thus, DBS has promise as a therapy of last resort for carefully selected cases of severe OCD.Expanding Indications of Deep Brain Stimulation. There are multiple disorders, both psychiatric and neurologic, that have exhibited significant promise as potential indications for DBS in large-scale


Surgery_Schwartz

Surgery_Schwartz. Indications of Deep Brain Stimulation. There are multiple disorders, both psychiatric and neurologic, that have exhibited significant promise as potential indications for DBS in large-scale trials. Recently, there have been reports of significant improvements in refractory depression with DBS. Lozano and colleagues performed an open label study with extended follow-up on 20 patients targeting an area within the subcallosal cin-gulate gyrus (SCG) with bilateral DBS.92 At the last follow-up visit in this study (range: 3–6 years), the average response rate was 64%, according to the Hamilton Rating Scale for Depres-sion. Of note, impairment in social functioning was improved, and no significant adverse events were reported. Because two patients died by suicide during depressive relapses, it remains unclear if DBS can only improve quality of life or significantly suppress relapses and extend life-span in this extremely delicate patient population. Of note, as seen in OCD, the ventral


Surgery_Schwartz

Surgery_Schwartz. it remains unclear if DBS can only improve quality of life or significantly suppress relapses and extend life-span in this extremely delicate patient population. Of note, as seen in OCD, the ventral capsule/ventral striatum has also been targeted for depression, as well as the nucleus accumbens directly, which lies within the ventral striatum. Studies of DBS in this region report an approximate 40% to 60% response rate, and results from a recent, multicenter randomized controlled trial are pending.93DBS as a potential therapy for epilepsy targeting the ante-rior nucleus of the thalamus has been investigated in a multi-center, double-blind, randomized trial (SANTE).94 In this trial, the group receiving DBS showed a 29% greater reduction in seizure frequency in relation to the sham group in the last month of the blinded phase. Complex partial and the “most severe” seizures were significantly reduced in the cohort who had the stimulator on DBS-on group. After the blinded phase of the


Surgery_Schwartz

Surgery_Schwartz. in the last month of the blinded phase. Complex partial and the “most severe” seizures were significantly reduced in the cohort who had the stimulator on DBS-on group. After the blinded phase of the trial was complete, 54% of patients had a seizure reduction of at least 50%. Fourteen patients were seizure-free for at least 6 months; eight were seizure-free for at least one year, four for at least two years, and one patient for more than four years. Because of the modest benefit during the blinded phase of this trial, FDA-approval has yet to be granted to DBS for epilepsy targeting the thalamus in the United States, though approval has been given in Europe and Canada.The region-specific, neuromodulatory capabilities of DBS have inspired the open label use of this technique in many other neurologic and psychiatric disorders, including but not limited to Tourette syndrome, Huntington’s disease, and Alzheimer dis-ease. Preclinical studies of both substance abuse and obesity have also


Surgery_Schwartz

Surgery_Schwartz. neurologic and psychiatric disorders, including but not limited to Tourette syndrome, Huntington’s disease, and Alzheimer dis-ease. Preclinical studies of both substance abuse and obesity have also shown promise.95,96 The opportunity to model reward-seeking behaviors associated with these disorders in animals provides the ability to not only test safety but also study mecha-nisms and inform the design of future clinical trials.Trigeminal NeuralgiaTrigeminal neuralgia, also known as tic douloureux, is charac-terized by repetitive, unilateral, sharp, and lancinating pains in the distribution of, typically, the second, but sometimes third, branch of cranial nerve V, the trigeminal nerve. The patient may describe a “trigger point,” an area on the face that elicits the pain when touched. A current leading etiologic hypothesis for trigeminal neuralgia is irritation and pulsatile compression of the root entry zone of the nerve by an artery in the posterior fossa, usually a loop of the


Surgery_Schwartz

Surgery_Schwartz. A current leading etiologic hypothesis for trigeminal neuralgia is irritation and pulsatile compression of the root entry zone of the nerve by an artery in the posterior fossa, usually a loop of the superior cerebellar artery. The pain is excruciating and can be debilitating. Medical therapy, including carbamazepine and amitriptyline, may reduce the frequency of events. Options for medically refractory cases include percuta-neous injection of glycerol into the path of the nerve, periph-eral transection of the nerve branches, SRS, and microvascular decompression (MVD).MVD involves performing a small posterior fossa crani-otomy on the side of the symptoms, retraction of the cerebellar hemisphere, and exploration of cranial nerve V. If an artery is found near the nerve, the vessel is freed of any adhesions and nonabsorbable material is placed between the nerve root and the artery. MVD remains the first definitive management option because SRS is associated with a substantial incidence of


Surgery_Schwartz

Surgery_Schwartz. any adhesions and nonabsorbable material is placed between the nerve root and the artery. MVD remains the first definitive management option because SRS is associated with a substantial incidence of facial numbness.97,98STEREOTACTIC RADIOSURGERYThe term stereotactic radiosurgery (SRS) refers to techniques that allow delivery of high-dose radiation that conforms to the shape of the target and has rapid isodose fall-off, minimiz-ing damage to adjacent neural structures. The two most common devices used for conformal SRS for intracranial lesions are the LINAC (linear accelerator) and the gamma knife. LINAC delivers a focused beam of x-ray radiation from a port that arcs part way around the patient’s head. Linear accelerators are commonly used to provide fractionated radiation for lesions outside the CNS. They are found in most radiation oncology departments. After upgrades to the software and collimators, SRS can be performed with these existing units. The gamma knife delivers 201


Surgery_Schwartz

Surgery_Schwartz. outside the CNS. They are found in most radiation oncology departments. After upgrades to the software and collimators, SRS can be performed with these existing units. The gamma knife delivers 201 focused beams of gamma radiation from cobalt sources through a specially designed colander-like helmet. Gamma knife units are used only for intracranial disease and cost up to $5 million; thus, they are most appropriate in high patient–volume centers. There is ongoing debate in the literature 9Brunicardi_Ch42_p1827-p1878.indd 187101/03/19 7:17 PM 1872SPECIFIC CONSIDERATIONSPART IIregarding the two technologies.99-101 Both continue to evolve, allowing more precise and complex isodose conformation to complex lesions. Most lesions can be treated equally well with either technology. Lesions abutting the medulla or the spinal cord should not be treated with SRS because these structures do not tolerate the radiation dose delivered to structures within mil-limeters of the target. Also,


Surgery_Schwartz

Surgery_Schwartz. abutting the medulla or the spinal cord should not be treated with SRS because these structures do not tolerate the radiation dose delivered to structures within mil-limeters of the target. Also, medullary or spinal cord compres-sion can result from swelling of the lesion after the radiosurgery dose, resulting in devastating neurologic deficit.Proton beam is an evolving SRS technology that may play a specialized role in treatment of lesions where posttarget exit-ing radiation limits photon-based therapies.102 For example, the physical properties of photons cause destruction upon entry and exit from tissue, which can be particularly harmful to skull-base or clival lesions such as chordoma, in which the exiting pathway travels through the brain stem. Proton beam therapy uses accel-erated protons, which dissipate energy upon impact and do not cause additional exiting damage. Currently, there are very few centers using this technology.CyberKnife is another radiosurgery system that has


Surgery_Schwartz

Surgery_Schwartz. protons, which dissipate energy upon impact and do not cause additional exiting damage. Currently, there are very few centers using this technology.CyberKnife is another radiosurgery system that has neu-rosurgical application. It is a frameless, robotic, LINAC-based system that allows for targeting of spinal neoplasms with higher resolution than conventional external beam radiotherapy.103 Using imaging tracking in real time, the CyberKnife is able to adjust to breathing artifact and patient movement. The applica-tion of this technology is rapidly growing.Arteriovenous MalformationsSRS has been found to be an effective stand-alone therapy for AVMs up to 3 cm in diameter. SRS is best for lesions that are dif-ficult to access surgically due to high likelihood of postoperative neurologic deficit. However, SRS is not effective for lesions >3 cm. Effective obliteration and elimination of the risk of hemorrhage takes 2 to 3 years. Overall, there is an approximately 2% annual incidence of AVM


Surgery_Schwartz

Surgery_Schwartz. However, SRS is not effective for lesions >3 cm. Effective obliteration and elimination of the risk of hemorrhage takes 2 to 3 years. Overall, there is an approximately 2% annual incidence of AVM hemorrhage,104 although one study found a 50% decrease in hemorrhage rate during the latency period before angiographic obliteration.105 Nonetheless, surgical excision remains the preferred therapeutic modality, while SRS is reserved for cases deemed very high risk for surgery due to location or patient factors.106 Some patients with large AVMs who undergo surgery will have unresectable residual lesions. In these patients, SRS may be used as an effective adjunctive therapy.Vestibular SchwannomasSRS has been introduced as a therapeutic alternative to micro-surgical resection for vestibular schwannomas up to 2.5 cm in maximum diameter. SRS provides high rates of tumor growth arrest and possible reduction in size with low rates of facial nerve palsy. Patients with functional ipsilateral


Surgery_Schwartz

Surgery_Schwartz. schwannomas up to 2.5 cm in maximum diameter. SRS provides high rates of tumor growth arrest and possible reduction in size with low rates of facial nerve palsy. Patients with functional ipsilateral preprocedure hearing may be more likely to retain functional hearing postpro-cedure than with microsurgery. The limitations of SRS include inability to treat tumors >2.5 cm, the possibility of radiation-induced malignant transformation of these benign tumors, and lack of long-term follow-up. SRS centers are accumulating experience with these tumors and accumulating data on long-term results.107,108 The indications for microsurgery and SRS will continue to evolve. Either approach should be undertaken at a high-volume center, as studies show the patient outcomes improve with increased surgeon experience.109Intracranial MetastasesPatients with solitary or multiple intracranial metastases may be treated primarily with SRS.110 Patients have improved survival after SRS compared to no treatment


Surgery_Schwartz

Surgery_Schwartz. MetastasesPatients with solitary or multiple intracranial metastases may be treated primarily with SRS.110 Patients have improved survival after SRS compared to no treatment or WBRT, and similar sur-vival to patients undergoing total surgical resection. Patients with lesions >3 cm in diameter or evidence of ICH should undergo surgical decompression rather than SRS. Some studies show improved survival with up to seven intracranial masses. Patients with multiple intracranial masses have almost zero long-term survival, and most will die of their intracranial dis-ease. Patients with intracranial metastases live 3 to 6 months on average with medical care and WBRT. This can be extended to 9 to 16 months with SRS or surgery, depending on tumor type, age, and patient condition.111CONGENITAL AND DEVELOPMENTAL ANOMALIESDysraphismDysraphism describes defects of fusion of the neural tube involving the neural tube itself, or overlying bone or skin. Dys-raphism may occur in the spine or head.


