Neurosurgical Interventions
Abstract
Neurosurgery is a rapidly growing field that includes surgery of the brain and spinal cord. Nursing for patients who have undergone neurosurgical interventions encompasses preoperative care, such as preparing a patient for surgery; intraoperative care, such as positioning and monitoring; and postoperative care, such as preventing complications and controlling pain. Awareness of the patient’s positioning during the surgical procedure, as well as the surgical approach used, will help nurses prepare for postoperative outcomes and anticipate possible complications.
Keywords: craniotomy, intensive care unit, patient positioning, postanesthesia care unit, spine surgery, surgical approaches
15.1 Neurosurgical Interventions
Despite recent advances in the field, the prospect of neurosurgery is still a major source of anxiety for patients and families. This chapter describes common neurosurgical procedures undergone by many patients with neurologic disorders. These procedures may be the selected treatments for disorders discussed in previous chapters.
Caring for neurosurgical patients may involve preoperative care, intraoperative responsibilities, postoperative implications, and potential complications. For nurses who work in the surgical suite, or for those interested in what transpires behind the doors of the operating room, this chapter features a section on intraoperative care (i.e., patient positioning, prevention of skin breakdown, and implications of various surgical approaches). Neurosurgery is usually classified into two main groups: brain surgery and spine surgery.
15.2 Brain Surgery
Various brain surgery procedures are described below. Standard descriptive terms are used to communicate the purpose of a given procedure. Such terms may include clipping/obliteration, debridement, debulking, decompression, evacuation, excision, replacement, and resection.
The term craniotomy refers to the surgical opening of the skull to allow access to intracranial contents. It is usually performed to facilitate removal of a space-occupying lesion (e.g., blood, infection, or tumor) or to treat a vascular abnormality (Box 15.1 Indications for Craniotomy). Although craniotomy is a basic component of many brain surgeries, not all brain surgery requires craniotomy.
Box 15.1 Indications for Craniotomy
Tumor
Hematoma
Infection/abscess
Vascular malformation procedure
Aneurysm clipping
Arteriovenous malformation resection
Revascularization surgery (i.e., bypass)
Decompression
Hydrocephalus
Seizures
15.2.1 Craniotomy
Classification of Craniotomies
Craniotomies are defined as either above or below the tentorium; see also Chapter 1: Anatomy (▶ Fig. 15.1).
The term supratentorial refers to the region above the tentorium
The term infratentorial refers to the region below the tentorium.
Fig. 15.1 Approaches for craniotomy.
(Used with permission from Barrow Neurological Institute, Phoenix, AZ.)
Common Terms Related to Craniotomy
Biopsy
Surgical excision of a tissue sample to establish diagnosis
Useful for diagnosis of brain tumor, infection, or degenerative disease
Burr Holes
Small openings created in the cranium with a twist drill to access the subdural space (▶ Fig. 15.2)
Least invasive way to gain access to the brain
Often performed to drain a chronic subdural hematoma; see also Chapter 9: Traumatic Brain Injury
Used emergently to drain acute fluid collections in patients with life-threatening herniation syndromes
May serve as a temporary decompressive measure until craniotomy can be performed.
Fig. 15.2 Burr holes.
Craniectomy
Removal of a portion of the skull (the removed portion is referred to as a bone flap)
Relieves severe brain swelling
May be carried out to remove infected bone
In a craniectomy, the bone flap is not replaced right away
Cranioplasty
Repair of a skull defect (from trauma, malformation, or craniectomy)
Restores the contour and integrity of the skull
May be carried out to replace a bone flap; usually performed in the weeks or months after craniectomy
Timing of replacement or repair depends on the reason for the initial bone flap removal
Hemicraniectomy
Removal of part or half of the skull
Serves as an aggressive treatment option for patients whose persistent intracranial hypertension is refractory to conservative measures
May reduce mortality in some patients with nondominant hemisphere strokes
Microsurgery
Any surgery performed with the aid of an intraoperative microscope or a loupe magnifying glass (▶ Fig. 15.3)
Magnifies the operative field, enhancing visualization of small or hard-to-see structures
Fig. 15.3 Microsurgery.
