Handbook of Neurosurgery 8th Edition-4

Han d book of Neu rosu rger y Mark S. Green berg, MD Associate Professor Depart m en t of Neurosurger y an d Brain Repair Un iversit y of South Florida Tam pa, Florida Eigh th Edition 179 illustrations Th iem e New York • Stuttgart • Delh i • Rio de Jan eiro

Executive Editor: Tim othy Hiscock First edition , 1990 Man aging Editor: Sarah E. Lan dis Secon d edition , 1991 Director, Editorial Services: Mar y Jo Casey Th ird edition , 1994 Editorial Assistan t: Naam ah Schw artz Fourt h edition , 1997 Production Editor: Torsten Scheih agen Fift h edition , 2001 Internation al Production Director: An dreas Sch abert Sixth edition , 2006 Vice President, Editorial and E-Product Seven th edition , 2010 Developm ent: Vera Spilln er Im p ort an t n ote: Medicin e is an ever-ch angin g sci- Director, Clinical Solutions: Mich ael Wach inger en ce un dergoing con tin ual developm en t. Research Internation al Marketing Director: Fion a Hen derson and clinical experience are continually expan din g Internation al Sales Director: Louisa Turrell our kn ow ledge, in particular our kn ow ledge of Director of Sales, North Am erica: Mike Rosem an proper t reatm en t an d drug th erapy. In sofar as th is Sen ior Vice President and Chief Operating O cer: book m ent ions any dosage or application, readers m ay rest assured that the authors, editors, and pub- Sarah Van derbilt lishers have m ade every e ort to ensure th at such President: Brian D. Scanlan referen ces are in accordan ce w ith t h e st ate of Prin ter: Tran scontin en tal Printing kn owledge at the tim e of production of the book. Cover Illustrator: Jen nifer Pryll Neverth eless, th is does n ot in volve, im ply, or Libra r y of Congress Ca ta loging-in-Publica tion Da ta express any guarantee or responsibilit y on the part Nam es: Green berg, Mark S., M.D., auth or. of the publishers in respect to any dosage in struc- Title: Handbook of neurosurgery / Mark S. Greenberg. tion s an d form s of application s stated in th e book. Description : Eigh th edition . | New York : Th iem e, Ever y u ser is requ ested t o exam in e carefu lly th e [2016] | Preceded by Han dbook of n eurosurger y / m an ufacturers’ leaflets accom panyin g each drug editor, Mark S. Green berg. 7th ed. 2010. | In cludes and to check, if necessary in consultation w ith a bibliograph ical referen ces an d in dex. physician or specialist, w h eth er th e dosage sch ed- Iden tifiers: LCCN 2015051094| ISBN ules m entioned therein or th e contraindications 9781626232419 | ISBN 9781626232426 (e-book) stated by th e m an ufacturers di er from th e state- Subjects: | MESH: Ner vous System Diseases–sur- m en ts m ade in th e presen t book. Such exam ination gery | Neurosurgical Procedures | Handbooks is particularly im portant w ith drugs that are either Classification : LCC RD593 | NLM W L 39 | DDC rarely used or h ave been n ew ly released on th e 617.4/8–dc23 LC record available at h tt p://lccn .loc. m arket. Ever y dosage sch edule or every form of gov/2015051094 application used is en tirely at th e user’s ow n risk an d respon sibilit y. Th e auth ors an d publish ers © 2016 Th iem e Medical Publish ers, In c. request every user to report to the publishers any Th iem e Publish ers New York discrepan cies or in accuracies n ot iced. If errors in 333 Seven th Aven ue, New York, NY 10001 USA th is w ork are foun d after publicat ion , errata w ill be +1 800 782 3488 custom erser vive@th iem e.com posted at w w w.th iem e.com on th e product descrip - w w w.th iem e.com tion page. Th iem e Publish ers Stuttgart Som e of th e product n am es, patents, an d registered Rü digerstrasse 14, 70469 St uttgart, Germ an y design s referred to in th is book are in fact regis- + 49 [0]711 8931 421 tered t radem arks or proprietary n am es even custom erser vice@th iem e.com th ough specific referen ce to th is fact is n ot alw ays m ade in th e text. Th erefore, th e appearan ce of a Th iem e Publish ers Delh i n am e w ith out design ation as proprietary is n ot to A-12, Secon d Floor, Sector-2, Noida-201301 be construed as a represen tation by th e publish er Uttar Pradesh , In dia th at it is in the public dom ain . +91 120 45 566 00 custom erser vice@th iem e.in Th is book, in cluding all parts th ereof, is legally pro- tected by copyright . An y use, exploitation or com - Th iem e Publish ers Rio de Jan eiro, m ercialization outside th e n arrow lim its set by Th iem e Publicações Ltda. copyrigh t legislation , w ith out th e publish er’s con - Edifício Rodolph o de Paoli, 25º an dar sen t, is illegal an d liable to prosecution . Th is applies Av. Nilo Peçan h a, 50 – Sala 2508 in particular to photostat reproduct ion, copying, Rio de Jan eiro 20020-906, Brasil m im eographing or duplication of any kin d, t rans- +55 21 3172 2297 latin g, preparat ion of m icrofilm s, an d electron ic data processing and storage. Typeset tin g: DiTech Process Solution s Prin ted in Can ada ISBN 978-1-62623-241-9 123456 Also available as an e-book: eISBN 978-1-62623-242-6

5 Dedicat ion The eighth edit ion of the Han dbook of Neurosurger y is dedica ted to my wonderful w ife, Debbie. She inspires me to be the best I ca n be. This book is a lso dedica ted to “Duke” (August Henr y Wagner III), beloved uncle of contr ibutor Ja yson Sa ck, who su ered a fa ta l a neur ysma l suba ra chnoid hemorrha ge a s this book wa s going to press. His selfless life wa s a n inspira t ion to Ja yson a nd his fa mily. He w ill be missed a nd never forgotten.