Surgery_Schwartz

Surgery_Schwartz. AND DEVELOPMENTAL ANOMALIESDysraphismDysraphism describes defects of fusion of the neural tube involving the neural tube itself, or overlying bone or skin. Dys-raphism may occur in the spine or head. Neural tube defects are among the most common congenital abnormalities. Prenatal vitamins, especially folic acid, reduce the incidence of neural tube defects.Spina Bifida OccultaSpina bifida occulta is congenital absence of posterior vertebral elements. The spinous process is always missing, the laminae may be missing to various degrees, but the underlying neural tissues are not involved. Spina bifida occulta is found in 25% of the general population, and it is asymptomatic unless associated with other developmental abnormalities.Spina Bifida With MyelomeningoceleSpina bifida with myelomeningocele describes the congenital absence of posterior vertebral elements with protrusion of the meninges through the defect, with underlying neural structural abnormalities. Common findings include


Surgery_Schwartz

Surgery_Schwartz. describes the congenital absence of posterior vertebral elements with protrusion of the meninges through the defect, with underlying neural structural abnormalities. Common findings include weakness and atrophy of the lower extremities, gait disturbance, urinary incontinence, constipation, and deformities of the foot. Myelomeningoceles arising from the high lumbar cord usually cause total paraly-sis and incontinence, while those arising from the sacral cord may have only clawing of the foot and partial urinary function loss. Myelomeningocele patients often have hydrocephalus and a Chiari II malformation, an abnormal downward herniation of the cerebellum and brain stem through the foramen magnum. Patients with abnormal protrusion of meninges through the bony defect without abnormalities of the underlying neural tissue have a meningocele. Most of these patients are neurologically normal.EncephaloceleHerniation of brain encased in meninges through the skull that forms an intracranial


Surgery_Schwartz

Surgery_Schwartz. of the underlying neural tissue have a meningocele. Most of these patients are neurologically normal.EncephaloceleHerniation of brain encased in meninges through the skull that forms an intracranial mass is referred to as encephalocele. Herniation of meninges without brain tissue is referred to as a meningocele. Most occur over the convexity of the skull. More rarely, the tissue protrudes through the skull base into the sinuses. Treatment involves excision of the herniated tissue and closure of the defect. Most patients with encephaloceles and meningoceles have impaired cognitive development. Patients with greater amounts of herniated neural tissue tend to have more severe cognitive deficits.CraniosynostosisCraniosynostosis is the abnormal early fusion of a cranial suture line with resultant restriction of skull growth in the affected area Brunicardi_Ch42_p1827-p1878.indd 187201/03/19 7:17 PM 1873NEUROSURGERYCHAPTER 42Figure 42-34. A. Axial head computed tomography scan revealing


Surgery_Schwartz

Surgery_Schwartz. restriction of skull growth in the affected area Brunicardi_Ch42_p1827-p1878.indd 187201/03/19 7:17 PM 1873NEUROSURGERYCHAPTER 42Figure 42-34. A. Axial head computed tomography scan revealing dilated ventricular system. Note dilated atria of the lateral ventricles (arrowheads) and rounded third ventricle (arrow). The large size of the ventricles and lack of transependymal flow indicate a chronic process (contrast to Fig. 42-2). The patient had normal-pressure hydrocephalus and had improved ambulation after placement of a ventriculoperitoneal shunt. B. Higher cut from same scan showing ventricular catheter in place in the frontal horn of the right lateral ventricle.ABand compensatory bulging at the other sutures. Skull growth occurs at the cranial sutures for the first 2 years of life, at the end of which the skull has achieved >90% of its eventual adult size. Fusion of the sagittal suture, or sagittal synostosis, results in a boat-shaped head, known as scaphocephaly. Unilateral


Surgery_Schwartz

Surgery_Schwartz. at the end of which the skull has achieved >90% of its eventual adult size. Fusion of the sagittal suture, or sagittal synostosis, results in a boat-shaped head, known as scaphocephaly. Unilateral coronal synostosis results in ipsilateral forehead flattening and outward deviation of the orbit, known as plagiocephaly. The contralat-eral normal forehead appears to bulge by comparison. Bilat-eral coronal synostosis results in a broad, flattened forehead, known as brachycephaly, and is often associated with maxil-lary hypoplasia and proptosis. Unilateral or bilateral lambdoid synostosis results in flattening of the occiput. Occipital flat-tening can result from abnormal suture fusion (synostosis), or from physical remolding of the skull caused by always placing the baby in the supine position for sleep (known as positional plagiocephaly). Placing the baby in the prone position or tilted onto the contralateral side may restore near-normal skull shape in most cases of lambdoid synostosis,


Surgery_Schwartz

Surgery_Schwartz. for sleep (known as positional plagiocephaly). Placing the baby in the prone position or tilted onto the contralateral side may restore near-normal skull shape in most cases of lambdoid synostosis, avoiding surgery. Treat-ment for synostoses in general is surgical, involving resection of the fused suture, or more complex reconstructive techniques for severe or refractory cases.HydrocephalusExcess CSF in the brain that results in enlarged ventricles is known as hydrocephalus. CSF flows from the ventricles to the subarachnoid space and is then absorbed into the venous blood through the arachnoid granulations. Hydrocephalus may be classified as communicating or obstructive (outlined in the next two sections), and congenital or acquired. Congenital lesions associated with or causing hydrocephalus include stenosis of the cerebral aqueduct, Chiari malformation, myelomeningo-cele, and intrauterine infection. Acquired hydrocephalus may result from occlusion of arachnoid granulations by


Surgery_Schwartz

Surgery_Schwartz. include stenosis of the cerebral aqueduct, Chiari malformation, myelomeningo-cele, and intrauterine infection. Acquired hydrocephalus may result from occlusion of arachnoid granulations by meningitis, germinal matrix hemorrhage, or SAH. CSF pathways may be occluded by adjacent tumors (Fig. 42-34).Communicating Hydrocephalus. Obstruction at the level of the arachnoid granulations constitutes communicating hydro-cephalus. This usually causes dilation of the lateral, third, and fourth ventricles equally. The most common causes in adults are meningitis and SAH. Hydrocephalus may be transient after SAH, with reestablishment of normal CSF absorption after the protein content of the CSF returns to normal and the granula-tions reopen.Obstructive Hydrocephalus. Obstruction of CSF pathways is known as obstructive hydrocephalus. Ventricles proximal to the obstruction dilate, while those distal to the obstruction remain normal in size. Typical patterns include dilation of the lateral ventricles


Surgery_Schwartz

Surgery_Schwartz. as obstructive hydrocephalus. Ventricles proximal to the obstruction dilate, while those distal to the obstruction remain normal in size. Typical patterns include dilation of the lateral ventricles due to a colloid cyst occluding the foramen of Monro, dilation of the lateral and third ventricles due to a tectal (midbrain) glioma or pineal region tumor occluding the cerebral aqueduct, or dilation of the lateral and third ventricles with obliteration of the fourth ventricle by an intraventricular tumor of the fourth ventricle. Obstructive hydrocephalus may present precipitously and require urgent shunting to prevent herniation.Chiari I MalformationChiari I malformation is the caudal displacement of the cer-ebellar tonsils below the foramen magnum. It may be seen as an incidental finding on MRI scans in asymptomatic patients. Symptomatic patients usually present with headache, neck pain, or symptoms of myelopathy, including numbness or weakness in the extremities. A syrinx may be


Surgery_Schwartz

Surgery_Schwartz. on MRI scans in asymptomatic patients. Symptomatic patients usually present with headache, neck pain, or symptoms of myelopathy, including numbness or weakness in the extremities. A syrinx may be associated, but the brain stem and lower cranial nerves are normal in Chiari I malfor-mations. Chiari II malformations are more severe and involve caudal displacement of the lower brain stem and stretching of the lower cranial nerves. Symptomatic patients may be treated with suboccipital craniectomy to remove the posterior arch of the foramen magnum, along with removal of the posterior ring Brunicardi_Ch42_p1827-p1878.indd 187301/03/19 7:17 PM 1874SPECIFIC CONSIDERATIONSPART IIFigure 42-35. T1-weighted sagittal magnetic resonance imaging of a patient with a Chiari I malformation. The large arrowhead points to the cerebellar tonsils. The small arrowhead points to the posterior arch of the foramen magnum.of C1. Removal of these bony structures relieves the compres-sion of the cerebellar


