Neurosurgery resident doctors are expected to know the common neurosurgical conditions and their clinical presentations. The common neurosurgical conditions and common neurological symptoms with which majority of patients attend neurosurgery OPD are :
1. Head Injury
2. Brain tumor
3. Hydrocephalus: Post tubercular meningitis (TBM) hydrocephalus, post traumatic, congenital, secondary to intracranial tumor or other space occupying lesion ( ICSOL), Benign intracranial cyst
4.Lower Backache, weakness, numbness, parasthesia in in one or both lower limbs
5. Neck Pain, cervical spondylosis, Craniovertebral junction anomaly, Quadriparesis, weakness in upper limb, weakness of hand grip, atrophy of small muscles of hand, spasticity or stiffness of the body or limbs
6.Seizures, partial seizures, history of loss of consciousness
7. Meningomyelocele, spina bifida
8.Stroke, CVA, TIA, Spontaneous intracerebral hematoma, hypertensive bleed, hemorrhagic stroke
9. Cranial and/or spinal tuberculosis
9. Scalp or skull swelling, Sebaceous cyst, Dermoid, Neurofibroma, Lipoma, osteomyelitis, osteoma
10. Brain or spinal metastasis
The main difference between indoor and outdoor department is the paucity of time. So, in OPD it requires ability to obtain brief history and then do clinical examination accordingly. Advise relevant investigations and develop a management plan of the patient including radiological investigations and treatment. The prescription is the evidence of your clinical judgement and approach towards that disease. This OPD card consists of Provisional diagnosis, first investigation, investigation of choice for the particular disease and the appropriate prescription. Patient carries this prescription with him or her which guides the patient, pharmacist, Lab departments and other doctors and stakeholders. This prescription also guides you, your colleague or consultant when you or someone else sees the patient in follow up OPD. This prescription is carried by the patient and is very frequently shared with many stakeholders.
Although it seems challenging but with practice gradually becomes easy. The good part of this process is that it is very often repetitive and you observe a trend and develop your own pattern of seeing patients in OPD.
Learn to take history in brief for OPD and spend few minutes and listen to the complaints of the patient.
Learn neurological examination in the neurosurgery ward and try to emulate that in OPD.
Common investigations which are useful in the management of neurological diseases are:
Hemoglobin, RBC count, PCV( hematocrit), MCHC, PCV, reticulocyte count are useful in the diagnosis of anemia which is a very common cause of headache.
WBC for infection
Platelet count for the diagnosis of thrombocytopenia
ESR for predicting response to the treatment, or a chronic disease
Bleeding time, clotting time, PT for PAC
Peripheral blood smear for the diagnosis of type of anemia, Malarial parasite
RBS, HbAC1,( Diabetes) KFT, Serum electrolyte, LFT, Lipid profile are helpful in diagnosis of patients with stroke and comorbidity.
Thyroid function test: anxiety, depresssion, pituitary adenoma, headache
Urine routine microscopy, urine culture
Serum B12 level, serum vitamin D3 level
CRP, RA factor
Various imaging modalities used for investigating neurological disorders are:
X-Rays ( Plain radiography)
Ultrasonography
Carotid doppler
CT scan of the brain & Spine, CT scan with contrast, CT Angiography
MRI Brain and Spine, MR Angiography, MRI with contrast, MR Spectroscopy, MR Tractography, Functional MRI of the brain, MR cisternography
Angiography, Digital substraction angiography ( DSA)
Myelography, CT myelogram
PET CT Scan
PET MRI
TCD ( Transcranial Doppler)
SPECT
Plain Radiography
X-Ray skull is useful for the diagnosis of skull bone osteomyelitis, Craniovertebral junction abnormalitise, Tumors of the cranial bones like osteomas, osteosarcoma, metastasis to skull may be seen on skull X - ray films. Skull fractures in head injury & Growing skull fractures in children are diagnosed on skull radiography.
CT scan: CT scan is commonly used abbreviation of Computed Axial Tomography ( CAT ) scanning. This investigation machine was developed in 1970s and it was a most important development in the field of Neuroradiology after the development of X rays ( 1890s) and angiography ( 1920s and 1930s). It is a non invasive procedure and uses X-rays for the imaging. It utilizes X-Ray beam which passes through the tissue and produces a picture like x ray but in varying shades of grey. The density of tissue changes the picture. CT scan produces axial or cross sectional ( slices) images of the body.
Computer measures the density of the tissue through which x ray beam passes. CT scan machine uses multiple pencil beams of x ray which rotate in the gantry and pass through the body and on opposite side dosimeter measures the amount of radiation reaching it. Each cubic part of tissue is known as voxel ( in New machines about 512 voxels) . Each voxel produces a pixel. Computer measures the attenuation of the beam and assigns a Hounsfield Unit ( HU ).
Sir Godfrey Hounsfield from England and Allan McLeod Cormack from USA shared Nobel prize in 1979 for invention of CT scan . All shades of Gray for image May be assigned a number ' HU'. Any HU value below minus 15 will appear pure black on CT film and any HU value above 155 HU will appear pure white. Common HU values are water zero ( 0 )
CSF in brain 10 to 16, Air minus 1000, Fat minus 60 to minus 120. Fat containing medullary bone will appear less white as compared to compact cortical bone ( HU +1000).
CT scan of the brain is the investigation of choice
For brain trauma patients, because
- it is less time consuming,
-the presence of the metal ( bullet in gun shot injury, metal in stab injury) is not a contraindication,
- an trauma patient where the history of pace maker of heart or metallic implant is not known , CT scan is possible,
-detects bony injuries, like a fracture, depressed fracture and hematoma associated with fracture
-better delineation of hematoma .