6 Cont ribut ors Naom i A. Abel, MD Clayt on Bau er, MD, Ph D Assistan t Professor Residen t physician Departm en t of Neurosurger y an d Brain Repair Departm en t of Neurosurger y an d Brain Repair Un iversit y of South Florida Morsan i College of Un iversit y of South Florida Morsan i College of Medicin e Me d icin e Tam pa, Florida Tam pa, Florida Fa ilure of ca r pa l tunnel a nd ulna r ner ve surger y Sta tus epilepticus Electrodia gnost ics (EDX) Josh u a M. Beckm an , MD Siviero Agazzi, MD, MBA Residen t physician Associate Professor Departm en t of Neurosurger y an d Brain Repair Departm en t of Neurosurger y an d Brain Repair Un iversit y of South Florida Morsan i College of Un iversit y of South Florida Morsan i College of Me d icin e Medicin e Tam pa, Florida Tam pa, Florida Concussion (mTBI) Vest ibula r schwa nnoma s Ad arsh Bh im raj, MD Am ir Ah m ad ian , MD Atten ding physician Atten ding physician Sect ion Head, Neuroin fect ion s Neurosurgery of West Florida Clevelan d Clin ic Hudson , Florida Clevelan d, Oh io Adult spina l deformit y EVD-rela ted infections Ca vernous ma lforma tions* Elias Dak w ar, MD Norber t o An d alu z, MD Assistan t Professor Associate Professor Departm en t of Neurosurger y an d Brain Repair Departm en t of Neurosurger y Un iversit y of South Florida Morsan i College of Un iversit y of Cin cin n ati College of Medicin e Me d icin e Cin cin n at i VA Medical Cen ter Tam pa, Florida Cin cin n at i, Oh io CSF Fist ula s Ca rotid stenosis a nd enda rterectomy* Emergency ca rotid enda r terectomy* An gela Dow n es, MD Tota lly occluded ca rotid a rter y* Fellow, Neurocritical Care Departm en t of Neurosurger y Ram sey Ash ou r, MD Un iversit y of Colorado Com plex cran ial fellow Denver, Colorado Departm en t of Neurosurger y an d Brain Repair Stereota ctic ra diosurger y Un iversit y of South Florida Morsan i College of Sponta neous subdura l hema toma * Medicin e Tam pa, Florida Melissa Giarrat an o, Ph ar m D, BCPS Dura l a rter iovenous fistula e Clin ical Pharm acist – Neuroscien ces Tam pa Gen eral Hospital Ali A. Baaj, MD Tam pa, Florida Assistan t Professor Antibiot ics Departm en t of Neurological Surger y Weill Corn ell Medical College Alexan d er Haas, MD New York Presbyterian Hospital Residen t physician New York, New York Departm en t of Neurosurger y an d Brain Repair Moya moya disea se* Un iversit y of South Florida Morsan i College of Me d icin e Kon rad Bach , MD Tam pa, Florida Research Associate Colloid cysts Un iversit y of South Florida Morsan i College of Medicin e Gh ait h Habbou b, MD Tam pa, Florida Residen t physician Ankylosing spondylit is Neurological In stit ute Clevelan d Clin ic Clevelan d, Oh io EVD-rela ted infections

Cont ributors 7 Sh an n on Han n , MD Tim ot h y D. Miller Jr., MD Residen t physician Residen t physician Departm en t of Neurological Surger y Division of Neurosurgery Th om as Je erson Un iversit y Duke Un iversit y Sch ool of Medicin e Ph iladelph ia, Pen n sylvan ia Durham , North Carolin a Neurocuta neous mela nosis* Cerebra l va sospa sm Sh ah -Naz H. Kh an , MD, FRCS(C), FAANS Jose Mon t er o, MD Ch air an d Director Associate Professor In stit ute of Gen eral an d En dovascular Neuro- Depar tm en t of In tern al Medicin e su r ge r y Un iversity of South Florida Morsan i College of Clin ical Assistan t Professor Me d icin e Departm en t of Surger y Tam pa, Florida Mich igan State Un iversit y An t ibiot ics Flin t, Mich igan Endova scula r neurosurger y Jason Palu zzi, MD Residen t physician Tsz Y. Lau , MD Depar tm en t of Neurosurger y an d Brain Repair Assistan t Professor Un iversity of South Florida Morsan i College of Departm en t of Neurosurger y an d Brain Repair Me d icin e Un iversit y of South Florida Morsan i College of Tam pa, Florida Me d icin e Wilbra nd’s knee Tam pa, Florida Suba ra chnoid hemor rha ge Mich ael S. Park, MD Residen t physician Sh ih -Sin g Liu , MD Depar tm en t of Neurosurger y an d Brain Repair Assistan t Professor Un iversity of South Florida Morsan i College of Departm en t of Neurosurger y an d Brain Repair Me d icin e Un iversit y of South Florida Morsan i College of Tam pa, Florida Me d icin e Ca rot id enda rterectomy vs. stenting Tam pa, Florida Jugula r fora men Glen A. Pollock, MD Anticoa gula tion & a nt ipla telet thera py Atten ding physician Raleigh Neurosurgical Clin ic Wai-m an Liu , MBBS, FRCS, FHKAM Raleigh , North Carolin a Ch ief of Ser vice, Hon orar y Associate Professor PRES* Division of Neurosurgery, Departm en t of Sur- gery Kan -su en Jen n y Pu , BSC, MBBS, FHKAM, Li Ka Sh ing Facult y of Medicin e FRCSHK, FRCS (Su rgical Neu rology) Th e Un iversit y of Hon g Kon g Division of Neurosurgery, Depart m en t of Sur- Pokfulam , Hon g Kon g gery Ast r ocyt om a Li Ka Sh ing Facult y of Medicin e Th e Un iversit y of Hon g Kon g Jot h am Man w arin g, MD Pokfulam , Hon g Kon g Atten ding physician Ast r ocyt om a South ern Utah Neuroscien ces In stit ute St . George, Utah Ed w in Ram os, MD Third ventr iculostomy (ETV) Assistan t Professor X-linked hydrocepha lus* Depar tm en t of Surger y Th e Un iversit y of Ch icago Medicin e Car los R. Mar t in ez, MD, FACR Ch icago, Illin ois Professor of Radiology Hypotha la mic ha ma rtoma s* USF College of Medicin e Assistan t Ch ief of Radiology Step h en Rein t jes, MD Bay Pin es VA Hospital Residen t physician Tam pa, Florida Depar tm en t of Neurosurger y an d Brain Repair Int ra cra nia l hypotension Un iversity of South Florida Morsan i College of Me d icin e Melein e Mar t in ez-Sosa, MD Tam pa, Florida Residen t physician Anticoa gula t ion & a nt ipla telet thera py Departm en t of Neurosurger y an d Brain Repair Un iversit y of South Florida Morsan i College of Me d icin e Tam pa, Florida Int ra cra nia l hypotension

8 Contributors Jayson Sack, MD Roh it Vasan , MD Residen t physician Atten ding physician Division of Neurosurgery Departm en t of Neurosurger y an d Brain Repair Un iversit y of Californ ia, San Diego Un iversit y of South Florida Morsan i College of San Diego, Californ ia Me d icin e Suba ra chnoid hemor rha ge Tam pa, Florida Syn cop e* Step h en San d w ell, MD Residen t physician Ch ar les E. Wr igh t , MD Departm en t of Neurosurger y Medical Director Un iversit y of Roch ester LifeLin k of Florida Roch ester, New York Tam pa, Florida Centra l neurocytoma Bra in dea th & orga n dona t ion Josep h Serron e, MD Ch u n -Po Yen , MD Atten ding physician Fellow Virgin ia Mason Hospital an d Seattle Medical Departm en t of Neurosurger y an d Brain Repair Cen ter Un iversit y of South Florida Morsan i College of Seattle, Wash in gton Me d icin e Pleomor phic xa nthoa strocytoma s* Tam pa, Florida Tra nspsoa s a pproa ch San an t h an Sivakan t h an Stereota ctic ra diosurger y Medical student Un iversit y of South Florida Morsan i College of Ash raf Sam y You ssef, MD, Ph D Medicin e Visitin g Associate Professor Tam pa, Florida Director of Skull Base Surger y Jugula r fora men Departm en t of Neurosurger y Un iversit y of Colorado Sch ool of Medicin e L. Bran n on Th om as, MD, Ph D Denver, Colorado Atten ding physician Management of pineal region tumors* Jam es A. Haley Veteran s Adm in istration Hospi- tal *Or igin a lly cont r ibu ted to the Ha ndbook of Un iversit y Com m un ity Hospital Neurosu rger y, seventh edit ion Tam pa, Florida Neuropa thology Fern an d o L. Vale, MD Professor an d Vice-Ch airm an Departm en t of Neurosurger y an d Brain Repair Un iversit y of South Florida Morsan i College of Medicin e Tam pa, Florida Seizure surger y Jam ie J. Van Gom p el, MD Assistan t Professor Departm en t of Neurosurger y Mayo Clin ic Roch ester, Min n esota Esthesioneurobla stoma s Ju an S. Uribe, MD Associate Professor Director, Spin e Sect ion Departm en t of Neurosurger y an d Brain Repair Un iversit y of South Florida Morsan i College of Medicin e Tam pa, Florida Tra nspsoa s a pproa ch Lher mitte-Duclos disea se* Bone gra ft ma teria ls* New spine fusion techniques*

