Causes and Manifestation of Neurosurgical Illness
The nervous system, brain, spinal cord and nerves do not tolerate compression. In fact, the most common reason for surgery on the nervous system is to remove the external or internal pressure. The compression can be caused by many reasons such as tumors, disc herniation or collection of blood. Magnetic reasonance imaging (MRI), computerized tomography scanner (CTSCAN) and x-rays are the diagnostic imaging to visualize the nervous system and the problems. When pressure exerts on the nervous system acutely (all of a sudden) it is not tolerated as much as if it is gradual. For that reason, sudden disc herniation (when a piece of disc get extruded and pushes on the nerve) it will produce sudden severe sciatica where pain like toothache travels all the way from the back to the leg. Also, when sudden brain hemorrhage can squeeze the brain inside the skull and the patient will drift into coma from being awake after a brief episode of headache. Removing the focal disc material will relieve the sciatica and removing the hemorrhage collection will release the pressure from the brain.
If however, the compression on the nervous system occurs gradually (chronic), the nervous system will adapt and symptoms and signs early on will be minimal. For instance, patient was hit on the head and a small hemorrhage occurred and gradually increased in size, the patient will have headache for some time, then gradually drift into confusion and he or she becomes sleepy and sleepier when it continues to reach large size.
Most common manifestations for neurosurgical lesions are headache and pain. The nervous system is tedious and difficult to diagnose because it does not complain. Paying attention to details with diary of the daily complaints is helpful when you share with your physician. Detailed history and examination is needed and early referral to specialist is recommended. Time is “brain” is common rule and when the problem gets diagnosed early on, more options are usually available and success of intervention is high. Early on symptoms can be confusing especially of brain problems because they are non specific and can match common daily complaints.
For instance, headache occurs in more than 90% of the population and in some are daily complaints. Early on, patient may complain of general non specific symptoms, such as “migraines like headaches” or “lightheadedness like flu”. These “general” complaints get overlooked by the patient. It continues to progress but over time so becomes unnoticed until it reaches serious stage. The patient is the only person that can help him or herself to get early assistance. Patient awareness of the nervous system illness therefore becomes essential for early diagnosis. The current book may assist the patient and provide a “map” from other patients that may guide other patients.
So how can we know which one is dangerous- more than another? Usually the patient will know that the ominous headache is sudden, severe and different from all other headaches and can be associated with new complaints such as lightheadedness, sleepy, drowsy, blurry or double vision, word finding difficulty or slurred speech, confusion, ringing in the ears (tinnitus), feel like spinning (vertigo), numbness in the face, drooling of the face, starring look, difficulty swallowing, choking sensation, numbness in one side, heaviness in the arm or the leg, walking difficulty or gait disturbance, fever, neck rigidity, stiffness of the arms and legs, involuntary movements and seizures.
More specific finding can be searched for like reaction of pupils to light, dancing eyes (nystagmus), and abnormal posturing. For the level of the coma, there is a scale that can evaluate the depth of the coma and standardized across the world. Glasgow coma scale is the most common and used for patient exposed to head trauma and suffered from traumatic brain injury (TBI). If there is no response, the score is 3 and if the patient is fully awake and normal is 15 and if severe < 8. It includes eyes opening spontaneously and pain, speech output and response of the arms and legs spontaneously and to pain. When the coma is deep, pinching the arms or legs cause “abnormal posture” response, flex (decorticate” or extend (decerebrate). Patient will not answer questions or “follow command”. As the pressure increase before the coma, the patient appear confused and “disoriented where he does not know where “place”, when “time “and what “person”. It is not uncommon that deterioration in the mental status occurs so rapid that one minute looks awake and next minute is in coma. For that reason, head injury is taken seriously and be admitted for “neuro-observation”.