CT scan brain is also an investigation of choice
For detecting subarachnoid hemorrhage ( spontaneous subarachnoid hemorrhage) due to rupture of an intracranial aneurysm
CT angiography ( CTA ) is an investigation to detect the aneurysm of the brain. It has become an important tool for detecting the site of aneurysm bleed, location , and other characteristics of the aneurysm of the brain . It is more sensitive than MR Angiography and its sensitivity is comparable to the Digital Substarction Angiography.
CT scan of the spine: Although MRI of the spine is undoubtedly the investigation of choice for spine, CT scan of the spine is still an important investigation. CT scan of the spine is required when MRI of the spine is not possible, for example, if a patient is with metal prosthesis ( spinal instrumentation with ferromagnetic material like steel), or a metallic bullet is impinged in the spinal cord following a gun shot injury. CT spine also helps in conditions like canal stenosis, bony fractures, ossified posterior longitudinal ligaments, etc.
High resolution CT scan, 3D reconstruction, CT myelogram , Perfusion Coputed Tomography , Intraoperative CT scan are other applications of CT scan.
MRI is the most important development in the field of neuroradiology after the development of X- rays, Angiography, and CT scan.
MRI is a non invasive radiological investigation. It does not expose the patient to the risk of radiation. It uses magnetic field . It provides multiplanar images, i.e, images in sagittal, coronal and axial planes.
Functional MRI is another non invasive investigation which helps in imaging of the eloquent area of the brain.
MR Spectroscopy provides the clue about the nature of the lesion and helps in identifying infective and neoplastic lesions of the brain.
Intraoperative MRI is an advanced technique for intraoperative imaging of the lesions inside the operation theater.
How to interpret MRI brain images?
MRI images are usually black & white. There are T1 weighted, T2 weighted, FLAIR , Diffusion weighted images and if contrast is given then T1 contrast images.
To identify T1 weighted image, see the ventricles. lateral Ventricles are in the center and contain CSF.
On CT usually only Axial images are seen but on MRI Axial, Coronal and sagittal images are seen.
On T1 weighted image, CSF will appear Black (Hypointense).
On T2 weighted image , CSF will appear White ( Hyperintense).
On FLAIR ( Flow Attenuation Inversion Recovery) the intraventricular CSF will appear Black but brain edema will appear White.
Contrast images are usually T1 contrast Images. So, CSF will appear Black and some lesions like Meningioma will become white ( Hyperintense) after contrast enhancement.
PET and SPECT are nuclear neuroimaging and help in physiological assessment. PET ( Positron Emission Tomography) is further advanced to utilize CT or MRI imaging techniques and known as PET- CT or PET-MR. PET is used for detecting metastasis and recurrence of the tumor. PET scan commonly utilizes Flurodeoxy glucose ( FDG) which is a radioactive tracer.
Digital substraction angiography ( DSA) is invasive investigation which involves introducing a catheter and injecting intravenous contrast into the femoral artery. It is the gold standard investigation for defining an intracranial aneurysm, Arteriovenous malformation ( AVM) , vasospasm after Subarachnoid hemorrhage ( SAH) and other diseases of intracranial vasculature.
TCD ( Transcranial Doppler ): Noninvasive investigation to detect the vasospasm in a case of SAH.
Although Ultrasound is not a good investigation to detect intracranial pathologies as ultrasound waves do not cross bones, there are certain places where bone is very thin like temporal squama or areas in cranium which have windows like orbit. So, the flow of blood through the intracranial arteries may be detected through these windows. In vasospasm the vessels are narrowed and flow velocity increases. This is the basis of TCD, which is a noninvasive procedure and can be performed on bedside.
Ultrasonography can be used to detect hydrocephalus and meningomyelocele in prenatal period . USG can also detect hydrocephalus in infant as anterior fontanel is not closed.
Intraoperative USG is used for real time imaging , localization, extent of resection of the tumor after craniotomy at the time of neurosurgery.
Neuronavigation is used to localize the lesion, route of the surgery, safer trajectory, etc.
Neurointervention is a very promising development in the field of Neuro-radiology. It is not only useful for the diagnosis but it also offers to treat many ailments of the brain and spine. The ost important and exciting applications of neurointerventions are: Coiling of the intracranial aneurysms, Preoperative embolization of the vascular tumors like meningioma, Embolization of the intracranial and spinal AVMs, Stenting of the vessel.
Listen to the patient. Patient is the best guide and will provide you the important clue for the diagnosis. History taking is an opportunity to interact with people from diversified background.
While taking history of a patient who is suspected to have a neurological disorder it should always be prudent to take history pertaining to lesions of brain, spinal cord and peripheral nerves. In this manner you can complete and cover the entire central and peripheral nervous system.
So, if you suspect a lesion of the cerebral hemispheres then it will be relevant to obtain the history of seizure, headache, vision and , deterioration of conscious level or loss of consciousness, weakness of the face or limbs.
If you suspect a lesion of cerebellum, then history of imbalance, ataxia and difficulty in walking should always be taken.
And, if you suspect a lesion of the brain stem ( Midbrain , pons, medulla Oblongata), the symptoms of multiple cranial nerve deficits ( speech abnormality, nystagmus, difficulty in deglutition, loss of Gag reflex), and long tract signs ( weakness in limbs, hyperreflexia, increased tone in limbs, positive Babinski sign) are expected.