9 Pr e fa ce Sh ortly after fin ish in g m y residen cy t rain ing in 1989, in a tim e lon g before th e in tern et, I w rote th e first edition of th e Ha ndbook of Neurosurger y w ith th e in ten t to m ake pract ical, act ion able n eurosur- gical in form at ion accessible at th e fin gert ips of th e pract it ion er. Over th e years, I used desktop publish ing tech n ology to expan d th e scope of th e book, an d to in corporate diagram s an d literature referen ces. I always w an ted to m ake th e book “academ ic” by presen ting data that backed up the assertions. My goal was to n ever publish a cookbook. W ith out advert isin g, I relied solely on w ord-of-m outh to prom ote th e book. I believed in th e sam e th in g th at Edw in Lan d m ust h ave w h en h e said, “Marketin g is w h at you do w h en your product is n o good.” I h ad a test run of 600 copies of th e book prin ted at a sm all van it y press in An n Arbor, an d sold copies to in dividuals by m ail. My big break cam e w h en th e m edical bookstore at th e State Un iversity of New York in Syracuse purch ased 6 copies to put on th eir sh elves. After th at, I regularly packaged 5 or 6 books in a box dest in ed for various bookstores an d dropped th em o at th e loading dock on m y w ay to th e O.R. in th e m orn in g. After a tim e, th e m ajor m edical book distributors in th e coun tr y began ordering cases of books and m y garage becam e a shipping departm ent. (I still h ave th e pallet jack th at I used to un load th e deliver y trucks.) Th en , som eh ow, in tern at ion al orders began to arrive. I w as fin ally able to get out of th e packing an d t ran sport in g busin ess w h en I partn ered w ith Th iem e Medical Publish ers in 2001. At th at tim e th e in tern et w as just becom ing “a th in g,” an d w h ile it w as a great w ay to m ake con n ect ion s, th e in form ation explosion w as still to com e. Th e goal of th e book regardless w as still th e sam e—to m ake useful in form ation readily available. By th e tim e th e 6th edition w as publish ed in 2006, th e process I used to produce th e book w as becom ing m ore di cult. Th e page layout soft w are th at h ad been m y w orkh orse for over 10 years w as n o lon ger supported, an d th e developers of th e referen ce m an ager I ut ilized h ad ch anged th eir focus an d th e product w as n ow com pat ible prim arily w ith w ord processors (w h ich w ere poorly suited for com plex m ulti-ch apter books like th is on e). As a result , I w as forced to use an obsolete Pow erPC com puter an d h ad to h ack th e ch apter files in order to trick th e referen ce m an ager to w ork w ith th em ! After th e 7th edition w as com pleted, I could see n o w ay forw ard w ith th is approach . I n ever im agin ed th at desktop publish ing w as going to atrophy an d fall vict im to th e sam e fate th at w ould later com e to claim print n ewspapers. With the availability of th e w orld w ide w eb, th e inter- n et w as quickly becom in g th e ch ief m ean s of accessin g in form ation on dem an d. Th e birth of th is 8th edition of th e h an dbook th at you are n ow reading w as a particularly di cult on e. Th an ks to th e people at Th iem e, th e m aterial w as pain stakin gly converted from th e defun ct soft w are platform to a con tem porar y form at th at w ill facilitate con tin ued updates an d availabilit y in digital m edia. Th is tim e-con sum ing an d labor-in ten sive process in cluded port in g th ousan ds of cross referen ces, in dex en tr ies, an d literature citation s. In terestin gly, th e objectives of th e h an dbook h ave also gon e th rough a t ran sform ation . It is ch al- len gin g to distill w h at all of th ose objectives are, but I believe th at it is im portan t to present m aterial in a fram ework th at can ser ve as a foun dation for st udying th e field of n eurosurger y. Th is book is in ten ded to be a place th at brin gs togeth er th e im por tan t in form ation th at is in creasingly scattered across th e literature and th e w eb (for in stan ce, pract ice guidelin es for disparate subjects like spin al cord injur y, st roke, an eur ysm s…) th at m igh t n ot n ecessarily be en countered un less on e is actively seeking it out. My goal w ith th e book h as alw ays been to presen t in form at ion succin ctly an d clearly. To th at en d, th is edition is a com pletely restruct ured version of th e Ha ndbook of Neurosurger y, presen tin g th e en tire con ten t in a collection of m ore th an 100 w ell-ordered ch apters of com parable len gth an d for- m at w h ile retain ing th e w ealth of crosslin ks an d referen ces th e book is kn ow n for. Th is n ew organ - ization was design ed to m ake th e con ten t m ore easily digestible an d accessible – for both brow sing th e prin t book an d n avigatin g any elect ron ic version . W ith its n ew struct ure an d form at, as w ell as revised an d updated con ten t, I h ope I h ave provided readers w ith an even m ore valuable resource in th is 8th edit ion of th e Ha ndbook of Neurosurger y.

10 Acknow ledgm ent s I w ould like to th an k all of th ose w h o par ticipated in th e preparation of th is edition . Th an ks to th e m any con tributors w h o h elped w ith th e m aterial, an d th e people kn ow n an d n ot kn ow n to m e at Th iem e Medical Publish ers. To Brian Scan lan , Presiden t of Th iem e Medical Publish ers, for m akin g th e resources available to save th e book from disappearin g en tirely. To Sarah Lan dis an d Torsten Scheih agen for th eir editorial h elp. An d th e deepest debt of gratitude to Dr. Mich ael Wach in ger, Th iem e’s Director of Clin ical Solution s, w h o person ally spen t coun tless h ours an d a n um ber of tran s- atlan tic trips, guiding th e restructur ing of th e in form ation in to a m ore accessible an d logical fram e- w ork, an d en surin g th at th e con ten t w as preser ved in th e soft ware tran sfer. Th an ks also to m y colleagues an d th e residen ts in th e n eurosurger y program at th e Un iversit y of South Florida from w h om I learn ever y day. Special th an ks to our ch airm an , Dr. Harr y van Loveren , for h is advice, calm leadersh ip an d for in spirin g excellen ce in n eurosurger y.