Surgery_Schwartz

Surgery_Schwartz. arrowhead points to the cerebellar tonsils. The small arrowhead points to the posterior arch of the foramen magnum.of C1. Removal of these bony structures relieves the compres-sion of the cerebellar tonsils and cervicomedullary junction, and may allow reestablishment of normal CSF flow patterns. Figure 42-35 demonstrates typical MRI appearance of a Chiari I malformation.REFERENCESEntries highlighted in bright blue are key references. 1. Kandel E, Schwartz J, Jessell T. Principles of Neural Science, 4th ed. New York: McGraw-Hill Professional; 2000. 2. Schellinger PD, Bryan RN, Caplan LR, et al. Evidence-based guideline: The role of diffusion and perfusion MRI for the diagnosis of acute ischemic stroke. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2010;75(2):177-185. 3. Wintermark M, Flanders AE, Velthuis B, et al. Perfusion-CT assessment of infarct core and penumbra. Stroke. 2006;37(4):979-985. 4. Takasawa M, Jones


Surgery_Schwartz

Surgery_Schwartz. of Neurology. Neurology. 2010;75(2):177-185. 3. Wintermark M, Flanders AE, Velthuis B, et al. Perfusion-CT assessment of infarct core and penumbra. Stroke. 2006;37(4):979-985. 4. Takasawa M, Jones PS, Guadagno JV, et al. How reliable is perfusion MR in acute stroke? Stroke. 2008;39(3):870-877. 5. Masters SJ, McClean PM, Arcarese JS, et al. Skull x-ray examinations after head trauma. Recommendations by a multidisciplinary panel and validation study. N Engl J Med. 1987;316:84-91. 6. Bullock MR, Chesnut R, Ghajar J, et al. Surgical man-agement of depressed cranial fractures. Neurosurgery. 2006;58:S56-S60. 7. Dula DJ, Fales W. The ‘ring sign’: is it a reliable indicator for cerebral spinal fluid? Annals of emergency medicine. 1993 Apr 1; 22(4):718-20. 8. Sonig A, Thakur JD, Chittiboina P, Khan IS, Nanda, A. Is posttraumatic cerebrospinal fluid fistula a predictor of post-traumatic meningitis? A US Nationwide Inpatient Sample database study. Neurosurgical Focus. 2012;32(6):E4. 9. Ratilal


Surgery_Schwartz

Surgery_Schwartz. IS, Nanda, A. Is posttraumatic cerebrospinal fluid fistula a predictor of post-traumatic meningitis? A US Nationwide Inpatient Sample database study. Neurosurgical Focus. 2012;32(6):E4. 9. Ratilal BO, Costa J, Sampaio C, Pappamikail L. Antibiotic pro-phylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev. 2015;(4):CD004884. 10. Carney N, Totten AM, OMReilly C, et al. Guidelines for the management of severe traumatic brain injury. Neuro-surgery. 2017;80(1):6-15. 11. Brain Trauma Foundation, American Association of Neuro-logical Surgeons, Congress of Neurological Surgeons. Guide-lines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24:S91-S95. 12. Ingebrigtsen T, Romner B. Routine early CT-scan is cost sav-ing after minor head injury. Acta Neurologica Scandinavica. 1996;93:207-210. 13. Stein SC, Ross SE. The value of computed tomographic scans in patients with low-risk head injuries. Neurosurgery.


Surgery_Schwartz

Surgery_Schwartz. sav-ing after minor head injury. Acta Neurologica Scandinavica. 1996;93:207-210. 13. Stein SC, Ross SE. The value of computed tomographic scans in patients with low-risk head injuries. Neurosurgery. 1990;26:638-640. 14. Kelly JP, Nichols JS, Filley CM, et al. Concussion in sports. Guidelines for the prevention of catastrophic outcome. JAMA. 1991;266:2867-2869. 15. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus state-ment on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013;47(5):250-258. 16. Forgione MA, Moores, LE, Wortmann GW; Prevention of Combat-Related Infections Guidelines Panel. Prevention of infections associated with combat-related central nervous system injuries. J Trauma Acute Care Surg. 2011;71(2): S258-S263. 17. Bullock MR, Chesnut R, Ghajar J, et al. Surgical man-agement of acute subdural hematomas. Neurosurgery. 2006;58:S16-S24. 18. Howard MA III, Gross AS, Dacey RG Jr, et al. Acute


Surgery_Schwartz

Surgery_Schwartz. S258-S263. 17. Bullock MR, Chesnut R, Ghajar J, et al. Surgical man-agement of acute subdural hematomas. Neurosurgery. 2006;58:S16-S24. 18. Howard MA III, Gross AS, Dacey RG Jr, et al. Acute subdural hematomas: an age-dependent clinical entity (see comment). J Neurosurg. 1989;71:858-863. 19. Hamilton MG, Frizzell JB, Tranmer BI. Chronic subdural hematoma: the role for craniotomy reevaluated. Neurosurgery. 1993;33:67-72. 20. Almenawer SA, Farrokhyar F, Hong C, et al. Chronic subdural hematoma management: a systematic review and meta-analysis of 34829 patients. Ann Surg. 2014;259(3):449-457. 21. Lega BC, Danish SF, Malhotra NR, Sonnad SS, Stein SC. Choosing the best operation for chronic subdural hema-toma: a decision analysis: clinical article. J Neurosurg. 2010;113(3):615-621. 22. Bullock MR, Chesnut R, Ghajar J, et al. Surgical manage-ment of traumatic parenchymal lesions. Neurosurgery. 2006;58:S25-S46. 23. Dandy WE. Pneumocephalus (intracranial penumatocele or aerocele). Arch Surg.


Surgery_Schwartz

Surgery_Schwartz. MR, Chesnut R, Ghajar J, et al. Surgical manage-ment of traumatic parenchymal lesions. Neurosurgery. 2006;58:S25-S46. 23. Dandy WE. Pneumocephalus (intracranial penumatocele or aerocele). Arch Surg. 1926;12(5):949-982. 24. Schirmer CM, Heilman CB, Bhardwaj A. Pneumocepha-lus: case illustrations and review. Neurocrit Care. 2010; 13(1):152-158. 25. Ishiwata Y, Fujitsu K, Sekino T, et al. Subdural tension pneu-mocephalus following surgery for chronic subdural hema-toma. J Neurosurg. 1988;68(1):58-61. 26. Gore PA, Maan H, Chang S, Pitt AM, Spetzler RF, Nakaji P. Normobaric oxygen therapy strategies in the treatment of post-craniotomy pneumocephalus. 2008;108(5):926-929. 27. Temkin NR, Dikmen SS, Wilensky AJ, et al. A random-ized, double-blind study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med. 1990;323:497-502. 28. Edwards P, Arango M, Balica L, et al. Final results of MRC CRASH, a randomised placebo-controlled trial of intrave-nous corticosteroid in adults


Surgery_Schwartz

Surgery_Schwartz. seizures. N Engl J Med. 1990;323:497-502. 28. Edwards P, Arango M, Balica L, et al. Final results of MRC CRASH, a randomised placebo-controlled trial of intrave-nous corticosteroid in adults with head injury-outcomes at 6 months. Lancet. 2005;365(9475):1957-1959. 29. Chesnut RM, Marshall LF, Klauber MR, et al. The role of sec-ondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34(2):216-222. 30. Berry C, Ley EJ, Bukur M, et al. Redefining hypotension in traumatic brain injury. Injury. 2012;43(11):1833-1837.Brunicardi_Ch42_p1827-p1878.indd 187401/03/19 7:17 PM 1875NEUROSURGERYCHAPTER 42 31. Spaite DW, Hu C. Bobrow BJ, et al. Mortality and prehos-pital blood pressure in patients with major traumatic brain injury: implications for the hypotension threshold. JAMA Surg. 2017;152(4):360-368. 32. Basali A, Mascha EJ, Kalfas I, Schubert A. Relation between perioperative hypertension and intracranial hemorrhage after craniotomy. J Am Soc Anesthesiol.


Surgery_Schwartz

Surgery_Schwartz. JAMA Surg. 2017;152(4):360-368. 32. Basali A, Mascha EJ, Kalfas I, Schubert A. Relation between perioperative hypertension and intracranial hemorrhage after craniotomy. J Am Soc Anesthesiol. 2000;93(1):48-54. 33. Kuramatsu JB, Gerner ST, Schellinger PD, Glahn J, Endres M, Sobesky J, Flechsenhar J, Neugebauer H, Jüttler E, Grau A, Palm F. Anticoagulant reversal, blood pressure levels, and anti-coagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. Jama. 2015 Feb 24;313(8):824-36. 34. Sorrentino E, Diedler J, Kasprowicz M, et al. Critical thresh-olds for cerebrovascular reactivity after traumatic brain injury. Neurocrit Care. 2012;16(2):258-266. 35. Cooper DJ, Rosenfeld JV, Murray L, et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011;364(16):1493-1502. 36. Hutchinson PJ, Kolias AG, Timofeev IS, et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med.