In patients with lesions of the spinal cord history must include details about weakness of the limbs, bladder and bowel involvement.
History of headache must include Onset ( sudden, gradual), Site ( holocranial, hemicranial , temporal), Frequency, duration, severity, Character ( Aching, throbbing), timing ( e.g., morning , evening), Precipitating factors (coughing, strenuous work) , Relieving factors ( analgesics, rest) , Associated features ( nausea, vomiting, visual disturbance).
History of Visual Disorder should include onset, frequency, impairment ( uniocular or both eyes, partial or total), diplopia, Precipitaing factor, Associated features
History of Loss of Consciousness may be due to syncope because of cardiac causes or vasovagal shock or due to neurological causes like a part of seizure or neurotrauma or a space occupying lesion in the brain. Loss of consciousness may also be due to low blood sugar level in a patient on diabetic treatment or alcohol or drug abuse.
Speech disorder may be a difficulty in Articulation or Expression or Understanding.
Weakness in the limbs may be Quadriparesis, Hemiparesis or Monoparesis with or without involvement of facial muscles.
History of Sensory system abnormalities may expressed by the patient as Numbness, feeling of crawling of ants or insects, Tingling or inability to feel a part of the body.
History of cranial nerve deficits may be expressed by the patient as inability to smell, inability to read, loss of vision, diplopia, frequent changes of spectacle, partial closure of the eyelid ( Ptosis)loss of sensation over the face, drooling of saliva from the side, difficulty in closing eye, slurring of speech or change in voice, difficulty in hearing or Deafness, Tinnitus, Vertigo or Dizziness, inability to swallow, inability to shrug and turn face and inability to protrude tongue.
Neurological examination is straight forward, It is like substraction and addition of numbers, like 2+2=4. So, if there is right hemiparesis of body and face and the deep tendon reflexes are increaded, there must be some lesion on the left side of the brain. There is nothing wrong in rechecking the neurological examination findings. But, be sure of your neurological examination findings. Your examination may have a great impact on clinical outcome and plan of the treatment. In Neuroscience most of the things are evident. As students we used to think that many things may be theortical. But, with the advent of newer and advanced neuroradiology, microneurosurgery and functional neurosurgery, lot of procedures are now based on physiological and neuroanatomical localization.
One should begin with systemic examination. See Pallor ( anemia), Icterus ( jaundice), Lymhadenopathy. Anemia may explain many symptoms. Lymhadenopathy may indicate infection, lymphoma or metastasis.
Irregular Pulse may indicate syncope
Blood pressure : Hypertension may indiacte raise ICP
Respiratory Rate: Irregular Respiration, Bradycardia and Hypertension are parts of Cushing reflex which is due to raised ICP.
Neck rigidity may indicate meningitis or subarachnoid hemorrhage. Restriction of neck movement may be due to cervical spondylosis. One should be very careful while examining a patient with head injury. if a patient is unconscious and his GCS is 8 or less, it is presumed that there may be associated cervical spine injury. So, in severely head injured patient , neck should be immobilized by putting a cervical collar while shifting the patient
Neurological examination begins with higher mental function. orientation to time, place and person should be asked.
cranial nerve examination: Soap may be used to examine olfaction. Vision should be seen in both eyes. If patient is unable to count fingers, then perception of light should be examined with a torch. Pupillary light reflex,ie, constrction of both the pupils when light is projected in eye , gives a clue about both second and third cranial nerves. because second cranial nerve (Optic Nerve) is afferent and third cranial nerve ( Occulomotor nerve) is efferent of this light reflex. Although this is very simple examination but it has great value. We often presume that vision is normal and miss it. A child with craniopharyngima, an adult with clinodal meningima or pituitary adenoma may not have any vision in one eye but even patiets or their parents may not be aware about the uniocular visual loss. So, if a doctor misses this finding, there may be catastrophic consequences. As immediately following the surgery , there is natural tendency in everyone to check the vision and it could be concluded that this visual loss be due to surgery. Optic nerve tumor, optic nerve injury, retinal detachmentmay also present with uniocular visual loss.
3,4,6 cranial nerves function may be examined by seeing the conjugate eye movements of both eyes together.
5th cranial nerve, 7th cranial nerve is by examining the face. sensation over the face is mainly by the Vth cranial nerve ( Trigeminal nerve). There are three sensory divisions of Trigeminal nerve ( V1, V2, V3). 7th cranial nerve is the motor supply to the face.
Hearing is through 8th cranial nerve. Ideally 8th cranial nerves should be examined by Tuning forks. If patient hears the rubbing of fingers of the examiner close to each ear, it may give some clue to the intact hearing.
If the gag reflex is intact, 9th and 10th cranial nerves are intact.
Patient is asked to Shrug the shoulder and turn the face against the resistance to examine sternocleidomastoid and trapezius muscle which are suppled by the spinal accessory nerve.
Protrusion of tongue is possible with the 12th cranial nerve. If Hypoglossal nerve is damaged the tongue deviates to the injured side on protruding.
Sensory nervous examination should be done before motor examination. Because patients usually are cooperative and sensory system examination is subjective and needs patient,s cooperation.
Motor examination : Movement of all four limbs. Power in all four limbs should be checked separately and should be compared with your own strength. Deep tendon reflexes and tone should also be examined.
Gait; If a patient is able to walk, gait should alsio be examined to complete the thorough neurological examination
Headache is a very common symptom. Almost everyone experiences headache at some stage of life. Despite of being so common it becomes sometimes it becomes a matter of concern.