The brain is a quiet organ and when it reaches a certain stage, “critical level” drifts into coma and death occurs in no time. Be on alert and be observant is the key for salvage. Brain “herniation” is a terminal event which occurs when the pressure on the brain gets ignored and the brain gets squeezed more and more inside the skull where there is no room except to squeeze the essential part of the brain through rigid membranes and openings such as “tentorial incisura” for tentorial herniation, subfalcine herniation and tonsillar herniation. Once herniation occurs if intervention by surgical release of pressure do not take place within minutes to maximum of two hours, permanent destruction of the brain occurs and “brain death”.
It is important to realize before declaring a person “brain dead” that the person is not hypothermic (temperature < 95F), or has sedative drugs or neuromuscular blockade on board. It is ideal to be aggressive in the treatment of patient for the first 24 hours and in children to 72hours and continue documentation of “brain dead” examination regardless of the maximum treatment received.
Things change later and for that reason, doing the maximum in the beginning before it is too late is essential. The “brain dead” examination includes no response what so ever to pain, no cough when tube placed inside the throat and trachea, no gag when tube placed inside the mouth , no spontaneous respiration, no corneal reflex when stimulation to the cornea, no reaction to the light applied at the pupils, no eye movements when the head is moved and eyes open, no movement of the eys when iced water applied to the ears. Eyes are not open to pain, arms and legs are not moving to deep pinching pain. When the respiratory machine stops temporarily, despite good oxygenation, patient will not initiate spontaneous respiration even at arterial carbon dioxide level >60mmHg “positive sleep apnea” test. Electroencephalogram will show flat line or e “isolectric EEG”, blood flow study will show no blood flow to the brain and transcranial Doppler will show biphasic flow.
When pressure occurs on the nerve, pain and tingling and numbness sensation travels through the nerve to the area where the nerves supply. A “dermatome” for sensation and “myotome” for motor. In the neuro-anatomy, each nerve has special distribution of the human body and from following the course of the dermatome and myotome, we can know which nerve is affected.
This traveling aching pain and numbness is called “radiculopathy” and it is known as “sciatica” if it affects the legs. MRI, CTscan and X-rays are the imaging ordered to look for the problem affecting the nerve root in the spine. Early one, patient may complain of general non specific such as “arthritis like feeling” in the arm or the leg, numbness in the hand or joint pain. These “general” complaints get overlooked by the patient. It continues to progress but over time so becomes unnoticed until it reaches serious stage. The patient is the only person that can help him or her get early assistance. Patient awareness of the nervous system illness therefore becomes essential for early diagnosis. The current book may assist the patient and provide a “map” from other patients that may guide other patients.
If however, the compression on the nervous system occurs gradually (chronic), the nervous system will adapt and symptoms and signs early on will be minimal. For instance, patient was hit on the head and a small hemorrhage occurred and gradually increased in size, the patient will have headache for some time, then gradually drift into confusion and he or she becomes sleepy and sleepier when it continues to reach large size.
Most common manifestations for neurosurgical lesions are headache and pain. The nervous system is tedious and difficult to diagnose because it does not complain. Paying attention to details with diary of the daily complaints is helpful when you share with your physician. Detailed history and examination is needed and early referral to specialist is recommended. Time is “brain” is common rule and when the problem gets diagnosed early on, more options are usually available and success of intervention is high. Early on symptoms can be confusing especially of brain problems because they are non specific and can match common daily complaints.
For instance, headache occurs in more than 90% of the population and in some are daily complaints. Early on, patient may complain of general non specific symptoms, such as “migraines like headaches” or “lightheadedness like flu”. These “general” complaints get overlooked by the patient. It continues to progress but over time so becomes unnoticed until it reaches serious stage. The patient is the only person that can help him or herself to get early assistance. Patient awareness of the nervous system illness therefore becomes essential for early diagnosis. The current book may assist the patient and provide a “map” from other patients that may guide other patients.