Surgery_Schwartz

Surgery_Schwartz. brain injury. N Engl J Med. 2011;364(16):1493-1502. 36. Hutchinson PJ, Kolias AG, Timofeev IS, et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med. 2016;375(12):1119-1130. 37. Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection. Stroke. 2004;35:613-614. 38. Maynard FM Jr, Bracken MB, Creasey G, et al. International standards for neurological and functional classification of spi-nal cord injury. American Spinal Injury Association. Spinal Cord. 1997;35:266. 39. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817-831. 40. Biffl WL, Cothren CC, Moore EE, et al. Western Trauma Association critical decisions in trauma: screening for and treatment of blunt cerebrovascular injuries. J Trauma Acute Care Surg. 2009;67(6):1150-1153. 41. Lockwood MM, Smith GA, Tanenbaum J, Lubelski D, Seicean A, Pace J, Benzel EC, Mroz TE, Steinmetz MP. Screening via CT


Surgery_Schwartz

Surgery_Schwartz. cerebrovascular injuries. J Trauma Acute Care Surg. 2009;67(6):1150-1153. 41. Lockwood MM, Smith GA, Tanenbaum J, Lubelski D, Seicean A, Pace J, Benzel EC, Mroz TE, Steinmetz MP. Screening via CT angiogram after traumatic cervical spine fractures: nar-rowing imaging to improve cost effectiveness. Experience of a Level I trauma center. Journal of Neurosurgery: Spine. 2016 Mar;24(3):490-5. 42. Bracken MB, Shepard MJ, Collins WF, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the second national acute spinal cord injury study (see comment). N Engl J Med. 1990;322:1405-1411. 43. Bracken MB, Shepard MJ, Collins WF Jr, et al. Methyl-prednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second national acute spinal cord injury study (see comment). J Neurosurg. 1992;76:23-31. 44. Bracken MB, Shepard MJ, Holford TR, et al. Admin-istration of methylprednisolone


Surgery_Schwartz

Surgery_Schwartz. data. Results of the second national acute spinal cord injury study (see comment). J Neurosurg. 1992;76:23-31. 44. Bracken MB, Shepard MJ, Holford TR, et al. Admin-istration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury: results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. JAMA. 1997;277(20):1597-1604. 45. Bracken MB. Steroids for acute spinal cord injury. Cochrane Database Syst Rev. 2012;(1):CD001046. 46. Walters BC, Hadley MN, Hurlbert RJ, et al. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery. 2013;60:82-91. 47. Fehlings M. Recommendations regarding the use of methyl-prednisolone in acute spinal cord injury: making sense out of the controversy [editorial]. Spine J. 2001;26(suppl):S56-S57. 48. Hugenholtz H, Cass DE, Dvorak MF, et al. High-dose meth-ylprednisolone for acute closed spinal cord injuryord injuryyy Injury


Surgery_Schwartz

Surgery_Schwartz. out of the controversy [editorial]. Spine J. 2001;26(suppl):S56-S57. 48. Hugenholtz H, Cass DE, Dvorak MF, et al. High-dose meth-ylprednisolone for acute closed spinal cord injuryord injuryyy Injury Random Can J Neurol Sci. 2002;29:227-235. 49. Resnick DK, Kaiser MG, Fehlings M, et al. Hypothermia and Human Spinal Cord Injury: Position Statement and Evidence Based Recommendations From the AANS/CNS Joint Section on Disorders of the Spine and the AANS/CNS Joint Section on Trauma. Washington: AANS/CNS Joint Section of Disorders of the Spine and Peripheral Nerves; 2007. 50. Vaccaro AR, Falatyn SP, Flanders AE, Balderston RA, Northrup BE, Cotler JM. Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine disloca-tions. Spine. 1999;24(12):1210-1217. 51. Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical


Surgery_Schwartz

Surgery_Schwartz. spine disloca-tions. Spine. 1999;24(12):1210-1217. 51. Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PloS One. 2012;7(2):e32037. 52. Seddon HJ. Three types of nerve injury. Brain. 1943;66:237. 53. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. (see comment). N Engl J Med. 1991;325:443-445. 54. Ferguson GG, Eliasziw M, Barr HW, et al. The North Amer-ican Symptomatic Carotid Endarterectomy Trial : surgical results in 1415 patients. Stroke. 1999;30(9):1751-1758. 55. Brott TG, Howard G, Roubin GS, et al; CREST Investigators. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med. 2016;374(11):1021-1031. 56. The National Institute of Neurological Disorders and Stroke rt-PA Stroke


Surgery_Schwartz

Surgery_Schwartz. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med. 2016;374(11):1021-1031. 56. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. (see comment). N Engl J Med. 1995;333:1581-1588. 57. Bhatia R, Hill MD, Shobha N, et al. Low rates of acute recana-lization with intravenous recombinant tissue plasminogen acti-vator in ischemic stroke: real-world experience and a call for action. Stroke. 2010;41(10):2254-2258. 58. Jovin TG, Chamorro A, Cobo E, et al; REVASCAT Trial Inves-tigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):2296-2306. 59. J0. J24 E, Unterberg A, Woitzik J, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 2014;370(12):1091-1100. 60. Pledl HW, Hoyer C, Rausch J, et al. Decompressive hemi-craniectomy in malignant middle cerebral artery


Surgery_Schwartz

Surgery_Schwartz. with extensive middle-cerebral-artery stroke. N Engl J Med. 2014;370(12):1091-1100. 60. Pledl HW, Hoyer C, Rausch J, et al. Decompressive hemi-craniectomy in malignant middle cerebral artery infarction: the ‘real world’ beyond studies. Eur Neurol. 2016;76(1-2): 48-56. 61. Mendelow AD, Gregson BA, Fernandes HM, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005;365:387-397. 62. Fam MD, Hanley D, Stadnik A, et al. Surgical performance in minimally invasive surgery plus recombinant tissue plasmino-gen activator for intracerebral hemorrhage evacuation phase III clinical trial. Neurosurgery. 2017;81(5):860-866. 63. Molyneux A, Kerr R, Stratton I, et al. International sub-arachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial


Surgery_Schwartz

Surgery_Schwartz. A, Kerr R, Stratton I, et al. International sub-arachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial (see comment) (reprint in J Stroke Cerebrovasc Dis 11:304, 2002). Lancet. 2002;360:1267-1274. 64. Mitchell P, Kerr R, Mendelow AD, et al. Could late rebleeding overturn the superiority of cranial aneurysm coil embolization over clip ligation seen in the international subarachnoid aneu-rysm trial? J Neurosurg. 2008;108:437-442. 65. Raftopoulos C, Goffette P, Vaz G, et al. Surgical clipping may lead to better results than coil embolization: results from a series of 101 consecutive unruptured intracranial aneurysms. Neurosurgery. 2003;52:1280-1287, discussion 1287-1290.Brunicardi_Ch42_p1827-p1878.indd 187501/03/19 7:17 PM 1876SPECIFIC CONSIDERATIONSPART II 66. Mohr JP, Parides MK, Stapf C; International ARUBA Inves-tigators. Medical management with or without interventional


Surgery_Schwartz

Surgery_Schwartz. 187501/03/19 7:17 PM 1876SPECIFIC CONSIDERATIONSPART II 66. Mohr JP, Parides MK, Stapf C; International ARUBA Inves-tigators. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet. 2014;383(9917):614-621. 67. Patchell RA, Tibbs PA, Walsh JW, et al. A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med. 1990;322:494-500. 68. Aoyama H, Shirato H, Tago M, et al. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized con-trolled trial. JAMA. 2006;295:2483-2491. 69. Stupp R, Mason WP, van den Bent MJ; European Organisa-tion for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups; National Cancer Institute of Canada Clinical Trials Group. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med.


Surgery_Schwartz

Surgery_Schwartz. of Cancer Brain Tumor and Radiotherapy Groups; National Cancer Institute of Canada Clinical Trials Group. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med. 2005;352(10):987-996. 70. Patchell RA, Tibbs PA, Regine WF, et al. Direct decompres-sive surgical resection in the treatment of spinal cord compres-sion caused by metastatic cancer: a randomised trial. Lancet. 2005;366:643-648. 71. Fisher CG, DiPaola CP, Ryken TC, et al. A novel classifi-cation system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976). 2010;35(22): E1221-E1229. 72. Louis DN, Perry A, Reifenberger G, et al. The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary. Acta Neuropathol. 2016;131(6):803-820. 73. Le Roux PD, Haglund MM, Harris AB. Thoracic disc disease: experience with the transpedicular approach in twenty con-secutive


Surgery_Schwartz

Surgery_Schwartz. Nervous System: a summary. Acta Neuropathol. 2016;131(6):803-820. 73. Le Roux PD, Haglund MM, Harris AB. Thoracic disc disease: experience with the transpedicular approach in twenty con-secutive patients. Neurosurgery. 1993;33:58-66. 74. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonop-erative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006;296(20):2451-2459. 75. Delitto A, Piva SR, Moore CG, Fritz JM, Wisniewski SR, Josbeno DA, Fye M, Welch WC. Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial. Annals of internal medicine. 2015 Apr 7;162(7):465-73. 76. Mulholland RC, Sengupta DK. Rationale, principles, and experimental evaluation of the concept of soft stabilization. Eur Spine J. 2002;11:S198-S205. 77. Dawson D, Hallett M, Wilbourn A. Entrapment Neuropathie. 3rd ed. Baltimore: Lippincott Raven; 1999. 78. Darouiche RO. Spinal epidural abscess. N Engl J Med.