Navigational Systems
Used for image-guided or stereotactic surgery
Allow the neurosurgeon to identify the exact location of a lesion by providing its three-dimensional coordinates
Patients scheduled for this type of procedure will undergo preoperative stereotactic magnetic resonance imaging (MRI) or computed tomography (CT); see also Chapter 14: Neuroradiology and Neuroendovascular Interventions
These preoperative images are loaded into a navigational system computer that generates a three-dimensional map of the brain intraoperatively
15.2.2 Other Types of Brain Surgery
Amygdalohippocampectomy
Surgical interruption of seizure pathways
Common treatment for patients with temporal lobe epilepsy refractory to medical treatment
Usually reserved for patients who do not respond to pharmacologic intervention for seizures; see also Chapter 6: Seizures
Deep Brain Stimulation
Insertion of stimulators into targeted areas of the brain (▶ Fig. 15.4)
Used to treat epilepsy, Parkinson’s disease, and some chronic pain syndromes
Fig. 15.4 Common anatomical structures targeted in deep brain stimulation.
Microvascular Decompression
Treatment designed to relieve pressure on a cranial nerve (CN); the most commonly affected CNs include CN V, CN VII, CN IX, CN X, and CN XI
The pressure is caused by a vessel pulsating against the CN, resulting in a range of conditions including trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia
A microscope or endoscope is used to identify and reposition the vessel or to place padding (e.g., Teflon or cotton) between the vessel and the compressed nerve (▶ Fig. 15.5)
Fig. 15.5 Microvascular decompression.
Revascularization Procedures
Include direct and indirect procedures (▶ Fig. 15.6)
Artery-to-artery bypass is an example of direct bypass
Temporalis muscle overlay is an example of indirect bypass
Used as treatment for some cerebrovascular diseases (e.g., moyamoya disease) or skull base tumors
Fig. 15.6 Combined direct (arrowhead) and indirect bypass procedures. STA, superficial temporal artery.
Ventriculoperitoneal, Lumboperitoneal, or Ventriculoatrial Shunt
Shunts placed to divert excess cerebrospinal fluid (CSF) away from the ventricular system
Used to treat hydrocephalus or benign intracranial hypertension (i.e., pseudotumor cerebri); see also Chapter 4: Hydrocephalus
15.3 Spine Surgery
Indications for spinal surgery may include normal degenerative processes or traumatic events (Box 15.2 Indications for Spine Surgery). Many of these conditions were discussed in Chapter 11: Spinal Disorders and Chapter 12: Traumatic Spine Injury.
Box 15.2 Indications for Spine Surgery
Abscess
Degenerative disk disease
Herniated disk
Kyphosis
Myelopathy
Radiculopathy
Spinal instability
Spondylolisthesis
Spondylolysis
Spondylosis
Stenosis
Tumor
Vascular lesion
15.3.1 Common Types of Spine Surgery
Anterior Lumbar Interbody Fusion
Removal of disk material followed by placement of a cage device between the two vertebral bodies
Cage device is packed with autograft and/or allograft bone (Box 15.3 Types of Grafts)
Procedure may be combined with posterior lumbar spinal fusion to stabilize the spine
Box 15.3 Types of Grafts
Autograft: Refers to harvest of bone from patient’s own body (e.g., iliac crest bone from the pelvis)
Allograft: Refers to use of cadaver bone or synthetic material
Diskectomy
Excision and removal of disk material or the entire herniated disk (▶ Fig. 15.7)
In a microdiskectomy procedure, the surgeon uses a microscope or magnifying eyeglasses to view the operative field and remove disk material
Fig. 15.7 Anterior cervical diskectomy.
Fusion
Addition of bone (allograft and/or autograft) to a specific area of the spine, either with or without a cage (▶ Fig. 15.8)
Fosters ossification and solidification in the space between bones
Limits range of motion at that level, thereby decreasing pain
Fig. 15.8 Cervical fusion.
