Neuro & Spine 00 / 24 , all cards and bookmarks
Perfusion pressure: the number everything turns on 01 / 24 Cerebral perfusion pressure (CPP) is mean arterial pressure (MAP) minus the higher of intracranial pressure (ICP) or central venous pressure (CVP): hold 60-70, treat ICP over 20-22.
Perfusion pressure target Intracranial pressure thresholds When to monitor intracranial pressure (Brain Trauma Foundation) Report a problem with card 1: Perfusion pressure: the number everything turns on
Lowering intracranial pressure 02 / 24 Raised ICP: head up, sedate, osmotherapy; brief hyperventilation only if refractory; steroids only for tumour oedema.
Tight brain at craniotomy Raised ICP after head injury: first line, then rescue Hyperventilation limits Osmotherapy and steroids Report a problem with card 2: Lowering intracranial pressure
Protect the injured brain 03 / 24 After brain injury prevent the second hit: hypoxia, hypotension, hypercarbia, fever, hyperglycaemia, hypotonic fluid, steroids.
Threat after brain injury What to do Targets after severe head injury → , open its explanation PaO2 >60, PaCO2 35–40, MAP >80, temperature ≤37 Glucose after head injury → , open its explanation Keep below 180; no tight control Glasgow Coma Scale (GCS) 8 or less, or rising PaCO2 → , open its explanation Intubate and ventilate; then normocapnia Resuscitation fluid → , open its explanation Normal saline; no hypotonic fluid, no albumin Corticosteroids (methylprednisolone) → , open its explanation Raise mortality about 20% in a large trial; contraindicated
Report a problem with card 3: Protect the injured brain
Chronic disease before surgery 04 / 24 Continue the patient's drugs, switch off their devices, screen and protect what the disease threatens.
Disease and concern Decision Parkinson disease: levodopa before surgery → , open its explanation Continue up to anaesthetic induction Parkinson disease: levodopa during long surgery → , open its explanation Redose on schedule by nasogastric tube, never intravenously Parkinson disease: gut unusable → , open its explanation Bridge with subcutaneous apomorphine Parkinson disease: deep brain stimulator → , open its explanation Off before induction (advanced disease: after intubation); bipolar Parkinson disease: deep brain stimulator after surgery → , open its explanation Restart and check it in recovery Multiple sclerosis: body temperature → , open its explanation Even 1 °C rise worsens symptoms; keep normothermic Becker muscular dystrophy: life expectancy → , open its explanation Shortened, but varies widely Becker muscular dystrophy: asymptomatic heart → , open its explanation Screen every 5 years Rheumatoid arthritis: cervical spine → , open its explanation Atlantoaxial subluxation; look for it before surgery Rheumatoid arthritis: laryngoscopy → , open its explanation Minimise head and neck movement
Report a problem with card 4: Chronic disease before surgery
Relaxants in neuromuscular disease 06 / 24 Denervation, myotonia and bulbar disease bar succinylcholine; myasthenia is sensitive, anticonvulsant users resistant, to non-depolarisers.
Technique in neuromuscular disease 07 / 24 In neuromuscular disease favour neuraxial amide local anaesthetic; if general, intubate.
Disease and operation Technique Prior Guillain–Barré, limb surgery → , open its explanation Neuraxial acceptable after documenting deficits; never succinylcholine Myotonic dystrophy, lower‑limb surgery → , open its explanation Spinal or lumbar epidural; peripheral block ultrasound‑guided only Myotonic dystrophy, if general anaesthesia → , open its explanation Rapid sequence intubation with tracheal tube; no laryngeal mask Bulbar amyotrophic lateral sclerosis (ALS), lower‑body surgery → , open its explanation Spinal with plain bupivacaine; no intrathecal opioid, no succinylcholine Myasthenia gravis, labour epidural → , open its explanation Amide local anaesthetic; avoid esters
Report a problem with card 7: Technique in neuromuscular disease
Position and reference points 08 / 24 Zero pressures at the brain, keep the head above the heart, never force the neck.