11 Abbreviat ions and Sym bols Abbreviation s used on ly locally are defin ed in th at sect ion usin g boldface t ype. Num bers follow in g en tries below in dicate th e page n um ber for th e relevan t sect ion . Ab b re via t io n s artery (aa. = arteries) a. anaplastic astrocytoma (p. 616) AA aneurysm al bone cyst (p. 784) ABC a n t ib iot ics Ab x. arachnoid cyst (p. 248) AC anterior cerebral artery ACA asymptomatic carotid artery stenosis (p. 1275) or Asymptomatic Carotid Atherosclerosis Study ACAS (p. 1276) anterior cervical discectomy & fusion (p. 1072) ACDF angiotensin-converting enzyme ACE acet ylcholine (neurotransm it ter) ACh anterior choroidal artery AChA anterior com municating artery ACoA adrenocorticotropic horm one (corticotropin) (p. 151) ACTH autosomal dominant AD antidiuretic horm one (p. 151) ADH atlantodental interval (p. 213) ADI autosomal dominant polycystic kidney disease (p. 1193) ADPKD abductor digiti quinti (or m inim i) ADQ anti-epileptic drug (anticonvulsant) (p. 443) AED alpha-fetoprotein (p. 600) AFP a n t ig e n Ag Agency for Health Care Policy and Research (of the U. S. Public Health Service) AHCPR anterior inferior cerebellar artery (p. 83) AICA acute inflam m atory demyelinating polyradiculoneuropathy (p. 185) AIDP acquired im munodeficiency syndrom e (p. 329) AIDS anterior interosseous neuropathy (p. 518) AIN autosomal dominant (inheritance) AD ankle-foot-orthosis (p. 537) AFO also known as AKA anterior lum bar interbody fusion (p. 1493) ALIF As Low As Reasonably Achievable (p. 224) ALARA

12 Abbreviations and Sym bols A-line arterial line ALL anterior longitudinal ligam ent ALS amyotrophic lateral sclerosis (p. 1086) AMS acute m ountain sickness (p. 848) AN acoustic neurom a (p. 670) ANA antinuclear antibodies AOD atlantooccipital dislocation (p. 963) AOI atlantooccipital interval (p. 964) AP a n t e ro -p o st e rio r APAG antipseudom onal am inoglycoside APAP acetam inophen (p. 137) APD afferent pupillary defect (p. 562) APTT (or PTT) activated partial throm boplastin time ARDS adult respiratory distress syndrom e ASA Am erican Societ y of Anesthesiologist s or aspirin (acet ylsalicylic acid) ASAP as soon as possible ASD antisiphon device AT anterior tibialis (tibialis anterior) AT/ RT at ypical teratoid/rhabdoid tumor (p. 666) ASHD atherosclerotic heart disease AVM arteriovenous malform ation (p. 1238) AVP arginine vasopressin (p. 151) β-hCG beta-human chorionic gonadotropin (p. 600) BA basilar artery BBB blood-brain barrier (p. 90) BC basal cisterns (p. 921) BCP birth control pills (oral contraceptives) BCVI blunt cerebrovascular injury (p. 849) BG basal ganglia BI basilar impression/invagination (p. 217) BMD bone mineral densit y (p. 1009) BMP bone morphogenic protein (p. 1439) BOB benign osteoblastoma (p. 792) BP blood pressure BR bed rest (activit y restriction) BSF basal skull fracture (p. 884)

BSG Abbreviations and Sym bols 13 Ca CA brainstem gliom a (p. 633) CAA cancer CABG cavernous angioma (p. 1247) CAD cerebral am yloid angiopathy (p. 1334) CAT coronary artery bypass graft CBF coronary artery disease CBV (or CT) com puterized (axial) tomography CBZ cerebral blood flow (p. 1264) CCB cerebral blood volum e CCF carbamazepine (p. 449) CCHD calcium-channel blocker CD carotid-cavernous (sinus) fistula (p. 1256) CEA congenital cyanotic heart disease CECT Cushing’s disease (p. 723) cf carotid endarterectomy (p. 1290) or carcinoem bryonic antigen (p. 601) cGy contrast enhanced CT CHF (Latin: confer) compare CI centi-Gray (1cGy = 1 rad) CIDP congestive heart failure CIP confidence interval (statistics) CJD chronic inflamm atory demyelinating polyradiculoneuropathy (p. 186) CM critical illness polyneuropathy (p. 542) CMAP Creutzfeldt-Jakob disease (p. 367) CMRO2 cavernous malform ation (p. 1247) CMT compound m otor action potential (EMG) CMV cerebral metabolic rate of oxygen consumption (p. 1265) CNL Charcot-Marie-Tooth (p. 541) CNS cyt o m e ga lo virus cCO ch e m o n u cle o lysis CO central nervous system CPA continuous cardiac output CPM cardiac output or carbon monoxide (p. 208) CPN cerebellopontine angle CPP central pontine m yelinolysis (p. 115) common peroneal nerve (p. 535) cerebral perfusion pressure (p. 856)

14 Abbreviations and Sym bols Cr. N. cranial nerve(s) CRH corticotropin-releasing horm one (p. 151) CRP C-reactive protein CRPS com plex regional pain syndrome (p. 497) CSM cervical spondylotic m yelopathy (p. 1084) CSO craniosynostosis (p. 252) CSW cerebral salt wasting (p. 118) CTA CT angiogram (p. 227) CTP CT perfusion (p. 228) CTS carpal tunnel syndrom e (p. 519) CVA cerebrovascular accident (stroke) (p. 1264) CVP central venous pressure CVVT cerebrovascular venous throm bosis (p. 1308) CVR cerebrovascular resistance (p. 1264) CVS cerebral vasospasm (p. 1178) CXR chest x-ray DACA distal anterior cerebral artery DAI diffuse axonal injury (p. 848) DBM dem ineralized bone m atrix (p. 1439) D/ C d isco n t in u e DDAVP 1-deam ino-8-D-arginine vasopressin (desmopressin) (p. 125) DDx differential diagnosis (p. 1395) DBS deep brain stimulation (p. 1524) DI diabetes insipidus (p. 120) DIND delayed ischem ic neurologic deficit (p. 1179) DIG desmoplastic infantile astrocytom a and gangliogliom a (p. 645) DISH diffuse idiopathic skeletal hyperostosis (p. 1129) DKA diabetic keto-acidosis DLC disco-ligam entous com plex (p. 986) DLIF direct lateral lum bar interbody fusion (p. 1498) DOC drug of choice DM diabetes m ellitus DMZ dexam ethasone DNT (or DNET) dysembryoplastic neuroepithelial tum ors (p. 646) DOE dyspnea on exertion DOMS delayed onset m uscle soreness (p. 1101)