Interspinous Process Device
Device placed between lumbar spinous processes, placing the spine in a slightly flexed position, which widens the spinal canal and the nerve root foramen
Alternative to laminectomy for treatment of lumbar spinal stenosis
Laminectomy
Also referred to as open decompression
Removal of spinous process and bilateral laminae (▶ Fig. 15.9)
Used to treat spinal stenosis and foraminal narrowing, usually at multiple levels
Fig. 15.9 Laminectomy.
Laminotomy
Lamina is opened to relieve pressure on the nerve root or the spinal canal
Used to treat spinal stenosis at a single level, usually on one side
Pedicle Screws and Rods
Screws are placed through the pedicles and into the vertebral bodies at the consecutive spine segments being fused (two or more segments may be fused at a time)
The screws are attached to a rod, preventing motion at the fused segments (▶ Fig. 15.10)
Fig. 15.10 Pedicle screws and rods.
Plating
Most common in anterior cervical procedures after anterior cervical microdiskectomy and fusion device placement between vertebral bodies (▶ Fig. 15.11)
Decreases motion, secures fusion device, and provides additional stabilization until fusion is complete
Prevents anterior or posterior migration of the fusion device
Fig. 15.11 Anterior cervical plating.
Posterior Lumbar Interbody Fusion
After diskectomy, a cage device containing autograft and/or allograft bone is inserted into the disk space (▶ Fig. 15.12)
The desired outcome is a biological response: solid bony fusion between the two vertebrae, stopping motion at that segment
Fig. 15.12 Posterior lumbar interbody fusion.
15.4 Preoperative Nursing Care
In elective surgeries, the care team may have days or weeks to complete the preoperative steps that ensure optimal outcomes. However, surgeries may be emergent or scheduled during the current hospitalization, with little time to prepare. Regardless of the timeline or other circumstances surrounding the procedure, certain preoperative measures must be taken. These may include the following:
Medical clearance (i.e., Is the patient’s condition stable enough to withstand surgery?)
Review of current medications
Discontinuation of certain medications prior to surgery, especially anticoagulants such as clopidogrel, warfarin, and aspirin (Box 15.4 Clinical Alert: Anticoagulation/Antiplatelet Drugs)
Laboratory tests (▶ Table 15.1)
Coagulation profile
Complete blood cell count (CBC)
Electrolytes
Pregnancy test, if appropriate
If the patient is taking clopidogrel, a platelet aggregation panel and clopidogrel inhibition assay must be drawn to assess platelet function (Box 15.5 Preoperative Management of Coagulopathies)
Blood type and screen or crossmatch (autologous blood donation may be used for large-scale spine procedures, if this is the patient’s preference and if time permits)
Informed consent
Advanced directives
Patient/family teaching of expected preoperative, intraoperative, and postoperative course
Some cases of tumor resection may require wand-guided MRI or CT for intraoperative navigation.
Box 15.4 Clinical Alert: Anticoagulation/Antiplatelet Drugs
Patients who take antiplatelet medications or warfarin should discontinue these medications several days before surgery, as determined by the surgeon. Preoperative laboratories should include CBC and a coagulation profile, including a platelet aggregation panel/assay for patients receiving antiplatelet medications. The surgeon should be notified immediately of any abnormal laboratory values.