Setting Rule Sitting position, arterial line transducer → , open its explanation Zero at external auditory meatus, not the heart External ventricular drain (EVD) zero point, lateral position (journals) → , open its explanation Glabella or nose tip; supine, external auditory meatus Sitting position, extreme neck flexion → , open its explanation Midcervical quadriplegia Chin‑to‑sternum gap, sitting position → , open its explanation Keep at least two fingerbreadths Prone spine surgery, head and eyes → , open its explanation Head at or above heart; no eye pressure Lengthy or high‑blood‑loss prone spine surgery → , open its explanation Stage the operation
Report a problem with card 8: Position and reference points
The craniotomy, and procedures with their own rule 09 / 24 Craniotomy: test the function at risk, wake smoothly, treat pain; carotid clamping: keep pressure up.
Craniotomy, by phase Shunt and pituitary surgery Carotid endarterectomy Electroconvulsive therapy (ECT) Point Rule Absolute contraindications → , open its explanation Intracranial mass, head injury, aneurysm; recent myocardial infarction (MI) or stroke Glaucoma, retinal detachment, severe osteoporosis → , open its explanation Relative, not absolute, contraindications Hypnotic dose → , open its explanation Small, brief, just unaware; not deep or prolonged
Report a problem with card 9: The craniotomy, and procedures with their own rule
Vascular lesions: pressure by phase 10 / 24 Secure the aneurysm early, nimodipine for all; pressure up for clipping and vasospasm, never surging.
Scores and grades 12 / 24 GCS sums eyes, verbal, motor; American Spinal Injury Association (ASIA) turns on S4–5 sparing; Leventhal 10 points predicts ventilation.
Glasgow Coma Scale (Stoelting): add the best response in each, 3–15 GCS worked examples (eyes + verbal + motor) Patient Total Eyes to command, incomprehensible sounds, localises pain → , open its explanation 3 + 2 + 5 = GCS 10 No eye opening, moans, abnormal flexion to pain → , open its explanation 1 + 2 + 3 = GCS 6 No eye opening, incomprehensible sounds, withdraws from pain → , open its explanation 1 + 2 + 4 = GCS 7: withdrawal, not abnormal flexion
ASIA impairment scale (Barash, Miller): decided by S4–5 sparing Hunt and Hess grades (Stoelting): subarachnoid haemorrhage Grade Clinical state; mortality Grade 0 → , open its explanation Unruptured aneurysm; mortality 0–2% Grade 1 → , open its explanation Minimal headache, no deficit; mortality 2–5% Grade 2 → , open its explanation Moderate to severe headache, cranial nerve palsy only; mortality 5–10% Grade 3 → , open its explanation Drowsy, confused or mild focal motor deficit; mortality 5–10% Grade 4 → , open its explanation Stupor, marked hemiparesis or early decerebration; mortality 25–30% Grade 5 → , open its explanation Deep coma, decerebrate rigidity; mortality 40–50% Miller's version → , open its explanation Lists survival, not mortality: grade 4 survival 20%
Leventhal score: ventilation after thymectomy in myasthenia Report a problem with card 12: Scores and grades
Consciousness and brain death 13 / 24 Name the state from eye opening and awareness; brain death needs brainstem silence under set conditions.
Coma, vegetative state and locked-in syndrome The EEG in coma Brain-death tests Before brain-death testing (American Academy of Neurology) Report a problem with card 13: Consciousness and brain death
Localise the lesion 14 / 24 Root, nerve, cord and brainstem each have a signature: reflex, muscle, sensory pattern, breathing, crossed signs.
Signs Lesion Weak shoulder abduction, absent biceps reflex → , open its explanation C5 root Weak biceps and wrist extensors, lost brachioradialis jerk → , open its explanation C6 root Triceps weakness, middle‑finger radicular pain → , open its explanation C7 root, compressed by C6‑7 disc Thumb pain with triceps weakness → , open its explanation C6‑7 disc: the motor sign outranks the pain site (C5‑6 defensible) Lost knee jerk; numb medial shin, malleolus → , open its explanation L4 root; the leg decides, not the thigh Thumb, index, middle finger numbness, worse at night → , open its explanation Median nerve: carpal tunnel entrapment at wrist Post‑trauma: one leg weak, other loses pain, temperature → , open its explanation Brown‑Séquard syndrome: cord hemisection Ipsilateral facial signs, contralateral limb weakness → , open its explanation Brainstem: basilar or vertebral artery, not hemispheric vessel Acute bladder and bowel loss, both legs weak → , open its explanation Cauda equina syndrome until proven otherwise Post‑posterior fossa surgery: breath‑holding at full inspiration → , open its explanation Pons injury; chaotic irregular breathing means medulla
Report a problem with card 14: Localise the lesion
Name the neuromuscular disease 15 / 24 Ascending after infection is Guillain–Barré; fatigable is myasthenia; better with use is Lambert–Eaton.