So, one should not panic and should analyze the severity of the problem and proceed further for seeking the medical attention & investigations.
Lot of literature is available on the causes of headache but I would like to overly simplify this topic so that one can have an overview.
If headache is associated with exertion at the end of the working day and is over the vertex, frontal or occipital region of the skull and is relieved on taking rest or head massage, one should not worry.
if someone is very stressed and there is obvious stress then there can be psychogenic headache. That person should adopt the less stressful lifestyle and practice relaxation exercise , yoga , and very rarely psychotherapy or some medicines may be required.
Maxillary or frontal sinusitis also causes headache.
Redness of eyes, frequent sneezing, cold , allergy may also cause headache.Cluster headache occurs in clusters.
In older persons headache may occur due to hypertension and temporal arteritis.
Refractive errors like myopia and hypermetropia may also cause periorbital pain and headache especially in young children going to school. So vision examination should also be done in patients complaining of headache.
If a child complains of headache it may due to refraction error in vision. Common cause is myopia when someone complains of difficulty in seeing distant things. child may not read the letters written on blackboard in a class and there may be decrease in scholastic performance in school. Another refractive error is hypermetropia which is difficulty in reading the small letters. Although, this is a common problem in people over 40 years of age, it is becoming more common in childrenm because of too much indulgence in mobile games, computer games and less outdoor play activities.
So common cause of Persistent headache is refractive error of vision.
Other common cause is sinusitis. Such patients will have frequent history of nasal infections, pain over the bony air sinuses in skull. Maxillary sinusitis, frontal air sinusitis may be diagnosed by tenderness and X-Ray Skull. Sometimes CT scan may be needed. Most of the patients are treated by antibiotics.
Common cause of headache is tension headache. In this type is headache pain is over the vertex, i.e, top of the head. Since the muscles are under continuous tension , such headache will diminish if head massage is given.
Hypertension, anemia may also cause headache.
Migraine is very common and typically paroxysm of throbbing type of headache on irregular intervals, unilateral, associated with vomiting. Migraine is more common in females. There are many variants of migraine.Migraine is the diagnosis of exclusion. Before labelling a ptient with this diagnosis all other causes must be ruled out, like anemia, brain tumor, hemorrhage, infection. CT scan or MRI of the brain rules out any intracranial mass occupying lesion. It is normally hemicranial,i.e., involes one half of the head. It is usually throbbing headache and associated with nauses and vomiting. Migraine is recurrent and gradually the duration between episodes become less.
What should not be missed?
Any physician or person should not ignore headache due to brain tumor and subarachnoid hemorrhage due intracranial aneurysm rupture.
How to recognize headache due to brain tumor? Usually progressive, associated with vomiting, temporarily relieved after vomiting, may be associated with blurring of vision ( due to papilloedema), or other neurological deficit.
How to recognize headache due to subarachnoid hemorrhage caused by rupture of intracranial aneurysm? It is sudden onset severe headache ( bolt from blue, thunderclap headache which a patient in the age group of 4th - 5th decade, says that he or she had never experienced such type of headache in life time. Sometimes headache may not be so severe and it is called warning leak. There may be associated neck rigidity.
What is the most valuable investigation in the management of headache??
If Visual examination of the patient is performed and Non contrast CT scan of the head is advised one will never be guilty of missing a life threatening brain condition like SAH ( subarachnoid hemorrhage and brain tumor) and it will guide the further course of treatment.
Sudden onset severe headache in a person of about 40 to 50 years of age which is so intense as patient describes that he or she had never experienced such headache in his or her life time,"Bolt from Blue," is typical of spontaneous subarachnoid hemorrhage ( SAH) due to rupture of intracranial aneurysm.
Head trauma, cervical spondylosis may also cause headache.
Headache associated with seizures is alarming. CT scan or MRI of the brain must be done.
So, if a patient of head injury comes to OPD you ask for the mode, manner, time of injury, initial prersentation, initial condition, initial treatment, concussion, post traumatic amensia , seizures, Ear Nose or Throat ( ENT ) bleed, vomiting, any extracranial injury. You advise NCCT head which is the investigation of choice for diagnosis of head injury.
Concussion means transient loss of consciousness due to head injury.
Concussion is also known as Mild Traumatic Brain Injury (MTBI).
It may be described as alteration of consciousness without structural damage as a result of head trauma.
Trauma to the head may cause sudden linear or rotational movement of the brain. This sudden acceleration and deacceleration movements of the brain and brain stem disrupts the normal cellular activities in the brain ( including fornix, corpus callosum, temporal lobe, frontal lobe) and in the the reticular activating system of the midbrain.
Most of the non medical people use word coma to describe a patient who is unconscious. But for a medical professional word "coma" is very specific because the impairment of arousal can vary from drowsiness ( sleepiness) to non-responding to any stimulus like sound or pain. Coma is the severest impairment of arousal, and is defined as the inability to obey commands, speak, or open the eyes to pain.
One should learn the GCS scale to better understand the different levels of impairment of conscious level and to avoid descrepencies in describing the daily condition of the patient by different medical professionals and nurses.
Teasdale and Jennet, in year 1875, proposed a scale known as GCS ( Glasgow Coma Scale). Three types of stimulus and response to the patient to these three stimuli is described.
First is EYE OPENING
If patient opens his eyes spontaneously , i.e., like a normal person without any problem , then 4 point is mentioned.