Box 15.5 Preoperative Management of Coagulopathies
Coagulopathies must be corrected before surgery
Platelet dysfunction
A medication the patient is taking (e.g., aspirin or clopidogrel) may be causing platelet dysfunction. The platelet count may be normal, but platelet function is altered
Patient may need a platelet transfusion, which will give the patient functioning platelets capable of clotting
Platelet transfusion may be carried out pre-, intra-, and/or postoperatively, as needed
Thrombocytopenia
Patients with a low platelet count will require a preoperative platelet transfusion, and may require additional intra-, and/or postoperative transfusion
Elevated INR
Patients receiving warfarin with elevated INR are treated with vitamin K (Aquamephyton), fresh frozen plasma, or both
Oral vitamin K may be preferred over subcutaneous or intravenous vitamin K
Oral vitamin K may correct excessive anticoagulation more effectively than subcutaneous vitamin K
Intravenous vitamin K has been associated with anaphylactic reactions
Bleeding prophylaxis
Tranexamic acid
Tranexamic acid inhibits multiple plasminogen-binding sites, decreasing fibrinolysis and plasmin formation
Elevated PTT
Patients receiving heparin with a prolonged PTT need to be treated with protamine sulfate
Test | Normal values |
CBC | |
Hemoglobin Hematocrit White blood cells Platelets | 12.9–16.1 g/dL 37.7–51.3% 3.6–11.1/μL 150–450 × 103/μL |
BMP | |
Sodium Potassium BUN Creatinine Glucose | 135–145 mmol/L 3.6–5.3 mmol/L 8–25 mg/dL 0.65–1.25 mg/dL 65–99 mg/dL |
Coagulation profile | |
Prothrombin time PTT INR TEG | 9.3–12.9 s 21–31 s 0.8–1.2 55–73 mm |
Platelet inhibition assay | Depends on physician preference and type of surgery to be performed |
Abbreviations: BMP, basic metabolic profile; BUN, blood urea nitrogen; CBC, complete blood cell count; INR, international normalized ratio; PTT, partial thromboplastin time; TEG, thromboelastography. Note: Normal laboratory values are slightly different at every laboratory/institution. | |
15.4.1 Patient and Family Teaching
For all surgeries emergent and planned, it is critical to educate and support the patient and family. Important information to relay includes the following:
Type of surgery (as listed on surgical consent), including the approach and the area of planned incision
Location of operating room and waiting room for family members
Anticipated duration of surgery
Location of recovery room and anticipated length of stay in the hospital
Expected location of patient’s room after recovery unit
Intensive care unit (ICU) information
Visiting hours
Restrictions (e.g., whether children are allowed, acceptable number of visitors)
Increased stimulation in ICU (noise, alarms, increased frequency of assessments)
Expected length of stay in ICU, if appropriate
15.4.2 Informed Consent
The nurse is occasionally called upon to assist with obtaining informed consent for surgery. Informed consent should be obtained after the physician discusses the following with the patient and/or family:
Reason for proposed surgery
Alternative treatments, if any
Potential consequences/risks of surgery
Potential consequences/risks of foregoing surgery
The adult patient should sign the consent. If the patient’s medical condition renders the patient unable to sign, a surrogate decision maker, usually the next of kin or the medical power of attorney, may be called upon to sign the informed consent.
It is important that all questions are answered and the patient and/or family have the information needed to consent to surgery. Informed consent forms must include the following details:
Patient’s full name
Attending surgeon’s full name
Complete descriptive name of intended surgical procedure, including site (left or right), with all words spelled out completely. Abbreviations are not acceptable on informed consent forms
15.4.3 Advanced Directives
Advanced directives are personalized legal documents that define and clarify the patient’s wishes for health care and end-of-life issues. These documents direct specific care. If the patient is rendered unable to participate in decisions regarding his or her own medical care, the advanced directives should be consulted to determine the next step. Ideally, these forms are completed prior to hospital admission, but they can be completed during the admitting process, during hospitalization, or just before surgery. Ensuring the inclusion of the patient’s advanced directives in the medical chart is an important element of preoperative nursing care.
Durable Power of Attorney for Health Care
The durable power of attorney for health care is the person designated to make health care decisions in the event when the patient is unable to make decisions regarding his or her own care
Living Will
A living will is a document that specifies what treatments the patient does or does not want to receive at the end of life
It applies only if medical treatment in question is necessary to prolong life and the patient is unable to speak for himself
Hospital chaplains are excellent resources who are usually available to assist with writing living wills and naming the medical power of attorney
15.4.4 Preoperative Nursing Checklist
Prior to surgery, the nurse should review the following checklist to ensure that the patient is properly prepared. Policies and procedures may vary among institutions. This preoperative nursing checklist can also be found in Appendix C: Preoperative Nursing Checklist.