Presentation Disease Ascending weakness after infection, even respiratory failure → , open its explanation Guillain–Barré syndrome Guillain–Barré at onset → , open its explanation Limb weakness with numbness, lost reflexes; not heart or kidney Proximal arm weakness improving with activity → , open its explanation Lambert–Eaton myasthenic syndrome, not myasthenia gravis Lung mass, dry mouth, constipation, proximal weakness → , open its explanation Lambert–Eaton myasthenic syndrome Weakness worsening with sustained contraction → , open its explanation Myasthenia gravis Proximal weakness, muscle pain, lung cancer → , open its explanation Lambert–Eaton myasthenic syndrome Guillain–Barré in late pregnancy or postpartum → , open its explanation No relief from delivery; postpartum relapse reported
Report a problem with card 15: Name the neuromuscular disease
The body after a brain insult 16 / 24 Read sodium with volume and urine; the heart and glucose change from the catecholamine surge.
Finding Diagnosis Hyponatraemia, low CVP, high haematocrit after subarachnoid haemorrhage (SAH) → , open its explanation Cerebral salt wasting; replace volume with normal saline Hyponatraemia after SAH, with SIADH (inappropriate antidiuretic hormone secretion syndrome) suspected → , open its explanation Still normal saline; never fluid restriction Low sodium, sodium‑rich urine, normal or high CVP → , open its explanation SIADH Low sodium, sodium‑rich urine, low CVP → , open its explanation Cerebral salt wasting: volume status decides Large volumes of dilute urine after pituitary surgery → , open its explanation Central diabetes insipidus; expect hypernatraemia, not hyponatraemia Marked new hyperglycaemia after aneurysm bleed → , open its explanation Stress response: insulin resistance, not organ failure Prolonged QT after subarachnoid haemorrhage → , open its explanation Neurogenic: catecholamine surge; recedes within 72 hours
Report a problem with card 16: The body after a brain insult
Air embolism 18 / 24 Falling end-tidal CO2 head-up is air: flood the field, then support; precordial Doppler detects it non-invasively.
Venous air embolism: management Detecting venous air embolism Report a problem with card 18: Air embolism
Spinal cord injury 19 / 24 Cord injury: decompress within 24 hours; neurogenic shock early, autonomic dysreflexia later, remove its trigger first.
Timing of surgery Shock after cord injury Autonomic dysreflexia, later Report a problem with card 19: Spinal cord injury
Acute weakness 20 / 24 Failing ventilation comes first; edrophonium separates myasthenic from cholinergic crisis; Guillain–Barré gets intravenous immunoglobulin (IVIG), never steroids.
Finding Action Hypercapnia and tiring in myasthenia → , open its explanation Intubate and ventilate; atropine treats only muscarinic signs Myasthenia weaker after edrophonium test → , open its explanation Diagnose cholinergic crisis, not myasthenic crisis Weak on anticholinesterase, before edrophonium → , open its explanation Either crisis: signs and edrophonium response decide; airway first Weakness on anticholinesterase, edrophonium worsens → , open its explanation Cholinergic crisis: stop the drug, atropine, support ventilation Weakness on anticholinesterase, edrophonium improves → , open its explanation Myasthenic crisis: give more anticholinesterase Guillain–Barré syndrome leg weakness after vaccination → , open its explanation IVIG or plasma exchange within two weeks; never steroids
Report a problem with card 20: Acute weakness
Complications after neurosurgery 21 / 24 A new deficit after surgery is ischaemia or compression until imaging says otherwise.