Abbreviations and Sym bols 15 DPL diagnostic peritoneal lavage DREZ dorsal root entry zone lesion (p. 1550) DSA digital subtraction angiogram DSD degenerative spine disease (p. 1096) DST dural sinus throm bosis (p. 1308) DTs delirium trem ens (p. 206) DTT diffusion tensor tractography MRI (p. 234) DVT deep-vein thrombosis (p. 167) DWI (or DWMRI) diffusion-weighted imaging (MRI) (p. 232) EAC external auditory canal EAM external auditory m eatus EAST Eastern Association for the Surgery of Trauma EBRT external beam radiation therapy EBV Epstein-Barr Virus ECM erythem a chronicum m igrans (p. 334) EDC electrolytically detachable coils EDH epidural hem atoma (p. 892) EHL extensor hallicus longus ELISA enzym e-linked im munosorbent assay ELST endolym phatic sac tum ors (p. 705) EM electron m icroscope (m icroscopy) ENG electronystagmography (p. 674) ENT ear, nose and throat (otolaryngology) EOM extra-ocular muscles (p. 565) EOO external oculom otor ophthalmoplegia ESR erythrocyte sedimentation rate EST endoderm al sinus tumor (p. 660) Et OH ethyl alcohol (ethanol) ET tube endotracheal tube ETV endoscopic third ventriculostomy (p. 415) EVD external ventricular drain (ventriculostomy) FCU flexor carpi ulnaris FDP flexor digitorum profundus FIM Functional Independence Measure (p. 1362) FLAIR fluid-attenuated inversion recovery (on MRI) (p. 229) FM face m ask

16 Abbreviations and Sym bols FMD fibrom uscular dysplasia (p. 200) FSH follicle stimulating horm one (p. 151) F/ U follow-up FUO fever of unknown origin GABA gamm a-am inobut yric acid GBM glioblastoma (m ultiforme) (p. 616) GBS Guillain-Barré syndrom e (p. 184) GCA giant cell arteritis (p. 195) GCS Glasgow coma scale (p. 296) GCT granular cell tum or (p. 727) or germ cell tum or (p. 659) GD Graves’ disease GFAP glial fibrillary acidic protein (p. 598) GGT gamm a glutam yl transpeptidase GH growth hormone (p. 151) GH-RH growth hormone releasing horm one (p. 151) GMH germ inal m atrix hem orrhage (p. 1346) GNR gram negative rods GnRH gonadotropin-releasing horm one (p. 151) GSW gunshot wound GTC generalized tonic-clonic (seizure) H/ A headache (p. 174) H&H Hunt and Hess (SAH grade) (p. 1162) H&P history and physical exam HBsAg hepatitis B surface antigen HCD herniated cervical disc (p. 1069) hCG hum an chorionic gonadotropin (p. 600) HCP hydrocephalus (p. 394) HDT hyperdynamic therapy (p. 1186) HGB hem angioblastoma (p. 701) Hg b -A1 C hem oglobin A1C hGH human growth hormone HH hypothalam ic ham artomas (p. 261) or hom onymous hem ianopsia HHT hereditary hemorrhagic telangiectasia (p. 1246) HIV hum an imm unodeficiency virus HLD herniated lumbar disc (p. 1046) HLA hum an leukocyte antigen

H.O. Abbreviations and Sym bols 17 HNP HNPP house officer HOB herniated nucleus pulposus (herniated disc) (p. 1046) HPA hereditary neuropathy with liability to pressure palsies (p. 541) HSE head of bed HTN hypothalam ic-pituitary-adrenal axis IAC herpes sim plex encephalitis (p. 364) IASDH h yp e rt e n sio n ICA internal auditory canal ICG infantile acute subdural hem atom a (p. 898) ICH internal carotid artery IC-HTN indocyanine green ICP intracerebral hemorrhage (p. 1330) ICU intracranial hypertension (increased ICP) IDDM intracranial pressure (p. 856) IDET intensive care unit IEP insulin-dependent diabetes m ellitus IG intradiscal endotherm al therapy (p. 1053) IGF-1 im mune electrophoresis IIH im age guidance (intra-operative) IIHWOP insulin-like growth factor-1 (AKA som atom edin-C) (p. 151) IJV idiopathic intracranial hypertension (pseudotumor cerebri) (p. 766) IMRT idiopathic intracranial hypertension without papilledem a (p. 768) INO internal jugular vein INR intensit y m odulated radiation therapy IPS internuclear ophthalm oplegia (p. 565) IPA international norm alized ratio (p. 164) ISAT inferior petrosal sinus IT idiopathic paralysis agitans (Parkinson’s disease) (p. 176) ITB International Subarachnoid Hemorrhage Aneurysm Trial (p. 1195) IVC in t ra t h e ca l IVH intrathecal baclofen (p. 1531) IVP intraventricular catheter or inferior vena cava JPS intraventricular hemorrhage (p. 1386) LBP intravenous push (m edication route) or intravenous pyelogram (x-ray study) joint position sense low back pain (p. 1024)

18 Abbreviations and Sym bols LDD Lherm itte-Duclos disease (p. 647) LE lower extrem it y LFTs liver function tests LGG low-grade glioma LH luteinizing horm one (p. 151) LH-RH luteinizing horm one releasing hormone (p. 151) LMD low m olecular weight dextran LMN lower m otor neuron (p. 504) LMW low-m olecular-weight (e.g. heparins) LOC loss of consciousness LOH loss of heterozygosity LP lum bar puncture (p. 1504) LSO lum bo-sacral orthosis MAC m ycobacterium avian com plex (p. 354) MAOI m onoam ine oxidase inhibitor MAP m ean arterial pressure MAST® m ilitary anti-shock trousers MB m edulloblastom a (p. 664) MBEN m edulloblastom a with extensive nodularit y (p. 665) MBI m odified Barthel index ( Table 88.6) MBS m edulloblastom a (p. 664) MCA m iddle cerebral artery m cg (or µg) microgram MCP mean carotid pressure or m etacarpal phalangeal MDCTA multidetector CT angiography MDMA methylenedioxym ethamphetam ine (p. 177) mg m illig ra m MI myocardial infarction MIB-1 monoclonal anti-Ki-67 antibody (p. 599) MIC minim um inhibitory concentration (for antibiotics) MID multi-infarct dementia MISS minim ally invasive spine surgery m JOA modified Japanese Orthopedic Association scale (p. 1086) MLF medial longitudinal fasciculus MLS midline shift (p. 921) MM myelomeningocele (p. 265) or multiple m yelom a (p. 714)

MMD Abbreviations and Sym bols 19 MMN MMPI moyamoya disease (p. 1313) mos multifocal motor neuropathy (p. 1410) MPTP Minnesota Multiphasic Personalit y Inventory MRA months MRS 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (p. 177) MRSA MRI angiogram (p. 232) MS MRI spectroscopy (p. 233) MSO4 methicillin resistant staphylococcus aureus MTP microsurgery or multiple sclerosis (p. 179) MTT morphine sulfate MUAP metatarsal phalangeal MVA meant transit tim e (on CT perfusion) (p. 228) MVD motor unit action potential (p. 243) MW motor vehicle accident n. microvascular decompression (p. 488) Na molecular weight N2O nerve (nn. = nerves) NAA (or Na+) sodium NAP nitrous oxide (p. 105) NASCET N-acetyl aspartate (p. 233) NB nerve action potential (p. 509) NC North Am erican Symptom atic Carotid Endarterectomy Trial (p. 1290) NCCN (Latin: nota bene) note well NCD nasal cannula NCV National Comprehensive Cancer Network NEC neurocutaneous disorders (p. 603) NEXUS nerve conduction velocit y NF neurenteric cyst (p. 290) or necrotizing enterocolitis NF1 National Em ergency X-Radiography Utilization Study (p. 953) NF2 (or NFT) neurofibromatosis (p. 603) NG tube neurofibrom atosis t ype 1 (p. 604) NGGCT neurofibrom atosis t ype 2 (p. 605) NIHSS nasogastric tube NMBA non-germ inom atous germ cell tum ors (p. 659) NIH Stroke Scale (p. 1282) neuromuscular blocking agent (p. 134)