Informed consents
Surgical consent
Blood consent or refusal of blood/blood products
Anesthesia consent
Preoperative teaching
Patient and family education about the procedure, the expected timeline, and expected outcomes
History and physical examination
Allergies, including reactions
Laboratory tests as ordered. These may include the following:
CBC
Coagulation profile
Urinalysis
Blood tests
Type and screen
Crossmatch
Number of units ordered and availability
Pregnancy test, if appropriate
Comprehensive metabolic profile or basic metabolic profile
Electrocardiogram
Chest radiograph
Old chart, if available
Special preparatory measures, if ordered
Identification bracelet
Compliance with orders for nil per os (NPO), or nothing by mouth, and ordered duration
Removal of undergarments
Removal of bobby pins, combs, wig, hairpiece, and false eyelashes
Removal of jewelry, watches, and/or religious medals. Document placement (e.g., with a specific family member or with hospital security staff)
Rings taped
Removal of dentures (bridge, plates, partials), container labeled
Removal of prostheses, with documentation of placement. Prostheses may include the following:
Artificial eye (if removal is necessary for surgical access)
Contact lenses
Glasses
Hearing aids
Prosthetic limbs
Other
Identification labels with chart
Face sheet, or a one-page sheet that summarizes important patient information, attached to chart
Measures to prevent deep vein thrombosis (DVT)
Sequential compression devices or antiembolism stockings, unless contraindicated
Documentation of the time of last void or catheter placement
Compliance with necessary isolation precautions
Medication reconciliation on chart
List of medications administered preoperatively, with documented drug/dose/time
Time of last dose of β-blockers, if applicable
For patients receiving β-blocker therapy at home, the β-blocker must be administered 24 hours before surgery or within the perioperative period (within 6 hours of the end of surgery for patients going directly to ICU postoperatively)
Document whether a β-blocker was given within 24 hours of surgery
Document whether a β-blocker was not administered before surgery
Safety
Side rails up
Call light within reach
Vital signs, including the following:
Blood pressure
Temperature
Pulse
Respiration rate
Oxygen saturation
Special comments and considerations for operating room and recovery room nurses
Communication of patient limitations
Sight
Motion
Hearing
Speech
Other
Measure patient’s height and weight
Test bedside blood glucose level (for patients with diabetes mellitus or on steroids)
Document last dose of insulin or oral hypoglycemic agent
Include type and amount
The night before or day of surgery
Preoperative shower/shampoo (preferably with chlorhexidine)
15.5 Intraoperative Nursing Care
15.5.1 Patient Positioning
Effective patient positioning should offer ideal operative exposure for the neurosurgeon; maintain adequate cerebral circulation; promote optimum cardiovascular, hemodynamic, and respiratory function; and prevent position-related injury.
Although it may sound trivial, precise patient positioning must not be overlooked because it can prevent significant pre-, intra-, and postoperative complications and contribute to positive outcomes for neurosurgical patients. Preparing the operating room with the correct positioning equipment before the patient is brought in for surgery is an efficient way to prevent position-related injuries. This section describes three positions commonly used to access the brain and spine (supine, prone, and lateral) and covers some variations of these positions.
15.5.2 Surgical Approaches: Indications, Concerns, and Implications
Craniotomy: Supine Position
Head position is determined by surgeon preference, but the most common positions are the following:
Mayfield 3-point head holder
Horseshoe head rest
Gel or foam donut head rest
Right arm wrapped circumferentially in egg crate and tucked at the patient’s side with safety strap or 3-inch-wide adhesive tape wrapped around the entire torso, arms, and operating table three times (▶ Fig. 15.13). The wrist and fingers, as well as the median, ulnar, and radial nerves, should be protected
Left arm rests on egg crate or padded arm board for anesthesia access
Pillow under the knees
Foam padding between the ankles and the knees
Small towel under the lordotic curve of the lower back
Padded safety strap across the anterior thighs
Fig. 15.13 Supine position for craniotomy.