What sets cerebral blood flow 22 / 24 Carbon dioxide and metabolism set flow, autoregulation holds it; anaesthetics lower both, volatiles uncouple, ketamine raises.
Anatomy and physiology worth holding 23 / 24 Plain facts: outflow levels, carbon dioxide raises eye pressure, stroke risk and its salvageable penumbra.
Traps Check these before you finish 1 card · about 1 min 24 Traps
Traps 24 / 24 The tempting choice is the familiar one; the books often name another.
Clinical situation What the books say, not the familiar choice Drug raising mortality after head injury → , open its explanation Corticosteroids (methylprednisolone), not propofol IV agent lowering cerebral blood flow most → , open its explanation Thiopental or propofol equally; not midazolam Phenytoin for a bulging brain → , open its explanation Does not relax the brain; furosemide helps mannitol Leading cause of death after SAH admission → , open its explanation Rebleeding, not vasospasm; secure aneurysm within 24 hours Surgery months after Guillain–Barré → , open its explanation Neuraxial acceptable after documenting deficits; never succinylcholine Cerebral palsy on anticonvulsants: relaxant response → , open its explanation Resistance to non‑depolarising blockers Long QT after SAH with low calcium → , open its explanation Neurogenic catecholamine surge; not the hypocalcaemia CPP when CVP exceeds ICP → , open its explanation MAP minus CVP, the larger; not MAP minus ICP Surgeon asks for deeper hyperventilation, brain injury → , open its explanation Osmotherapy first; brief hyperventilation only for refractory ICP Single agent needing an intact blood–brain barrier → , open its explanation Mannitol (classic); Miller: hypertonic saline also barrier‑dependent Painless one‑eye visual loss after prone spine surgery → , open its explanation Posterior ischaemic optic neuropathy, not retinal artery occlusion Hypertension and bradycardia right after coil deployment → , open its explanation Hyperventilate on 100% oxygen (fastest); protamine; mannitol slower Duration of hyperventilation's effect on ICP → , open its explanation About 6 h (Barash, Stoelting); 8–12 h (Miller); not minutes
Report a problem with card 24: Traps
Quiz Check yourself 23 practice scenarios · one to a screen Quiz Check yourself 23 practice scenarios Answers checked against the books and guidelines.
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Sheet 04 · Neuro & Spine 24 / 24
That is Neuro & Spine, all 24 cards.
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Part 1 · Decisions What to do
04 · Chronic disease before surgery Continue the patient's drugs, switch off their devices, screen and protect what the disease threatens. 05 · Which test Image the part the signs point to, at once when a new deficit follows surgery. 06 · Relaxants in neuromuscular disease Denervation, myotonia and bulbar disease bar succinylcholine; myasthenia is sensitive, anticonvulsant users resistant, to non-depolarisers. 07 · Technique in neuromuscular disease In neuromuscular disease favour neuraxial amide local anaesthetic; if general, intubate. 08 · Position and reference points Zero pressures at the brain, keep the head above the heart, never force the neck. 09 · The craniotomy, and procedures with their own rule Craniotomy: test the function at risk, wake smoothly, treat pain; carotid clamping: keep pressure up. 10 · Vascular lesions: pressure by phase Secure the aneurysm early, nimodipine for all; pressure up for clipping and vasospasm, never surging. Part 2 · Recognition What it is
11 · Neuromonitoring: evoked potentials, jugular bulb, EEG Each monitor warns at a threshold: amplitude down 50%, latency up 10%, jugular saturation under 50%. 12 · Scores and grades GCS sums eyes, verbal, motor; American Spinal Injury Association (ASIA) turns on S4–5 sparing; Leventhal 10 points predicts ventilation. 13 · Consciousness and brain death Name the state from eye opening and awareness; brain death needs brainstem silence under set conditions. 14 · Localise the lesion Root, nerve, cord and brainstem each have a signature: reflex, muscle, sensory pattern, breathing, crossed signs. 15 · Name the neuromuscular disease Ascending after infection is Guillain–Barré; fatigable is myasthenia; better with use is Lambert–Eaton. 16 · The body after a brain insult Read sodium with volume and urine; the heart and glucose change from the catecholamine surge.