Next situation is that patient is drowsy or feeling sleepy and is having closed eyes. The sleepy patient if opens eyes on sound then 3 point is given.
If patient eyes are closed and he opens eyes only when painful stimulus is given the, only 2 points is given.
And patient does not open eyes even on a painful stimulus then only 1 point is given so the lowest score of eye opening is 1.
E 4 spontaneous eye opening
E 3 opening eyes to speech
E 2 opening eyes to pain
E 1 None
Then patient's verbal response is examined ( V stands for verbal response)
V 5 Person is oriented
(aware about what is happening around, Person is oriented to place, person and time )
V 4 Confused or disoriented
V 3 speaking inappropriate words
( Not producing sentences )
V 2 producing incomprehensible words
( Not producing word i.e. only some sound is produced by the patient)
V 1 None ( No verbal output means patient is not speaking and even not producing any sound)
Patient's Motor response is assessed
M 6 Obeys
(Best motor resonpse is M6 when patients moves limbs themselves and obey the command to move hand and feet whenever asked to do so)
M 5 patient localizes pain
( when patient is pinched he tries to remove your fingers)
M 4 Withdraws to pain
( here when patient is pinched feels pain and tries to withdraw from the pain)
M 3 Flexion to pain ( decorticate)
( in medical terminology it is known as decorticate posture , i.e., posture seen in an animal when the central nervous system is cut just below the level of cerebral cortex. Like in an experient by Sherrington, father of modern neurophysiology, when the brain of a cat was cut just above the midbrain or brain stem, animal,s upper limbs were flexed and lower limbs were extended. This abnormal posture is known as DECORTICATE POSTURE)
M 2 Extensor ( decerebrate )
( extensor response to a painful stimulus is a very bad neurological sign. When a patient is pinched his both upper and lower limbs are extended)
M 1 No response to the painful stimulus
The best responses of the patient are added . So, the maximum GCS score is 15 and minimum is 3.
Glasgow coma scale score of equal or less than 8 is a generally accepted operational definition of coma.
It can result from dysfunction of brain stem, diencephalon or lesions of both cerebral hemispheres.This may be due to neoplastic lesions, electrolyte imbalance, metablic or endocrine problems, vascular lesions, infections, trauma or nutritional reasons.
GCS is an important method of describing patient's neurological condition but blood pressure, pulse rate, respiratory rate, response of the pupils of eye to light, paralysis of the limbs are other important parts of the complete neurological assessment.
Plain CT scan of brain is the investigation of choice. It is normal in cases of concussion because it is a physiological impairment and so, no anatomical abnormality is seen on non-contrast CT scan of the brain. MRI of the brain is not required and is unnecessary. MRI will demonstrate abnormalities in up to 25% of cases where CT is normal. But, I do not suggest MRI in cases of concussion because CT actually guides the treatment. So, if CT is normal there is nothing serious and no active neurosurgical treatment is required. MRI just adds to the apprehension of the patients and their relatives and it does not provide any additional information of any use to the neurosurgeon.
Every person with post traumatic concussion requires emotional support.
Patient’s caregivers, family members, teachers and co-workers and colleagues must understand that some symptoms like irritability, headache, dizziness may be sequelae of concussion. So, a sympathetic and considerate attitude should be adopted towards the person who had suffered mild head injury with concussion and is experiencing long term sequelae of mild head injury.
Symptomatic treatment of like dizziness may be trated with Betahistine or Cinnarazine. Headache is a common complaint and requires both medical and psychological support.
Neurotrophic vitamins like vitamin B complex, Methylcobalamin, vitamin E are useful. Anxiety, sleeplessness are very well managed with tablet Clonazepam 0.25 mg at night and Psychological support.
Cranio-Vertebral Junction is the bony junction of the skull and vertebral column. It is formed by Clivus, Occipital bone and C1 and C2 vertebra.
This area is important as any abnormality in this area may lead to compression over the cervico- medullary junction, which is the junction of the cervical region of the spinal cord qnd medulla oblongata.
The abnormality at this region could be congeital anomaly or acquired.
Diagrammatic representation of 3 types of Sylvian fissure arachnoid cyts
Spina bifida is a common form of spinal dysraphism. The term spina bifida includes a wide variety of anomalies.
Congenital defect in the spine leads to spina bifida. This can be of two types: spina bifida occulta and spina bifida aperta.
In spina bifida aperta; visible lesion, like a swelling over the midline of the back may be noticed at the time of birth of a child. Such spinal dysraphism is known as Spinal Bifida Aperta.
But, a child may be having some abnormalty of the spine or spinal cord but without any externally visible lesion and overlying skin is intact, then it is known as Spina Bifida Occulta. This defect of the vertebrae of the spine of a child may not be visible at the time of birth and there may be no visible exposure of meninges or neural tissue. And, there may be congenital defect only in the lamina of the vertebrae of the spine without any involvement of underlying spinal cord. This is known as spine bifida occulta.
But, in spina bifida aperta there is a visible or open defect in the spine. There may be congenital defect in vertebral arches with cystic distension of meninges which is filled with CSF and is known as Meningocele. If, in this congenital defect of the vertebral arches there is a cystic dilatation of meninges and cerebrospinal fluid along with neural tissue or spinal cord ( Myelon) , then it is known as Myelomeningocele. If Myelomengocele contains fat tissue, then it is known as Lipomyelomengocele.
Myelmeningocele is one of the congenital open neral tube defect present at the birth on the back of the newborn.