So how can we know which one is dangerous- more than another? Usually the patient will know that the ominous headache is sudden, severe and different from all other headaches and can be associated with new complaints such as lightheadedness, sleepy, drowsy, blurry or double vision, word finding difficulty or slurred speech, confusion, ringing in the ears (tinnitus), feel like spinning (vertigo), numbness in the face, drooling of the face, starring look, difficulty swallowing, choking sensation, numbness in one side, heaviness in the arm or the leg, walking difficulty or gait disturbance, fever, neck rigidity, stiffness of the arms and legs, involuntary movements and seizures.
More specific finding can be searched for like reaction of pupils to light, dancing eyes (nystagmus), and abnormal posturing. For the level of the coma, there is a scale that can evaluate the depth of the coma and standardized across the world. Glasgow coma scale is the most common and used for patient exposed to head trauma and suffered from traumatic brain injury (TBI). If there is no response, the score is 3 and if the patient is fully awake and normal is 15 and if severe < 8. It includes eyes opening spontaneously and pain, speech output and response of the arms and legs spontaneously and to pain. When the coma is deep, pinching the arms or legs cause “abnormal posture” response, flex (decorticate” or extend (decerebrate). Patient will not answer questions or “follow command”. As the pressure increase before the coma, the patient appear confused and “disoriented where he does not know where “place”, when “time “and what “person”. It is not uncommon that deterioration in the mental status occurs so rapid that one minute looks awake and next minute is in coma. For that reason, head injury is taken seriously and be admitted for “neuro-observation”.
The brain is a quiet organ and when it reaches a certain stage, “critical level” drifts into coma and death occurs in no time. Be on alert and be observant is the key for salvage. Brain “herniation” is a terminal event which occurs when the pressure on the brain gets ignored and the brain gets squeezed more and more inside the skull where there is no room except to squeeze the essential part of the brain through rigid membranes and openings such as “tentorial incisura” for tentorial herniation, subfalcine herniation and tonsillar herniation. Once herniation occurs if intervention by surgical release of pressure do not take place within minutes to maximum of two hours, permanent destruction of the brain occurs and “brain death”.
It is important to realize before declaring a person “brain dead” that the person is not hypothermic (temperature < 95F), or has sedative drugs or neuromuscular blockade on board. It is ideal to be aggressive in the treatment of patient for the first 24 hours and in children to 72hours and continue documentation of “brain dead” examination regardless of the maximum treatment received.
Things change later and for that reason, doing the maximum in the beginning before it is too late is essential. The “brain dead” examination includes no response what so ever to pain, no cough when tube placed inside the throat and trachea, no gag when tube placed inside the mouth , no spontaneous respiration, no corneal reflex when stimulation to the cornea, no reaction to the light applied at the pupils, no eye movements when the head is moved and eyes open, no movement of the eys when iced water applied to the ears. Eyes are not open to pain, arms and legs are not moving to deep pinching pain. When the respiratory machine stops temporarily, despite good oxygenation, patient will not initiate spontaneous respiration even at arterial carbon dioxide level >60mmHg “positive sleep apnea” test. Electroencephalogram will show flat line or e “isolectric EEG”, blood flow study will show no blood flow to the brain and transcranial Doppler will show biphasic flow.
When pressure occurs on the nerve, pain and tingling and numbness sensation travels through the nerve to the area where the nerves supply. A “dermatome” for sensation and “myotome” for motor. In the neuro-anatomy, each nerve has special distribution of the human body and from following the course of the dermatome and myotome, we can know which nerve is affected.
This traveling aching pain and numbness is called “radiculopathy” and it is known as “sciatica” if it affects the legs. MRI, CTscan and X-rays are the imaging ordered to look for the problem affecting the nerve root in the spine. Early one, patient may complain of general non specific such as “arthritis like feeling” in the arm or the leg, numbness in the hand or joint pain. These “general” complaints get overlooked by the patient. It continues to progress but over time so becomes unnoticed until it reaches serious stage. The patient is the only person that can help him or her get early assistance. Patient awareness of the nervous system illness therefore becomes essential for early diagnosis. The current book may assist the patient and provide a “map” from other patients that may guide other patients.