Surgery_Schwartz

Surgery_Schwartz. Eur Spine J. 2002;11:S198-S205. 77. Dawson D, Hallett M, Wilbourn A. Entrapment Neuropathie. 3rd ed. Baltimore: Lippincott Raven; 1999. 78. Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006;355:2012-2020. 79. Benbadis SR, Heriaud L, Tatum WO, et al. Epilepsy surgery, delays and referral patterns patients controlled? Seizure. 2003;12:167-170. 80. Rausch R, Kraemer S, Pietras CJ, et al. Early and late cogni-tive changes following temporal lobe surgery for epilepsy (see comment). Neurology. 2003;60:951-959. 81. Ben-Menachem E, Manon-Espaillat R, Ristanovic R, et al. Vagus nerve stimulation for treatment of partial seizures. A controlled study of effect on seizures. First International Vagus Nerve Stimulation Study Group. Epilepsia. 1994;35:616-626. 82. Handforth A, DeGiorgio CM, Schachter SC, et al. Vagus nerve stimulation therapy for partial-onset seizures: a randomized active-control trial. Neurology. 1998;51:48-55. 83. Amar AP, Heck CN, Levy ML, et al. An institutional


Surgery_Schwartz

Surgery_Schwartz. Schachter SC, et al. Vagus nerve stimulation therapy for partial-onset seizures: a randomized active-control trial. Neurology. 1998;51:48-55. 83. Amar AP, Heck CN, Levy ML, et al. An institutional experi-ence with cervical vagus nerve trunk stimulation for medically refractory epilepsy: rationale, technique, and outcome. Neuro-surgery. 1998;1265-1276. 84. Fields JA, Troster AI, Woods SP, et al: Neuropsychologi-cal and quality of life outcomes 12 months after unilateral thalamic stimulation for essential tremor. J Neurol Neurosurg Psychiatry. 2003;74:305-311. 85. Rehncrona S, Johnels B, Widner H, et al. Long-term efficacy of thalamic deep brain stimulation for tremor: double-blind assessments. Mov Disord. 2003;18:163-170. 86. Kleiner-Fisman G, Herzog J, Fisman DN, et al. Subthalamic nucleus deep brain stimulation: summary and meta-analysis of outcomes. Mov Disord. 2006;21:S290-S304. 87. Perozzo P, Rizzone M, Bergamasco B, et al. Deep brain stimulation of the subthalamic nucleus in


Surgery_Schwartz

Surgery_Schwartz. deep brain stimulation: summary and meta-analysis of outcomes. Mov Disord. 2006;21:S290-S304. 87. Perozzo P, Rizzone M, Bergamasco B, et al. Deep brain stimulation of the subthalamic nucleus in Parkinsonor: es 12 mocomparison of preand postoperative neuropsychological evaluation. J Neurol Sci. 2001;192:9-15. 88. Weaver FM, Follett K, Stern M, et al. Bilateral deep brain stimulation vs. best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial. JAMA. 2009;301:63-73. 89. Follett KA, Weaver FM, Stern M, et al. Pallidal versus sub-thalamic deep-brain stimulation for ParkinsonWeaver FM, S N Engl J Med. 2010;362(22):2077-2091. 90. Vidailhet M, Vercueil L, Houeto JL, et al. Bilateral deep-brain stimulation of the globus pallidus in primary generalized dys-tonia. N Engl J Med. 2005;352(5):459-467. 91. Goodman WK, Foote KD, Greenberg BD, et al. Deep brain stimulation for intractable obsessive compulsive disorder: pilot study using a blinded,


Surgery_Schwartz

Surgery_Schwartz. dys-tonia. N Engl J Med. 2005;352(5):459-467. 91. Goodman WK, Foote KD, Greenberg BD, et al. Deep brain stimulation for intractable obsessive compulsive disorder: pilot study using a blinded, staggered-onset design. Biol Psychiatry. 2010;67:535-542. 92. Lozano AM, Giacobbe P, Hamani C, et al. A multicenter pilot study of subcallosal cingulate area deep brain stimu-lation for treatment-resistant depression. J Neurosurg 2012;116:315-322. 93. Bewernick BH, Kayser S, Sturm V, et al. Long-term effects of nucleus accumbens deep brain stimulation in treatment-resistant depression: evidence for sustained efficacy. Neuro-psychopharmacology 2012;37:1975-1985. 94. Fisher R, Salanova V, Witt T, et al. Electrical stimulation of the anterior nucleus of thalamus for treatment of refractory epilepsy. Epilepsia. 2010;51:899-908. 95. Vassoler FM, Schmidt HD, Gerard ME, et al. Deep brain stimulation of the nucleus accumbens shell attenuates cocaine priming-induced reinstatement of drug seeking in rats.


Surgery_Schwartz

Surgery_Schwartz. 2010;51:899-908. 95. Vassoler FM, Schmidt HD, Gerard ME, et al. Deep brain stimulation of the nucleus accumbens shell attenuates cocaine priming-induced reinstatement of drug seeking in rats. J Neurosci. 2008;28:8735-8739. 96. Halpern CH, Tekriwal A, Santollo J, et al. Amelioration of binge eating by nucleus accumbens shell deep brain stimu-lation in mice involves D2 receptor modulation. J Neurosci. 2013;33(17):7122-7129. 97. Barker FG II, Jannetta PJ, Bissonette DJ, et al. The long-term outcome of microvascular decompression for trigeminal neu-ralgia. N Engl J Med. 1996;334:1077-1083. 98. Kondo A. Microvascular decompression surgery for trigeminal neuralgia. Stereotact Funct Neurosurg. 2001;77:187-189. 99. Bova FJ, Goetsch SJ. Modern linac stereotactic radiosurgery systems have rendered the gamma knife obsolete. Medical Physics. 2001;28:1839-1841. 100. Konigsmaier H, de Pauli-Ferch B, et al. The costs of radio-surgical treatment: comparison between gamma knife and linear accelerator.


Surgery_Schwartz

Surgery_Schwartz. gamma knife obsolete. Medical Physics. 2001;28:1839-1841. 100. Konigsmaier H, de Pauli-Ferch B, et al. The costs of radio-surgical treatment: comparison between gamma knife and linear accelerator. Acta Neurochirurgica. 1998;140: 1110-1111. 101. Suh JH, Barnett GH, Miller DW, et al. Successful conver-sion from a linear accelerator-based program to a gamma knife radiosurgery program: The Cleveland Clinic experience. Stereot Funct Neurosurg. 1999;72:159-167. 102. Chen CC, Chapman P, Petit J, et al. Proton radiosurgery in neurosurgery. Neurosurg Focus. 2007;23:E5. 103. Gerszten PC, Ozhasoglu C, Burton SA, et al. CyberKnife frameless stereotactic radiosurgery for spinal lesions: clinical experience in 125 cases. Neurosurgery. 2004;55:89-98, discus-sion 98-99.Brunicardi_Ch42_p1827-p1878.indd 187601/03/19 7:17 PM 1877NEUROSURGERYCHAPTER 42 104. Karlsson B, Lax I, Soderman M. Risk for hemorrhage during the 2-year latency period following gamma knife radiosurgery for arteriovenous


Surgery_Schwartz

Surgery_Schwartz. 187601/03/19 7:17 PM 1877NEUROSURGERYCHAPTER 42 104. Karlsson B, Lax I, Soderman M. Risk for hemorrhage during the 2-year latency period following gamma knife radiosurgery for arteriovenous malformations. Int J Radiat Oncol Biol Phys. 2001;49:1045-1051. 105. Maruyama K, Kawahara N, Shin M, et al. The risk of hemor-rhage after radiosurgery for cerebral arteriovenous malforma-tions. N Engl J Med. 2005;352:146-153. 106. Pan DH, Guo WY, Chung WY, et al. Gamma knife radiosur-gery as a single treatment modality for large cerebral arterio-venous malformations. J Neurosurg. 2000;93:113-119. 107. Regis J, Pellet W, Delsanti C, et al. Functional outcome after gamma knife surgery or microsurgery for vestibular schwan-nomas. J Neurosurg. 2002;97:1091-1100. 108. Shin M, Ueki K, Kurita H, et al. Malignant transformation of a vestibular schwannoma after gamma knife radiosurgery. Lancet. 2002;360:309-310. 109. Elsmore AJ, Mendoza ND. The operative learning curve for vestibular schwannoma excision


Surgery_Schwartz

Surgery_Schwartz. transformation of a vestibular schwannoma after gamma knife radiosurgery. Lancet. 2002;360:309-310. 109. Elsmore AJ, Mendoza ND. The operative learning curve for vestibular schwannoma excision via the retrosigmoid approach. Br J Neurosurg. 2002;16:448-455. 110. Gerosa M, Nicolato A, Foroni R, et al. Gamma knife radio-surgery for brain metastases: a primary therapeutic option. J Neurosurg. 2002;97:515-524. 111. Pollock BE, Brown PD, Foote RL, et al. Properly selected patients with multiple brain metastases may benefit from aggressive treatment of their intracranial disease. J Neurooncol. 2003;61:73-80.Brunicardi_Ch42_p1827-p1878.indd 187701/03/19 7:17 PM


Surgery_Schwartz

Surgery_Schwartz. Brunicardi_Ch42_p1827-p1878.indd 187801/03/19 7:17 PMThis page intentionally left blank


Surgery_Schwartz

Surgery_Schwartz. Orthopedic SurgeryNabil A. Ebraheim, Bert J. Thomas, Freddie H. Fu, Bart Muller, Dharmesh Vyas, Matt Niesen, Jonathan Pribaz, and Klaus Draenert 43chapterIntroduction 1880Orthopedic Trauma 1881Introduction / 1881Open Fractures / 1881Compartment Syndrome / 1883Treatment of Fractures and Dislocations 1883Clavicle Fractures / 1883Scapula Fractures / 1883Shoulder Dislocations / 1884Proximal Humerus Fractures / 1884Humeral Shaft Fractures / 1884Distal Humerus Fractures / 1885Elbow Dislocations / 1885Radial Head Fractures / 1886Olecranon Fractures / 1886Forearm Fractures / 1886Distal Radius Fractures / 1886Scaphoid Fractures / 1887Pelvic Fractures / 1887Acetabular Fractures / 1888Hip Dislocations / 1888Hip Fractures / 1888Femoral Shaft Fractures / 1890Distal Femur Fractures / 1890Knee Dislocations / 1890Patella/Extensor Mechanism Injuries / 1891Tibial Plateau Fractures / 1891Tibial Shaft Fractures / 1891Tibial Plafond (Pilon) Fractures / 1892Ankle and Subtalar Dislocations / 1892Ankle