It is a common type of congental defect of the spine and its incidence is about 1 in 1,000 live births. Better nutrition and folic acid suplementatiion during the antenatal care of the mother decrease its occurrence.
Ultrasound study during the early antenatal care detects any occurrence of myelomeningocele in a fetus during pregnancy.
A newborn child should be assessed for any sensory or motor deficit due to meningocele or myelomeningocele. There may be associated congenital lesions, like cardiac lesions. Myelomeningocele may be associated with congenital hydrocephalus. So, MRI of the spinal cord and brain is investigation for choice for assessing a case of meningcele. MRI may show whether a swelling on the back of a child is only flled with CSF or does it contain any neural tissue. It detects any intraspinal extension, associated intrasinal dermoid, lipoma, dermal sinus, spina bifida, spinal dysrahism like duplication of the cord, any bony spur between the duplicated cord, Chiari malfomation, syrinx, hydrocephalus, thickened filum terminale, etc. So, MRI helps in diagnosis, surgical planning and predicting prognostic outcome.
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It is presumed that it originates from roof of third ventricle from rudimentary paraphysis ( evagination in roof of 3rd ventricle during development). It comprises of fibrous epithelial lined cyst filled with either mucoid or gelatinous or dense hyloid substance.
It is commonly seen in between age groups 20 and 40 years. Colloid cyst is usually located in the anterior third ventricle, at the level of foramen of Monro. It may block the cerebrospinal fluid ( CSF) flow causing symmetrical dilatation of both lateral ventricles and obstructive hydrocephalus. It may present insidiously or suddenly. Headache is a common presentation. Intermittent and postural nature of attacks are other common type of presentation. Drop attack due to sudden weakness of lower limbs with headache is also commonly seen in patients with colloid cyst.
Other common symptoms of colloid cyst are diplopia, gait disturbance, vomoting, disturbed mentattion, blurred vision, incontinence, and vertigo or dizziness.
Occurrence of intermittent symptoms is chracteristic of colloid cyst.
CT scan or MRI with contrast is able to detect a rounded lesion in the anterior third ventricle. Most clinicall significant cysts are more than 1.5 centimeter is size. It may show minimal enhancement or no enhancement on CT or MRI. So, the enlargement of both lateral ventricles and sparing of third and fourt ventricle along with a small globular intraventricular lesion at the level of Foramen of Monor should establish the diagnosis of colloid cyst.
Image 1: CT scan of the brain showing axial view of brain with a hyperdense lesion in the anterior third ventricle with enlargemtnt of both lateral ventricles.
Image 1 source: radiopaedia.org
Neurosurgery is the definitive treatment. Lumbar Puncture ( LP) is contraindiacted due to risk of herniation. It should be treated surgically as there is risk of acute hydrocephalus and sudden neurological deterioration. Open transcranial surgery or endoscopic neurosurgery are the treatment options. Transcranial surgery may be transcallosal or transcortical. Endoscopic neurosurgical excisison is the mainstay of treatment.
Trancortical approach involves reaching the third ventricle through right sided middle frontal gyrus. It is feasible when ventricles are enlarged.
Transcallosal approach involves approach to the 3rd ventricle either via the foramen of Monro or by interfornicial approach. This approach can be used even if ventricles are not enlarged. There is risk of venous infarction or fornicial injury in this approach.Injury to the fornisx is associated with memory deficits or behaviour abnormalities.
Reference
1. Handbook of Neurosurgery by Mark S Greenberg 7th Deition, Thieme publication
2. https://en.wikipedia.org/wiki/Colloid_cyst
3.radiopaedia.org
Intraoperative photograph of a frontal lobe metastasis
A middle age female patient had presented with swelling in the head and history of seizures
MRI of brain the above mentioned patient showing scalp swelling and involvement of the cranium and intracranial cystic lesion with enhancement
Abrupt onset of Neurologic deficit is caused by inadequate perfusion of a region of brain.
Stroke is a common cause of neurological disability and death in elderly persons. Arterial thrombosis with occlusion of the cerebral arteries is the most common cause of stroke.
Most common modifiable risk factors are hypertension, cigarette smoking, obesity, increased blood lipids, heavy alcohol consumption, poor control of diabetes mellitus, stress, etc.
TIA ( Transient ischemic attack)
Episode of focal neurological dysfunction as a result of ischemia which resolves completely within 24 hours.
TIA are important determinant of stroke. around 30-50% of cases had previous transient ischemic attacks.
STROKE or CVA
About 85% of strokes are Ischemic and 15% Hemorrhagic.
HEMORRHAGIC STROKE
About 20% of strokes are hemorrhagic which is due to the spontaneous intracerebral hematoma (ICH). Hemorrhage most commonly results from rupture of the small penetrating arteries damaged by the degenerative effects of chronic hypertension.. In 1868, Charcot and Bouchard described the rupture of " microaneurysms" as the cause of ICH.
Common cause of spontaneous intracerbral hematoma in elderly is hypertensive bleed. As commonly seen in elderly that there is unnoticed hypertension in many elderly persons who are not aware about this condition or on irregular treatment of hypertension. Common site of hypertensive bleed is basal ganglia.
So, the commonest cause of spontaneous intracerebral hematoma in adults is a hypertensive arteriosclerotic basal ganglionic bleed. The median age of spontaneous intracerebral hemorrhage is about 56 years.The common clinical features are sudden onset severe headache, vomiting, slurring of speeh, depressed level of consciousness and weakness of face and limbs.