20 Abbreviations and Sym bols NMO neurom yelitis optica (Devic disease) (p. 1409) NPH norm al pressure hydrocephalus (p. 403) NPS neuropathic pain syndrome (p. 476) NS norm al saline NSAID non-steroidal anti-inflam m atory drug (p. 137) NSCLC non-sm all-cell cancer of the lung (p. 803) NSF nephrogenic system ic fibrosis (p. 231) NSM neurogenic stunned myocardium (p. 1177) N/ V nausea and vom iting NVB neurovascular bundle OAD occipital atlantal dislocation, see atlantooccipital dislocation (p. 963) OALL ossification of the anterior longitudinal ligam ent (p. 1129) OC occipital condyle OCB oligoclonal bands (in CSF) (p. 181) OCF occipital condyle fracture (p. 885) ODG oligodendrogliom a (p. 638) OEF oxygen extraction fraction OFC occipital-frontal (head) circumference OGST oral glucose suppression test (for growth horm one) (p. 736) OMO open-m outh odontoid (C-spine x-ray view) OMP oculom otor (third nerve) palsy ONSF optic nerve sheath fenestration (p. 772) OP opening pressure (on LP) (p. 1505) OPLL ossification of the posterior longitudinal ligam ent (p. 1127) ORIF open reduction/internal fixation OS overall survival OTC over the counter (i.e. without prescription) PACU post-anesthesia care unit (AKA recovery room , PAR) PADI posterior atlantodental interval (p. 213) PAN poly- (or peri-) arteritis nodosa (p. 199) PBPP perinatal brachial plexus palsy (p. 552) p Bt O2 brain tissue oxygen tension (p. 865) PC pineal cyst (p. 658) PCA pilocytic astrocytoma (p. 629) or posterior cerebral artery PCB pneum atic com pression boot PCC prothrom bin complex concentrate (p. 166)

PCI Abbreviations and Sym bols 21 PCN PCNSL prophylactic cranial irradiation P-com m penicillin PCV prim ary CNS lym phom a (p. 710) PCWP posterior comm unicating artery PDA procarbazine, CCNU, & vincristine (chem otherapy) PDN pulm onary capillary wedge pressure PDR patent ductus arteriosus peds painful diabetic neuropathy (p. 476) PEEK Physicians Desk Reference® PET pediatrics (infants & children) p -fo ssa poly-ether-ether-ketone (graft material) PFS positron em ission tomography (scan) PFT posterior fossa PHN progression-free survival PHT pulm onary function test PICA postherpetic neuralgia (p. 493) PIF phenytoin (Dilantin®) (p. 446) PIN posterior inferior cerebellar artery (p. 82) PION prolactin release inhibitory factor (p. 151) PIVH posterior interosseous neuropathy (p. 532) PLAP posterior ischem ic optic neuropathy (p. 1056) PLEDs periventricular-intraventricular hemorrhage (p. 1346) PLIF placental alkaline phosphatase (p. 660) PM periodic lateralizing epileptiform discharges PMA posterior lum bar interbody fusion PMH pars m arginalis (p. 60) PML progressive m uscular atrophy (p. 183) or pilomyxoid astrocytoma (p. 632) PMMA pure m otor hem iparesis PMR progressive m ultifocal leukoencephalopathy (p. 329) PMV polym ethylm ethacrylate (methylm ethacrylate) PNET polymyalgia rheumatica (p. 198) POD pontom esencephalic vein PPV prim itive neuroectoderm al tum or (p. 663) post-operative day PR positive predictive value: in unselected patients who test positive, PPV is the probabilit y that the patient has the disease per rectum

22 Abbreviations and Sym bols PRES posterior reversible encephalopathy syndrom e (p. 194) PRF prolactin releasing factor (p. 151) PRIF prolactin (releasing) inhibitory factor (p. 151) PRN as needed PRSP penicillinase resistant synthetic PCN PSNP progressive supra-nuclear palsy (p. 178) PSR percutaneous stereotactic rhizotom y (for trigem inal neuralgia) (p. 483) PSW positive sharp waves (on EMG) (p. 242) pt p a t ie n t PT physical therapy or prothrom bin tim e PTC pituicytom a (p. 728) PTR percutaneous trigem inal rhizotomy PTT (or APTT) partial thromboplastin tim e PUD peptic ulcer disease PVP percutaneous vertebroplast y (p. 1011) PWI perfusion-weighted im aging (MRI) (p. 233) PXA pleomorphic xanthoastrocytom a (p. 635) q (Latin: quaque) every (medication dosing) RA rheum atoid arthritis RAPD relative afferent pupillary defect (p. 562) RASS Richmond agitation-sedation scale (p. 132) RCVS reversible cerebral vasoconstrictive syndrom e (p. 1158) rem roentgen-equivalent man REZ root entry zone RFR radiofrequency rhizotom y (p. 483) rFVIIa recombinant (activated) factor VII RH recurrent artery of Heubner rhBMP recombinant human BMP (p. 1439) R/ O rule out ROM range of m otion RPA recursive partitioning analysis RPDB randomized prospective double-blind RPLS reversible posterior leukoencephalopathy syndrom e; see posterior reversible encephalopathy syndrome (p. 194) RPNB randomized prospective non-blinded RTOG Radiation Therapy Oncology Group RTP return to play (sports)

rt -PA Abbreviations and Sym bols 23 RTX S/ S recombinant tissue plasminogen activator (AKA tissue plasminogen activator) SAH (or XRT) radiation therapy (p. 1560) SBE signs and symptom s SBO subarachnoid hem orrhage (p. 1191) SBP subacute bacterial endocarditis SCA spina bifida occulta (p. 265) SCLC systolic blood pressure SCD superior cerebellar artery SCI sm all-cell lung cancer (p. 802) SCM sequential com pression device SD spinal cord injury (p. 943) SDE sternocleidom astoid (m uscle) SDH standard deviation SE subdural em pyem a (p. 327) SEA subdural hem atoma (p. 895) SEP status epilepticus (for seizures) (p. 468) SG spinal epidural abscess (p. 349) SIAD (or SSEP) somatosensory evoked potential SIADH specific gravit y SIDS syndrom e of inappropriate antidiuresis (p. 112) SIH syndrom e of inappropriate antidiuretic hormone (ADH) secretion (p. 114) SIRS sudden infant death syndrom e SjVO2 spontaneous intracranial hypotension (p. 389) SLAD septic inflam m atory response syndrom e SLE jugular venous oxygen saturation (p. 865) SLIC surgical laser aim ing device SMC system ic lupus erythematosus SMT subaxial injury classification (p. 986) SNAP spinal m eningeal cyst (p. 1142) SNUC spinal m anipulation therapy (p. 1034) SOMI sensory nerve act ion potential (EMG) (p. 243) SON sinonasal undifferentiated carcinom a (p. 1387) S/ P sternal-occipital-m andibular im mobilizer (p. 935) SPAM supraorbital neuralgia (p. 491) st at u s-p o st subacute progressive ascending m yelopathy (p. 1019)