Surgery_Schwartz

Surgery_Schwartz. / 1890Patella/Extensor Mechanism Injuries / 1891Tibial Plateau Fractures / 1891Tibial Shaft Fractures / 1891Tibial Plafond (Pilon) Fractures / 1892Ankle and Subtalar Dislocations / 1892Ankle Fractures / 1893Maisonneuve Fractures / 1893Calcaneal Fractures / 1893Talus Fractures / 1894Foot Fractures / 1894Sports Medicine 1895Introduction / 1895Shoulder 1895Rotator Cuff / 1895Shoulder Instability / 1896Posterior Dislocation of the Shoulder / 1896Superior Labrum and Biceps Tendon / 1896Impingement Syndromes / 1896The Acromioclavicular Joint / 1897Knee 1897Menisci / 1897Collateral Ligaments / 1898Cruciate Ligaments / 1898Posterolateral Corner / 1899Hip 1899Femoroacetabular Impingement / 1899Spine 1900Spinal Trauma / 1900Occipital Cervical Dislocation / 1900Fractures of C1 (Jefferson Fracture) / 1900Fractures of C2 (Odontoid Fracture) / 1900Hangman’s Fractures of C2 / 1901Compression Fracture of the Cervical Spine / 1901Burst Fractures of the Cervical Spine / 1901Unilateral and


Surgery_Schwartz

Surgery_Schwartz. / 1900Fractures of C2 (Odontoid Fracture) / 1900Hangman’s Fractures of C2 / 1901Compression Fracture of the Cervical Spine / 1901Burst Fractures of the Cervical Spine / 1901Unilateral and Bilateral Facet Dislocation / 1901Clay-Shoveler’s Injury / 1902Fractures of the Thoracic and Lumbar Spine 1902Thoracic Lumbar Spine Injury / 1902Compression Fracture / 1902Burst Fracture / 1902Seatbelt Injuries (Flexion Distraction Injuries) / 1902Fracture Dislocations of the Spine / 1903Disc Herniation / 1903Cauda Equina Syndrome / 1903Spinal Stenosis / 1903Back Pain and Degenerative Disc Disease / 1904Scoliosis / 1904Idiopathic Scoliosis / 1904Neuromuscular Scoliosis / 1904Joint Reconstruction 1904Introduction to Arthritis / 1904Examination of the Patient / 1904Nonoperative Management and Prevention of Arthritis / 1905Injections / 1905Surgical Management of Arthritis / 1906Computer Navigation, Robotics, and Joint Arthroplasty / 1908Fixation Options in Joint Arthroplasty / 1910Complications


Surgery_Schwartz

Surgery_Schwartz. of Arthritis / 1905Injections / 1905Surgical Management of Arthritis / 1906Computer Navigation, Robotics, and Joint Arthroplasty / 1908Fixation Options in Joint Arthroplasty / 1910Complications in Joint Arthroplasty / 1910Orthopedic Pathology and Oncology 1910Diagnosis of Malignant Bone Tumors / 1910Osteosarcoma 1911Intramedullary Osteosarcoma / 1911Parosteal Osteosarcoma / 1912Periosteal Osteosarcoma / 1912Paget’s Sarcoma / 1912Radiation-Induced Sarcoma / 1912Ewing’s Sarcoma 1912Cartilage-Forming Tumors 1912Chondrosarcomas / 1912Fibrous Lesions of Bone 1912Desmoplastic Fibroma / 1912Malignant Fibrous Histiocytoma of Bone / 1913Malignant Vascular Tumors / 1913Miscellaneous Tumors 1913Giant Cell Tumor of Bone / 1913Adamantinoma and Osteofibrous Dysplasia / 1913Primary Lymphoma of Bone / 1914Chordoma / 1914Multiple Myeloma / 1914Metastatic Bone Tumors 1914Pediatric Orthopedics 1915Birth Injuries / 1915Skeletal Growth / 1915Pediatric Fractures / 1916Classification of Growth Plate


Surgery_Schwartz

Surgery_Schwartz. / 1914Chordoma / 1914Multiple Myeloma / 1914Metastatic Bone Tumors 1914Pediatric Orthopedics 1915Birth Injuries / 1915Skeletal Growth / 1915Pediatric Fractures / 1916Classification of Growth Plate Injuries / 1916Diaphyseal Injuries in a Pediatric Patient / 1916Fractures of the Pediatric Hip / 1916Fractures of the Femoral Shaft / 1916Pediatric Ankle Fractures / 1917Pediatric Elbow Fractures / 1917Brunicardi_Ch43_p1879-p1924.indd 187922/02/19 10:40 AM 1880Key Points1 The main principle of internal fixation for fracture care (most commonly intramedullary nails or plate and screw fixation) is to create a stable construct that will allow the fracture to heal in proper length, alignment, and rotation.2 In open fractures, early administration of intravenous antibiotics is important to avoid infection. An external fixator is used when the wound is grossly contaminated, and definitive treatment of the wound is delayed until the wound is sufficiently clean. Early wound coverage is


Surgery_Schwartz

Surgery_Schwartz. to avoid infection. An external fixator is used when the wound is grossly contaminated, and definitive treatment of the wound is delayed until the wound is sufficiently clean. Early wound coverage is important.3 Early diagnosis and treatment of compartment syndrome is important in order to prevent irreversible damage to the muscles and the nerves, which is time sensitive. Emergency fasciotomy by releasing the tight fascia is a limb-saving procedure.4 Fractures of the scapula are typically the result of a high-energy trauma with a high incidence of associated injuries that typically involve the ribs and the lungs.5 The shoulder is one of the most commonly dislocated joints, and most dislocations are anterior. Posterior dislo-cations may be missed and are typically associated with seizures or electric shock. Anterior-posterior and axillary views of the shoulder are necessary for the diagnosis.6 Isolated humeral shaft fractures are usually treated conser-vatively. The radial nerve


Surgery_Schwartz

Surgery_Schwartz. or electric shock. Anterior-posterior and axillary views of the shoulder are necessary for the diagnosis.6 Isolated humeral shaft fractures are usually treated conser-vatively. The radial nerve spirals around the humeral shaft and is at risk for injury; therefore, a careful neurovascular exam is important. The patient should be checked for wrist drop.7 Hemorrhage from pelvic trauma can be life-threatening. An important first line of treatment in the emergency department is resuscitation of the patient with fluids, including blood, and the application of a pelvic binder or sheet that is wrapped tightly around the pelvis to control bleeding.8 In spinal injury, spinal stability must be assessed, and the patient should be immobilized until there is further under-standing of the injury. A computed tomography scan is more reliable in assessing spine injury than plain radiographs.9 Spinal cord injuries can be complete or incomplete, and every attempt should be made to avoid further injury.


Surgery_Schwartz

Surgery_Schwartz. tomography scan is more reliable in assessing spine injury than plain radiographs.9 Spinal cord injuries can be complete or incomplete, and every attempt should be made to avoid further injury. Patients should be triaged to trauma centers since trauma center care is associated with reduced paralysis and improved outcome.10 According to the Centers for Disease Control and Prevention and the National Health Interview Survey, approximately 55 million adults have been diagnosed with some form of arthritis. This number is projected to grow substantially in the future.11 A combination of nonsteroidal anti-inflammatory medica-tions, physiotherapy, and weight loss with the help of a dietary consultation, and physical therapy are typically the first line of treatment for knee osteoarthritis. Weight loss of as little as 11 lbs (5 kg) has been shown to decrease the risk of developing knee osteoarthritis in women by 50%.12 Minimally invasive surgical techniques improve cosmesis and allow for


Surgery_Schwartz

Surgery_Schwartz. loss of as little as 11 lbs (5 kg) has been shown to decrease the risk of developing knee osteoarthritis in women by 50%.12 Minimally invasive surgical techniques improve cosmesis and allow for early rehabilitation. However, they may be associated with decreased visualization intraoperatively, associated risks of component malposition, intraoperative fracture, and nerve or vascular injury.Developmental Disease 1917Developmental Dysplasia of the Hip / 1917Treatment of DDH / 1918Legg-Calvé-Perthes Disease / 1918Slipped Capital Femoral Epiphysis / 1918Lower Extremity Rotational Abnormalities / 1918Congenital Talipes Equinovarus (Clubfoot) / 1918Osgood-Schlatter Disease / 1918INTRODUCTIONEvery physician should be familiar with orthopedics and ortho-pedic surgery. Anyone who cares for patients in an outpatient or emergency room setting will find that the majority of presenting complaints involve the musculoskeletal system. A basic under-standing of the principles of care for


Surgery_Schwartz

Surgery_Schwartz. for patients in an outpatient or emergency room setting will find that the majority of presenting complaints involve the musculoskeletal system. A basic under-standing of the principles of care for musculoskeletal conditions is essential for the health care profession.For physicians, the field of orthopedics offers an array of subspecialties with such diversity that it seems that “there is something for everyone.” Trauma specialists have the satis-faction of physically putting complex fractures back together. Sports medicine offers remarkably rapid recovery in athletes who have suffered fibrocartilage and ligament tears with ever-improving arthroscopic techniques and instrumentation. Spine surgeons see remarkable results from their minimally inva-sive microscopic techniques, while also managing massive deformities with new instrumentation and open surgery. Joint reconstruction is one of our most exciting subspecialties, work-ing with orthopedic bioengineers to develop improved


Surgery_Schwartz

Surgery_Schwartz. also managing massive deformities with new instrumentation and open surgery. Joint reconstruction is one of our most exciting subspecialties, work-ing with orthopedic bioengineers to develop improved designs, biomaterials, and minimally invasive surgical approaches for faster return to function for patients debilitated by arthritis and injury. Musculoskeletal oncology offers the intellectual chal-lenge of arriving at appropriate differential diagnoses as well as the technical challenge of limb salvage and major reconstruc-tive surgery. Pediatric orthopedics is an especially challenging and rewarding subspecialty because of the remarkable ability of children to heal their fractures quickly and remodel their bones. The incredible array of congenital and developmental disorders makes pediatrics a uniquely intellectually challenging field as well. The authors hope that our readers will share our enthusi-asm for orthopedic surgery and all of its subspecialties: trauma, sports, spine, joint