Commonest cause is long standing hypertension, irregular antihypertensive medication, history of smoking and alcohol intake, diabetes and lack of physical exercise.
CT scan of brain is the initial investigation.
Pain is a subjective sensation and the complaint of backache may vary from person to person. For example, for an athlete the lower backache after a prolong run or play may not be of a great concern but similar intensity of pain may be very debilitating for an old age person.
So, mild back pain which can be explained on the basis of obvious cause like prolong walk and play should not be investigated. Bed rest is the best medical advice for relieving backache.
However, severe persistent backache without any obvious precipitating factor may warrant a consultation with the medical specialist. Orthopedicians, Physiotherapists, Sport medicine physicians, Neurologists and Neurosurgeons commonly encounter patients with complaints of lower backache.
One of the common causes of lower backache is lumbar spondylosis, which is a progressive degenerative disease of the spine. With aging the water content in the intervertebral disc, ligament and bone is gradually decreased and it restricts the movement of the spine. The vertebral column or spine consists of cervical, thoracic, lumbar and sacral part.
A model image of the entire spine
diagram of spine
Cervical part is located on the back of the neck and is the most mobile part. Even without our notice we move our neck and cervical spine for about 80,000 times in a day. So, the cervical spine is very prone for the degenerative changes in older age group. Because thoracic spine ( chest ) is relatively less mobile due to rib cage it is less prone for spondylosis. Lumbar is the lower part and it bears the weight of the body. Due to excessive weight bearing this part of spine is prone for slip disc or listhesis.
What is Lumbar Spondylosis or Lumbar Degenerative disease?
Lumbar Spondylosis is medical term to describe a degenerative disease of the lower part of vertebral column. Our vertebral column or back bone or spine consists of four areas, namely: cervical, thoracic, lumbar and sacral region. Lower part of the spine, i.e, region below the rib cage , consists of lumar and sacral region.
There are 5 lumbar vertebrae with intervertebral discs between two adjacent vertebral bodies.So, progressive wear and tear of this region may cause different types of diseaes. Lumbar spondylosis may lead to lumbar canal stenosis, prolapse of intervertebral disc ( PIVD) and spondylolisthesis. Lumbar spondylosis is a common cause of lower backache.
Image showing parts of the vertebral bodies with disc.
Spinal cord is contained inside the spinal column which is formed anteriorly by the vertebral bodies and discs and bounded posteriorly by the lamina and spinous processes. In this image spinal nerve roots are seen emerging from the spinal cord ( source: http://www.medicinenet.com)
Our vertebral column consists of vertebrae and the intervertebral disc which are strengthened by many ligaments. The vertebral column contains vertebral canal within this bony canal a 45 centimetre long spinal cord is contained. The spinal nerves come out through the intervertebral foramina which are bordered by disc, pedicle, vertebral body and facet joints. So, any abnormality of disc, facet joint or vertebral joint leads to narrowing of the intervertebral neural foramina which compress the spinal nerves causing pain and later neurological deficit in the form of loss of sensation and muscle weakness.
Due to many risk factors, the disc may age prematurely and dries up ( disc dessication ), leading to narrowing of the disc space. This in turn decreases the flexibility of the spine and osteophyte formation in the vertebral bodies.
Nerve compression causes nerve edema, alteration in nutritional transport along the nerve, and local inflammation, therefore bed rest and anti-inflammatory medications may relieve the symptoms of the patient.
Lumbar canal stenosis is commonly a disease of the old age and commonly occurs due to hypertrophy of the ligamentum flavum. Patient complains of pain in lower back ( Claudication ) after walking for a long distance ( Claudication distance). Gradually , over a time , this distance decreases and person starts complaining of lower backache even after walking for 100 meters. Pain gets relieved on taking rest or in sitting position. There is no pain on bending. I this way pain due to Lumbar canal stenosis differs from the pain caused by PIVD. Pain due to disc prolapse usually increases on bending.
This problem is very commonly seen in old age persons. Initially they are able to walk for a long distance with very mild pain at the end of the walk. But, gradually with advancing age the intensity of pain increases and they start feeling pain even after walking for 200 meters or so. The moment they take rest and sit idle for a moment pain subsides. So, sitting is not painful. Some people find no difficulty in cycling but prolong walking induces lower backache.
Prolapse or buldge or protrusion of the intervertebral disc causes compression of the spinal nerve which causes lower backache. PIVD causes pain in the legs and sometimes bladder & bowel symptoms. Pain in the lower back is usually caused by muscle strain. It may also include sciatica (pain that radiates from the back to the buttock and down into the leg). Onset of pain may be immediate or occur some hours after an activity.
Image showing prolapse of the intervertebral disc posteriorly causing compression of the spinal nerve
Spondylolisthesis is another type of degeneration . The one vertebral body is slipped over the another vertebral body. It also leads to pain in lower back.
Spondylolisthesis is very common in lumbosacral region of the spine. L4 vertebra is displaced over the L5 vertebra ( L4/L5 spondylolisthesis) or L5 is displaced over the S1 verterbra ( L5/S1 spondylolisthesis). In old aged females osteoporosis is very common and the ligaments are also weakened , so the degenerative spondylolisthesis is very common in lumbosacral region.
MRI of the lumbosacral spine is the preferred investigation for diagnosis of cause of lower backache. It will show the alignment of the lumbar vertebrae and intervertebral disc, dural sac, lumbar canal diameter and nerve roots. So, even a minimal disc bulge is visible on MRI. MRI may exclude other causes of the lower backache line nerve sheath tumors, any other disease of this region like Potts spine ( tuberculosis), Multiple Myeloma, etc.