24 Abbreviations and Sym bols SPECT single positron emission com puted tomography (scan) SPEP serum protein electrophoresis sPNET supratentorial prim itive neuroectoderm al tum or (p. 666) SQ subcutaneous injection SRS stereotactic radiosurgery (p. 1564) SRT stereotactic radiotherapy (p. 1564) SSEP (or SEP) som atosensory evoked potential SSPE subacute sclerosing panencephalitis (p. 238) SSRI selective serotonin reuptake inhibitors SSS superior sagittal sinus STA superficial tem poral artery STICH Surgical Trial in Intracerebral Haem orrhage (p. 1343) STIR short tau inversion recover (MRI image) STN subthalam ic nucleus STSG Spine Traum a Study Group SUNCT short-lasting unilateral neuralgiform H/A with conjunctival injection and tearing (p. 478) SVC superior vena cava SVM spinal vascular m alformations (p. 1140) SVR system ic venous resistance SVT supraventricular tachycardia Sz. seizure (p. 440) T1WI T1 weighted image (on MRI) (p. 228) T2WI T2 weighted image (on MRI) (p. 229) TAL transverse atlantal ligam ent (p. 70) TBA total bilateral adrenalectomy (p. 743) TBI traumatic brain injury TCA tricyclic antidepressants TCD transcranial doppler (p. 1182) TDL tum efactive dem yelinating lesions (p. 181) TE time to echo (on MRI) (p. 228) TEE transesophageal echocardiogram TEN toxic epiderm al necrolysis TENS transcutaneous electrical nerve stim ulation TGN trigem inal neuralgia (p. 479) T-H lines Taylor-Haughton lines (p. 61) TIA transient ischem ic attack (p. 1264)

TICH Abbreviations and Sym bols 25 TIVA TLIF traumatic intracerebral hemorrhage (hem orrhagic contusion) (p. 891) TLISS total intravenous anesthesia TLJ transforaminal lum bar interbody fusion (p. 1497) TLSO thoracolumbar injury severity score (p. 1006) TM thoracolumbar junction TMB thoracolumbar-sacral orthosis t -PA t ym panic m embrane TR transient monocular blindness (am aurosis fugax) (p. 1271) TRH tissue plasm inogen activator TS tim e to repetition (on MRI) (p. 228) TSC thyrotropin releasing horm one; AKA TSH-RH (p. 151) TSH transverse sinus TSV tuberous sclerosis com plex (p. 606) TTP thyroid-stim ulating horm one (thyrotropin) (p. 151) TVO thalam ostriate vein Tx. throm botic throm bocytopenic purpura UBOs transient visual obscurations (p. 768) UE t re at m e n t UMN unidentified bright objects (on MRI) UTI upper extrem it y URI upper m otor neuron (p. 504) U/ S urinary tract infection VA upper respiratory tract infection VB u lt ra so u n d VBI vertebral artery or ventriculoatrial VEMP vertebral body VHL vertebrobasilar insufficiency (p. 1305) VMA vestibular evoked m yogenic potential (p. 675) VP von Hippel-Lindau (disease) (p. 703) VS vanillylm andelic acid VZV ve n t ricu lo p e rit o n e a l WBC vestibular schwannoma (p. 670) WBXRT (herpes) varicella zoster virus WFNS white blood cell (count) whole brain radiation therapy (p. 810) World Federation of Neurosurgical Societies (grading SAH) (p. 1163)

26 Abbreviations and Sym bols WHO World Health Organization. For tum or grading, e.g. WHO II indicates WHO grade II wks weeks WNL within norm al lim its w/o without WRS word recognition score (p. 673) W/ U work-up (evaluation) XLIF extrem e lateral lum bar interbody fusion (p. 1498) XRT (or RTX) radiation therapy (p. 1560) Sym bols prescribing information → causes or leads to Δ change check (e.g. lab or exam item to check) ↑ increased ↓ decreased ≈ approxim ately innervates (nerve distribution) vascular supply a branch of the preceding nerve crucial point caution; possible danger; negative factor… Σ summary t h e re fo re Instrum entation: the following shorthand allows rapid identification of m etrics for spinal instrum entation: ENTRY screw entry site TRAJ screw trajectory TARGET object to aim for SCREWS t ypical screw specifications

27 Co n ve n t io n s Box t yp es. Th e Ha ndbook of Neurosurger y uses th e follow in g seven box t ypes: Drug info Drug description & dosage. Key concept s Foundational knowledge in brief. Pract ice guideline Evidence-based guidelines. See below (in this section) for definitions. For a listing of evidence-based guidelines contained in this book, see the index under “Practice guideline.” Booking t he case These sections appear under certain specific operations to help when scheduling that surgery. Default information appears below (in this section), for exam ple, a specific t ype of anesthesia will only be mentioned if som ething other than general anesthesia is t ypically used. A list of operations addressed by this m eans can be found in the index under “Booking the case.” Σ Summarizing or synthesizing information from the associated text. Side inform at ion E.g., Greenberg IMHO. Signs / sym pt om s A description of signs and symptoms. Cr oss referen ces. Cross referen ces: th e term s “see below ” an d “see above” are n orm ally used w h en th e referen ced item is on th e sam e page, or at m ost on th e follow in g (or precedin g) page. W hen fur th er excursion s are n eeded, th e page n um ber w ill usually be in cluded. Defau lt valu es. Th ese details are n ot repeated in each sect ion or “Booking th e case” box. 1. position: (depends on th e operation) 2. pre-op: a) NPO after m idn igh t th e n igh t before except m eds w ith sips of w ater b) an t ith rom botics: discon tin ue Coum adin ® ≥ 3 days prior to surger y, Plavix® 5–7 d pre-op, aspirin 7–10 d pre-op, oth er NSAIDs 5 d pre-op