Surgery_Schwartz

Surgery_Schwartz. a uniquely intellectually challenging field as well. The authors hope that our readers will share our enthusi-asm for orthopedic surgery and all of its subspecialties: trauma, sports, spine, joint replacement, musculoskeletal oncology, foot and ankle, hand, and pediatric orthopedics.Brunicardi_Ch43_p1879-p1924.indd 188022/02/19 10:40 AM 1881ORTHOPEDIC SURGERYCHAPTER 43ORTHOPEDIC TRAUMAIntroductionMusculoskeletal injuries resulting from trauma include frac-tures of bones, damage to joints, and injuries to soft tissues. Long bone fractures can be described as transverse, oblique, spiral, segmental, or comminuted (Fig. 43-1). The goals of treat-ing musculoskeletal injuries are to restore the normal anatomy, stabilize fractures to allow early mobility and minimize com-plications related to multiple system trauma, and to repair or reconstruct these injuries to restore function.Fractures frequently result from high-energy trauma as well as from falls onto an extremity (Fig. 43-2). The


Surgery_Schwartz

Surgery_Schwartz. to multiple system trauma, and to repair or reconstruct these injuries to restore function.Fractures frequently result from high-energy trauma as well as from falls onto an extremity (Fig. 43-2). The majority of fractures can heal well with immobilization, which stabilizes the fracture while new bone forms at the fracture site. Methods of immobilization can vary and depend on the fracture being treated. The most common tool used in orthopedics to treat fractures is immobilization with a splint, cast, or braces, and their proper application is important to successfully treat the injury without causing additional problems. A successful splint contains adequate padding on the underlying skin, particularly over bony prominences, to prevent pressure or burns that can be caused by plaster. Splints, which are not circumferential, are preferred for acute injuries because they allow room for swell-ing that inevitably occurs after a fracture. The splint may later be changed to a cast as the


Surgery_Schwartz

Surgery_Schwartz. which are not circumferential, are preferred for acute injuries because they allow room for swell-ing that inevitably occurs after a fracture. The splint may later be changed to a cast as the swelling subsides.Fractures that are displaced or angulated require closed reduction to properly realign the bone. This is done using anal-gesia, local or general anesthesia, and often muscle relaxation. Reduction is performed with axial traction and reversal of the mechanism of injury in order to restore length, rotation, and angu-lation. A splint is then applied and can be gently molded to help hold the reduction in place. It is important to obtain X-rays after a closed reduction to verify acceptable alignment of the fracture, and to perform a neurovascular exam to ensure the splint is not too tight or that manipulation did not change the neurovascular status. Careful monitoring with timely clinical and radiological examination is necessary in the outpatient setting.For certain fractures,


Surgery_Schwartz

Surgery_Schwartz. tight or that manipulation did not change the neurovascular status. Careful monitoring with timely clinical and radiological examination is necessary in the outpatient setting.For certain fractures, splint or cast immobilization is inad-equate, and in these instances internal fixation or external fixa-tion is used. A variety of implants can be used to stabilize the fracture such as screws, plates, rods, and external fixators. The main principle of orthopedic implants for fracture care is to cre-ate a stable construct that will allow the fracture to heal in proper length, alignment, and rotation. Screws can be placed across a fracture to create compression at the fracture site, which promotes healing. Plates can be placed on the cortex of bones and held with screws, which creates a long area of fixa-tion to stabilize the fracture. Intramedullary rods are commonly used for long bone fractures, such as the femur and tibia (Fig. 43-3A,B). Usually, the fracture is reamed prior to the


Surgery_Schwartz

Surgery_Schwartz. area of fixa-tion to stabilize the fracture. Intramedullary rods are commonly used for long bone fractures, such as the femur and tibia (Fig. 43-3A,B). Usually, the fracture is reamed prior to the insertion of the rod into the intramedullary canal. Screws can then be placed across the cortices of the bone through holes in the rod proximal and distal to the fracture to create a locked construct that further stabilizes the rod. When the fracture is locked proximally and distally, this is called static locking. In situations where patients are severely injured and cannot safely undergo more invasive open surgery, damage control orthope-dics is done by utilizing an external fixator. External fixators are also used when the soft tissues are too swollen or injured to allow for surgical incisions to be safely made. The wrinkle test is helpful in guiding the most suitable time for definitive sur-gery. An external fixation device can be used to temporarily immobilize the fracture, especially


Surgery_Schwartz

Surgery_Schwartz. to be safely made. The wrinkle test is helpful in guiding the most suitable time for definitive sur-gery. An external fixation device can be used to temporarily immobilize the fracture, especially if the fracture is open and contaminated. External fixators involve pins placed into bone proximal and distal to the fracture (through healthy tissues), which are then connected by strong rods on the outside of the extremity, creating a stable construct.Open FracturesAn open fracture occurs when the bone breaks through the skin. These typically result from high-energy injuries and are often associated with significant damage to the surrounding soft tissues and contamination of the wound. These injuries are classified into three types according to the Gustillo-Anderson Classification.• Type I injuries are low energy and wounds are usually less than 1 cm.• Type II injuries have a wound length of 2 to 10 cm with mod-erate soft tissue damage and wound contamination.1ABCDEFFigure 43-1. Types of


Surgery_Schwartz

Surgery_Schwartz. are low energy and wounds are usually less than 1 cm.• Type II injuries have a wound length of 2 to 10 cm with mod-erate soft tissue damage and wound contamination.1ABCDEFFigure 43-1. Types of fractures. A. Normal bone. B. Transverse. C. Oblique. D. Spiral. E. Segmental. F. Comminuted.Figure 43-2. Transverse tibia fracture and segmental fibula fracture.Brunicardi_Ch43_p1879-p1924.indd 188122/02/19 10:40 AM 1882SPECIFIC CONSIDERATIONSPART II• Type III injuries are high-energy wounds usually greater than 10 cm in length with extensive muscle devitalization. The wound is highly contaminated with extensive soft tissue damage.These injuries require immediate administration of antibi-otics and irrigation and debridement of the wound. The goal of the treatment is to achieve fracture healing and to prevent wound infections and osteomyelitis. They are frequently associated with injuries to surrounding vessels and nerves, which must be addressed as well. When the wound is contami-nated, an


Surgery_Schwartz

Surgery_Schwartz. and to prevent wound infections and osteomyelitis. They are frequently associated with injuries to surrounding vessels and nerves, which must be addressed as well. When the wound is contami-nated, an external fixator is initially used (Fig. 43-4A,B). Often, definitive treatment of the fracture is delayed until the wound is 2ABFigure 43-3. A. Transverse femur fracture. B. Intramedullary rod stabilizes femur fracture.ABFigure 43-4. A. Gustillo-Anderson fracture type III open fracture. B. Image of external fixator of the tibia.Brunicardi_Ch43_p1879-p1924.indd 188222/02/19 10:40 AM 1883ORTHOPEDIC SURGERYCHAPTER 43sufficiently cleaned and healthy soft tissue is available to cover the fracture. Early coverage of the wound is important to avoid infection. Usually a large wound in the proximal or middle third of the tibia can be covered using local muscle flaps, while the distal third of the tibia will require a free flap. In general, an increase in Gustillo grade is associated with an


Surgery_Schwartz

Surgery_Schwartz. or middle third of the tibia can be covered using local muscle flaps, while the distal third of the tibia will require a free flap. In general, an increase in Gustillo grade is associated with an increase in infec-tion risk.Compartment SyndromeCompartment syndrome is an orthopedic emergency caused by significant swelling within a compartment of an injured extrem-ity that jeopardizes blood flow and microcirculation to the limb. Increased pressure within the compartment compromises perfu-sion to muscles and nerves and can cause ischemia or necrosis. Patients complain of pain that is greater than expected for the injury or surgery. There may be an increase in analgesic require-ments. Early high index of suspicion is necessary for timely diagnosis and treatment of compartment syndrome. The usual clinical findings are pain, swelling, and pain with passive stretch of the compartment muscles. Numbness, paralysis, and the absence of a pulse are late findings. While the diagnosis is usu-ally


Surgery_Schwartz

Surgery_Schwartz. clinical findings are pain, swelling, and pain with passive stretch of the compartment muscles. Numbness, paralysis, and the absence of a pulse are late findings. While the diagnosis is usu-ally based on clinical exam, compartment pressures can be mea-sured with needles placed into the compartment, which is necessary in unconscious patients and those who will not coop-erate with the exam. Compartment pressure within 30 mmHg of the diastolic pressure is diagnostic of compartment syndrome. When compartment syndrome is suspected, emergent fasciot-omy (Fig. 43-5A,B) must be performed in which the overlying tight fascia is released through long incisions. Fasciotomy must be done as soon as possible to prevent damage to muscles and nerves that will result in irreversible necrosis and Volkmann’s ischemic contractures with severe loss of function.TREATMENT OF FRACTURES AND DISLOCATIONSClavicle FracturesFractures of the clavicle are one of the most common fractures in orthopedics. They


Surgery_Schwartz

Surgery_Schwartz. ischemic contractures with severe loss of function.TREATMENT OF FRACTURES AND DISLOCATIONSClavicle FracturesFractures of the clavicle are one of the most common fractures in orthopedics. They typically occur following a fall onto the shoulder. The majority of clavicle fractures occur in the middle third of the clavicle. Since the clavicle is subcutaneous, the frac-ture is often evident on inspection. Most clavicle fractures can be treated nonoperatively with a sling, early range of motion exercises, and gradual return to normal activities. Fractures that are significantly displaced and shortened or that penetrate or tent the skin are treated with open reduction and internal fixa-tion, typically with plate and screw fixation.Distal clavicle fractures are less common and may occur with coracoclavicular ligament ruptures. These injuries can be more troublesome and are at risk for nonunion if the bone ends are not in contact. If there is displacement of the fracture and the fracture is