Frontal/Bifrontal Approach
This approach, through the forehead, allows access to the frontal lobe of the brain (▶ Fig. 15.14). Patients undergoing a procedure via this approach are usually positioned with the head in a neutral position.
Fig. 15.14 Bifrontal craniotomy.
Indications
Abscess
Aneurysm
CSF fistula
Frontal lobe tumor
Intracerebral hematoma
Lesion of the frontal sinus
Malignant intracranial hypertension
Olfactory groove lesion
Parasagittal meningioma
Sellar tumor, including craniopharyngioma and planum sphenoidale meningioma
Tumor/lesion of the third ventricle or hypothalamus
Common Surgical Procedures
Bifrontal decompressive craniectomy
Burr hole for endoscopic third ventriculostomy
Burr holes for placement of deep brain stimulators
Endoscopic wand-guided cyst fenestration
Eyebrow incision for endoscopic tumor resection
Frontal craniotomy for biopsy, debulking, and/or tumor removal
Postoperative Nursing Concerns
Sagittal sinus injury
Venous infarction
Hematoma due to inadequate hemostasis
CSF leak (frontal sinus)
Anterior cerebral artery injury
Superior facial nerve branches may be injured if skin incision is extended too far
Seizure
Incisional edema
Behavioral changes (e.g., loss of inhibition, disorientation)
Frontotemporal Approach
This approach facilitates access to the frontal and temporal lobes of the brain.
Indications
Most aneurysms of the anterior circulation
Tumor of the anterior fossa, middle fossa, frontal lobe, or temporal lobe
Suprasellar lesion
Lesion involving the anterior midbrain
Common Surgical Procedures
Pterional craniotomy (▶ Fig. 15.15)
Orbitozygomatic craniotomy (▶ Fig. 15.16)
Full
Modified
Miniature
Fig. 15.15 Pterional craniotomy.
Fig. 15.16 Orbitozygomatic craniotomy.
Postoperative Nursing Concerns
Orbital or periorbital edema and ecchymosis
Orbital muscle entrapment (partial ophthalmoplegia)
Optic nerve entrapment (blindness)
Injury to the frontalis nerve (ipsilateral forehead paralysis)
Hematoma
CSF leak
Parietal Approach
The parietal approach allows access to the parietal lobe of the brain (▶ Fig. 15.17).
Fig. 15.17 Parietal approach.
Indications
Tumor, vascular lesion, infection, or hemorrhage of the parietal lobe
Tumor or lesion surrounding the superior sagittal sinus
Common Surgical Procedures
Biparietal craniotomy (for a tumor or lesion surrounding the superior sagittal sinus)
Superior parietal lobe approach
Postoperative Nursing Concerns
Intraoperative injury to superior sagittal sinus
Hematoma related to inadequate hemostasis
Cerebral infarction (venous or arterial)
Postoperative Nursing Implications
Motor and sensory examination
Visual fields should be assessed and compared with preoperative assessment
Assess presence of seizures, monitor antiepileptic drug (AED) levels
Assess speech function (both receptive and expressive speech)
Temporal Approach
This approach allows access to the temporal lobe of the brain (▶ Fig. 15.18).
Fig. 15.18 Temporal approach.
Indications
Seizure monitoring or resection of seizure focus
Tumor or arteriovenous malformation (AVM) of the medial or lateral temporal lobe
Vascular lesion of the temporal lobe
Common Surgical Procedures
Anterior temporal lobectomy
Craniotomy for placement of grid/depth electrodes for seizure monitoring
Decompressive hemicraniectomy
Selective amygdalohippocampectomy
Postoperative Nursing Concerns
Language or speech impairment, especially after surgery on the left hemisphere of the brain
Neck pain related to intraoperative positioning of head
CSF leak
Deficits of CN III or CN VII
Visual field defect
Hemiparesis
Seizure
Trapped temporal horn of the lateral ventricle resulting in uncal herniation syndrome
Subtemporal Approach (Intradural or Extradural)
The subtemporal approach allows access to the posterior edge of the temporal lobe (▶ Fig. 15.19).
Fig. 15.19 Subtemporal approach.
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