So, Plain X-ray and MRI of the spine are indispensable for the diagnosis of any disease of the spine. Sometimes, CT scan of the spine may be required.
Almost everyone experiences pain after exercise or after a prolong walk or on exertion. So, all cases of mild lower backache need not to be investigated.
Many treatment options are available. Physiotherapy measures like short wave diathermy, ultrasound therapy , traction and exercise therapy may help in chronic cases of lumbar spondylosis.
Image suggests correct standing posture standing posture without a hunch or lordosis
SPINAL TRAUMA
OSTEOPOROSIS
NERVE SHEATH TUMORS , infections of the vertebrae like spinal tuberculosis,
OSTEOARTHRITIS OF HIP JOINT
Should also be investigated.
X-ray of the lumbosacral spine ( anteroposterior and lateral view May provide an initial clue to the diagnosis.
For diagnosis of L1 vertebra collapse fracture, x- ray film of dorsolumbar spine is advised. This is very common fracture in people who fall from height.
MRI is the investigation of choice. It shows intervertebral disc, ligaments, vertebral bodies, integrity of the spinal cord.
Sources
Naturopathy & yogic management of Lumbar spondylosis . Booklet of Central council for research in yoga and naturopathy ( An autonomous organisation under Ministry of AYUSH , Govt of India)
Online resources
Epilepsy is a symptom which indicates that there is some problem in the physiology of brain.
So, if a person presents with seizures a detailed work up should be done. It begins with detailed history.
Broadly epilepsy is classified as:
GTCS: Generalized Tonic Clonic Seizures
CPS: Complex Partial sezures ( Usually due to temporal lobe involvement, may be associated with hallucinations or other complex symptoms)
Focal seizures
Focal seizures with secondary generalization
In infants and children of less than five year of age, if single episode of seizure occurs during high grade fever, it is most likely a Febrile convulsion for which long term antileptic medication is not required.
In majority of cases , the cause of the seizure is not known. When neuroradiology does not reveal any abnormality and other causes are ruled out after detailed work up , it is labeled as idiopathic epilepsy.
The common causes are infections, neoplasm , trauma, vascular lesions, development, etc. The infective granulomas ( Tubercular, Neurocysticercus, Toxoplasma) , Abscess, Meningitis, encephalitis are the common infective etiologies.
Head injury ( Extradural hematoma, Subdural hematoma, Diffuse axonal injury,etc) may present as Post traumatic Epilepsy, immediately following trauma or at later stage, known as Post Traumatic Late onset Epilepsy.
Brain tumors can present as seizures. All the tumors which involve or compress the cerebral hemispheres may present with seizures. Supratentorial Gliomas and Meningiomas have very high incidence of seizures. Although, Meningioma is an extra axial lesion as it arises from dura ( originates from Arachnoidal Cap Cells), it is associated with brain edema, and so presents with seizures.
Brain metastasis is also associated with brain edema and presents with seizures.
Arterivenous malformation in the cerebral hemispheres usullay presents with seizures in children. Subarachnoid hemorrhage due to rupture of the intracranial aneurysm may present with seizures.
Other brain abnormalities like Schizencephaly, arachnoid cyst, epidermoid may present with seizures.
Mesial Temporal Sclerosis usually presents with Complex partial seizures.
How to investigate a case of Epilepsy?
History, Physical Examination may reveal a clue to the diagnosis, like Tuberculosis, Primary cancers elsewhere in the body.
CT scan or MRI of the brain with contrast with MR spectroscopy
EEG
How to treat Epilepsy?
Sodium Valproate or Phenyton should be used as primary antiepileptic medication, because these two antiepiletics had been in clinical use since very long time, their complications are well known and very much predictable. In case of status epilepticus , their injectable forms are available so a loading dose can easily be delivered. Because of injectable, neurosurgeons can also use them during perioperative period.
Carbamazepine can aso be used as primary antiepileptic medication.
It is very easy to remember the doses of these three very commonly used drugs.
Phenyton, 5 mg/ kg body weight ( so, in an adult of about 50 kg weight give Phenytoin 100 mg TthreeTimes a Day)
Carbamazepine, 10mg/ kg body weight ( so, in an adult of about 50 kg weight give CBZ 200 mg TDS)
Valproate, 15 mg/ kg body weight ( so, in an adult of about 50 kg weight give Valproate 300 mg TDS).Valproate is a very common conditions, like Migraine, Mood disorders, so it may help in comorbid conditions,as well)
Seizures are usually controlled with single antiepileptic drug if prescribed in proper dosage. If it is not controlled increase the dose.
For Long term Antiepileptic medication :Another add on therapy should only be given when the maximum dose of the first drug is already in use and seizures are still uncontrolled.
The first drug to be added is usually Clobazam.
For example, If in an adult operated patient of glioma , seizures were controlled earlier with Tab Phenytoin 100mg TDS, if Seizures occur, add 100 mg : So it will be 100 mg 4 times a day, and seizures are not controlled , an addition of Tablet Clobazam 10 mg can control the epilepsy.
Now, another epileptic is vigorously marketed as primary antiepileptic and also as add-on therapy, i.e., Levetiracetam. This drug has also been use in clinical practice with good safety profile. Moreover, the availability of injectable forms are added advantage, for treating status epilepticus.
Many other antiepileptics are used depending upon condition of the patient. Topiramate is used in cases of migraine and seizure patients with obesity.