Surgery_Schwartz

Surgery_Schwartz. ligament ruptures. These injuries can be more troublesome and are at risk for nonunion if the bone ends are not in contact. If there is displacement of the fracture and the fracture is proximal to the coracoclavicular ligament, surgical management is often recommended.Acromioclavicular (AC) joint injuries occur from either a fall directly onto the shoulder or onto an outstretched hand and can result in tears of the acromioclavicular and cora-coclavicular ligaments. A step-off, or separation, of the AC joint may be apparent on radiographs. The majority of these injuries can be treated with a sling and gentle range of motion. Although controversial, injuries resulting in severe displacement of the clavicle at the AC joint usually require open reduction and surgical repair, especially in athletes and manual workers.The sternoclavicular (SC) joint is the only articulation between the upper extremity and the axial skeleton. Injuries to this joint are rare. Anterior dislocations occur more


Surgery_Schwartz

Surgery_Schwartz. and manual workers.The sternoclavicular (SC) joint is the only articulation between the upper extremity and the axial skeleton. Injuries to this joint are rare. Anterior dislocations occur more frequently, and although closed reduction can be attempted, recurrence of the dislocation is typical. Patients are given a sling and the out-come is usually good, despite the visible bump and swelling. Posterior SC joint dislocations are rare and not grossly visible and can be easily missed. They can be dangerous injuries, result-ing in pulmonary or neurovascular compromise. Therefore, closed or open reduction under general anesthesia is recom-mended with a cardiac surgeon back-up.Scapula FracturesFractures of the scapula often result from significant high-energy trauma (Fig. 43-6) with about 80% associated injuries, 3Compartmentsyndrome ofthe forearmABFigure 43-5. A. Image showing compartment syndrome of the forearm. B. Fasciotomy of the leg. Notice gaping of the wound and bulging of the


Surgery_Schwartz

Surgery_Schwartz. 80% associated injuries, 3Compartmentsyndrome ofthe forearmABFigure 43-5. A. Image showing compartment syndrome of the forearm. B. Fasciotomy of the leg. Notice gaping of the wound and bulging of the muscles.Brunicardi_Ch43_p1879-p1924.indd 188322/02/19 10:40 AM 1884SPECIFIC CONSIDERATIONSPART IImost commonly involving the head, ribs, and lungs. Pulmonary injuries occur in over one-third of patients. Most scapula fractures are treated nonoperatively with a sling and early range of motion. Surgery is performed when there is involve-ment of the glenoid with a major articular step-off or if there is a glenoid rim fracture with subluxation of the joint.Shoulder DislocationsThe shoulder is the most commonly dislocated large joint. Most dislocations are anterior. They are often associated with injuries to the anterior inferior glenoid labrum (Bankart lesion), impac-tion fractures of the humeral head (Hill-Sachs lesion) (Fig. 43-7), and rotator cuff tears in the elderly. The axillary


Surgery_Schwartz

Surgery_Schwartz. with injuries to the anterior inferior glenoid labrum (Bankart lesion), impac-tion fractures of the humeral head (Hill-Sachs lesion) (Fig. 43-7), and rotator cuff tears in the elderly. The axillary nerve is at risk of being injured in shoulder dislocation. If the patient is unable to raise the arm after reduction of shoulder dislocation, then it is most likely due to a rotator cuff tear in the elderly and axillary nerve injury in the young.There is a high recurrence rate that correlates with the age of the patient at the time of dislocation. There is a 90% redislocation rate if the patient is younger than 20 years of age. Posterior dislocations are associated with seizures or electric shock. Adequate radiographs are required to diagnose a shoul-der dislocation, with the axillary view being the most important. The patient’s shoulder is usually locked in internal rotation with limitation of external rotation and axillary view will show the posterior dislocation (Fig. 43-8A,B). If proper


Surgery_Schwartz

Surgery_Schwartz. the most important. The patient’s shoulder is usually locked in internal rotation with limitation of external rotation and axillary view will show the posterior dislocation (Fig. 43-8A,B). If proper X-rays are not performed, then dislocations can be missed and can result in significant disability to the patient. A computed tomography (CT) scan should be performed if an axillary view is unable to be obtained. In general, dislocation of the shoulders can be managed with closed reduction followed by a short period of sling immobilization.Proximal Humerus FracturesProximal humerus fractures occur most frequently in elderly female patients following a fall onto the shoulder, though they can also occur following high-energy trauma in young patients. They have historically been classified by the number of fracture fragments using Neer’s classification (Fig. 43-9), which divides the proximal humerus into four parts: the humeral head, greater tuberosities, lesser tuberosities, and the humeral


Surgery_Schwartz

Surgery_Schwartz. number of fracture fragments using Neer’s classification (Fig. 43-9), which divides the proximal humerus into four parts: the humeral head, greater tuberosities, lesser tuberosities, and the humeral shaft. Treat-ment is determined by the displacement of the fracture frag-ments, the amount of angulation of the fracture, and the amount of comminution (which means multiple fracture fragments). If there is suspicion of an intra-articular fracture, CT scan is often indicated. The majority of proximal humerus fractures are mini-mally displaced and can be treated with sling immobilization, followed by early shoulder motion and pendulum exercises. Physiotherapy should be started within 2 weeks of the injury to prevent stiffness, especially in the elderly. Displaced fractures and fractures involving the humeral head are at increased risk for osteonecrosis, and therefore surgery is often recommended. If there is adequate bone stock and the fracture can be success-fully reduced, open reduction


Surgery_Schwartz

Surgery_Schwartz. the humeral head are at increased risk for osteonecrosis, and therefore surgery is often recommended. If there is adequate bone stock and the fracture can be success-fully reduced, open reduction internal fixation with plate and screw fixation is the treatment of choice. Older patients with osteoporosis, comminuted fractures, head-splitting fractures, and four-part fractures or fracture dislocations are typically treated with a prosthetic replacement of the humeral head or a hemiarthroplasty. Reverse shoulder arthroplasty is gaining popularity in the elderly as well.Humeral Shaft FracturesThe majority of humeral shaft fractures can heal with nonsurgi-cal management if they are within an acceptable degree of angulation. The radial nerve spirals around the humeral shaft and is at risk for injury; therefore, a careful neurovascular exam is important. If you have a patient with a humeral shaft fracture, check the patient for wrist drop (Fig. 43-10). Most radial nerve injuries are


Surgery_Schwartz

Surgery_Schwartz. for injury; therefore, a careful neurovascular exam is important. If you have a patient with a humeral shaft fracture, check the patient for wrist drop (Fig. 43-10). Most radial nerve injuries are neurapraxias, or stretching of the nerve, and function typically returns within 3 to 4 months. A spiral fracture of the distal one-third of the humeral shaft is commonly associated with neurapraxia of the radial nerve, and this fracture is called a Holstein-Lewis fracture. Humeral shaft fractures are typically treated with a coaptation splint or functional bracing, which consists of a plastic clamshell brace with Velcro straps. Criteria for acceptable alignment are less than 20° anterior angulation, less than 30° varus/valgus angulation, and less than 3 cm shortening. Radial nerve palsy is not a contraindication to conservative treatment. Close follow-up with serial radiographs 456Figure 43-6. Scapula fracture. Notice the body and the glenoid are involved.Figure 43-7. Hill-Sachs humeral head


Surgery_Schwartz

Surgery_Schwartz. contraindication to conservative treatment. Close follow-up with serial radiographs 456Figure 43-6. Scapula fracture. Notice the body and the glenoid are involved.Figure 43-7. Hill-Sachs humeral head impaction fracture and Bankart lesion, which is an avulsion of the anterior inferior labrum.Brunicardi_Ch43_p1879-p1924.indd 188422/02/19 10:40 AM 1885ORTHOPEDIC SURGERYCHAPTER 43is important to verify healing of the fracture, and gentle motion exercises are begun within 1 to 2 weeks. Fractures with signifi-cant angulation are most commonly treated with open reduc-tion and plate fixation, with care to protect the radial nerve as it often lies close to the fracture site. Intramedullary nailing can also be performed, though it carries the risk of shoulder pain from the nail insertion. A plate is usually more stable than a nail and allows early weight-bearing through the humerus. Sponta-neous recovery of radial nerve palsy can occur up to 6 months after injury. The patient should have an


Surgery_Schwartz

Surgery_Schwartz. is usually more stable than a nail and allows early weight-bearing through the humerus. Sponta-neous recovery of radial nerve palsy can occur up to 6 months after injury. The patient should have an EMG to monitor recov-ery of the nerve. In an open fracture of the humeral shaft with radial nerve palsy, the nerve should be explored for the possibil-ity of a significant nerve injury or laceration.Distal Humerus FracturesFractures of the distal humerus result from falls onto the elbow or onto an outstretched arm. Supracondylar fractures occurring above the elbow joint are most common and do not involve the articular surface. Minimally displaced fractures can occasion-ally be treated with a posterior long arm splint, with the elbow typically flexed to 90°. However, fixation is often recommended to allow early range of motion and prevent stiffness. Fractures involving the articular surface are treated with plate fixation, and depending on the fracture pattern they may require more than one


Surgery_Schwartz

Surgery_Schwartz. to allow early range of motion and prevent stiffness. Fractures involving the articular surface are treated with plate fixation, and depending on the fracture pattern they may require more than one (usually anatomically contoured) plate. As with other intra-articular fractures, the goals of treatment are anatomic reduction of the joint surface with stable fixation, restoration of the anatomic alignment of the joint, and early range of motion. Severely comminuted fractures, especially in the elderly, may be treated with a total elbow replacement. Fractures about the elbow are notorious for developing stiffness and therefore early motion of the elbow is paramount to a successful outcome. Range of motion should be started as soon as the patient can tolerate therapy.Elbow DislocationsDislocations of the elbow are common and typically occur posteriorly after a fall on an outstretched hand. A dislocation results in injury to the joint capsule and rupture of the lateral collateral ligament,