28 Conventions 3. cardiology/m edical clearance as needed 4. an esth esia: default = gen eral an esth esia, un less oth erw ise specified 5. equipm en t: special devices such as ult rason ic aspirator, im age guidan ce… 6. in st rum en tation : stan dard surgical in st rum en t trays for a specific operation are assum ed. Spe- cial in strum en tat ion residen t in th e h ospital w ill be listed 7. im plan ts: th is usually requires sch edulin g w ith a ven dor (m an ufacturers represen tative/distrib- utor) to provide 8. neurom onitoring w ill be listed if t ypically used 9. post-op: default care is on th e w ard (ICU is t ypically n eeded after cran iotom y) 10. blood availabilit y: specified if recom m ended 11. con sen t (th ese item s use lay term s for th e patien t – n ot all-in clusive): Disclaim ers: infor med consent for surger y requires disclosure of risks an d ben efits th at w ould substan tively a ect a n orm al person’s decision to h ave th e operation . It can n ot an d sh ould n ot attem pt to in clude ever y possibilit y. Th e item s listed in th is sect ion are in cluded as m em or y jog- gers for som e item s for various procedures, but are n ot m ean t to be all in clusive. Th e om ission of in form ation from th is m em or y aid is n ot to be con strued as im plying th at th e om it ted item is not im portant or should not be m en tion ed. a) procedure: th e typical operation and som e possible com m on contingencies b) altern atives: n on -surgical (AKA “con servative”) t reatm en t is alm ost always an opt ion c) com plications: ● risks of gen eral an esth esia in clude: h eart attack, stroke, pn eum on ia ● in fect ion : a risk w ith any invasive procedure ● usual cran iotom y com plications include: bleedin g intra-op and postop, seizure, stroke, com a, death , hydroceph alus, m en in gitis, an d n eurologic deficit related to th e area of sur- ger y in cludin g (for applicable location s): paralysis, lan guage or sen sor y dist urban ces, coor- dination im pairm ent… ● usual spin e su rger y com plications in clude: injury to nerve or spinal cord w ith possible n um bn ess, w eakn ess or paralysis, failure of th e operation to ach ieve th e desired result, dural open in g w h ich m ay cause a CSF leak w h ich occasion ally n eeds to be surgical repair. Hardw are com plicat ion s (w h en used) in clude: breakage, pull-out, m alposition . Alth ough a rare com plication, it is serious enough that it bears m en tioning in cases positioned prone w ith possible sign ifican t blood loss (> 2 L): blin dn ess (due to PION (p. 1056) ) Evid en ce-Based Med icin e: Defin it ion s. Th ese defin ition s are referred to in th e “Pract ice guide- line” boxes. St rength of recom m endat ion Descript ion Level I, II, IIIa Level A, B, C, Db Level I Level A Based on consistent Class I evidence (well-designed, High degree of clinical certaint y prospective randomized controlled studies) Level B Single Class I study or consistent Class II evidence or strong Class II evidence especially when circum stances preclude randomized clinical trials Level II Level C Usually derived from Class II evidence (one or m ore well-designed comparative clinical studies or less well- Moderate degree of clinical certainty designed randomized studies) or a preponderance of Class III evidence Level III Level D Generally based on Class III evidence (case series, Unclear clinical certaint y historical controls, case report s and expert opinion). Useful for educational purposes and to guide future research a as used in the Guidelines for the Managem ent of Severe Traum atic Brain Injury, 3rd edition (Brain Trauma Foundation: Introduction. J Neurotraum a 24, Suppl 1: S1–2, 2007). b as used in the Guidelines for the Surgical Managem ent of Cervical Degenerative Disease (Mat z P G, et al.: Introduction and m ethodology. J Neurosurg: Spine 11 (2): 101–3, 2009).

29 Cont ent s Anat om y and Physiology 1 Gross Anat om y, Cranial and Spine . . . . . . . . . . . . . . . . 58 1.1 Cort ical surface anat om y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 1.2 Cent ral sulcus on axial im aging . . . . . . . . . . . . . . . . . . . . . . . . . . 60 1.3 Surface anat om y of t he cranium . . . . . . . . . . . . . . . . . . . . . . . . . 61 1.4 Surface landm arks of spine le ve ls . . . . . . . . . . . . . . . . . . . . . . . . 65 1.5 Cranial foram ina and t he ir cont ent s . . . . . . . . . . . . . . . . . . . . . . 65 1.6 Int e rnal capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 1.7 Cerebe llopont ine angle anat om y . . . . . . . . . . . . . . . . . . . . . . . . 67 1.8 Occipit oat lant oaxial-com plex anat om y . . . . . . . . . . . . . . . . . . 68 1.9 Spinal cord anat om y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 2 Vascu lar An at o m y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 2.1 Cerebral vascular t errit ories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 2.2 Cerebral art e rial anat om y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 2.3 Cerebral venous anat om y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 2.4 Spinal cord vasculat ure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 3 Neurophysiology and Regional Brain Syndrom es 90 3.1 Ne urophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 3.2 Regional brain syndrom es . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 3.3 Jugular foram en syndrom es . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 General and Neurology 4 Ne u ro a n e st h e sia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 4.1 General inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 4.2 Drugs use d in neuroanest hesia . . . . . . . . . . . . . . . . . . . . . . . . . . 104 4.3 Anest het ic requirem ent s for int ra-operat ive evoked pot e nt ial m onit oring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 4.4 Malignant hype rt herm ia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

30 Contents 5 Sodium Hom eost asis and Osm olalit y . . . . . . . . . . . . 110 5.1 Serum osm olalit y and sodium concent rat ion . . . . . . . . . . . . . 110 5.2 Hypo nat re m ia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 5.3 Hype rn at re m ia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 6 Ge n e ral Ne u ro crit ical Care . . . . . . . . . . . . . . . . . . . . . . . . . 126 6.1 Parent eral agent s for hypert e nsion . . . . . . . . . . . . . . . . . . . . . . 126 6.2 Hypot e nsion (shock) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 6.3 Acid inh ib it o rs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 7 Se dat ive s, Paralyt ics, Analgesics . . . . . . . . . . . . . . . . . . 132 7.1 Sedat ives and paralyt ics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 7.2 Paralyt ics (neurom uscular blocking agent s) . . . . . . . . . . . . . . 134 7.3 An alg e sics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 8 En d o crin o lo g y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 8.1 Cor t icost e ro id s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 8.2 Hypo t hyro id ism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 8.3 Pit uit ary em bryology and neuroendocrinology . . . . . . . . . . . 149 9 He m a t o lo g y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 9.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 9.2 Blood com ponent t herapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 9.3 Ext ram edullar y hem at opoiesis . . . . . . . . . . . . . . . . . . . . . . . . . . 171 10 Ne uro lo gy for Ne u ro su rg e on s . . . . . . . . . . . . . . . . . . . . 174 10.1 De m e n t ia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 10.2 He adache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 10.3 Parkinson ism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 10.4 Mult iple scle rosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 10.5 Acut e dissem inat ed encephalom yelit is. . . . . . . . . . . . . . . . . . . 182 10.6 Mot or neuron disease s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 10.7 Guillain -Barré syndrom e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

Contents 31 10.8 Mye lit is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 10.9 Ne u rosarcoid osis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 11 Neurovascular Disorders and Neurot oxicology . . 194 11.1 Post erior reversible encephalopat hy syndrom e (PRES) . . . . 194 11.2 Crossed cerebellar diaschisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 11.3 Vasculit is and vasculopat hy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 11.4 Ne u rot oxicolog y. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 Im aging and Diagnost ics 12 Plain Radiology and Cont rast Agent s . . . . . . . . . . . . . 212 12.1 C-Spine x-rays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 12.2 Lum bosacral (LS) spine x-rays . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 12.3 Sku ll x-rays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 12.4 Cont rast age nt s in neuroradiology . . . . . . . . . . . . . . . . . . . . . . . 219 12.5 Radiat ion safet y for neurosurge ons . . . . . . . . . . . . . . . . . . . . . . 223 13 Im ag in g an d An g io g rap hy . . . . . . . . . . . . . . . . . . . . . . . . . 227 13.1 CAT scan (AKA CT scan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 13.2 Magnet ic resonance im aging (MRI) . . . . . . . . . . . . . . . . . . . . . . 228 13.3 Ang io graph y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 13.4 Mye log raph y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 13.5 Radionuclide scanning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 14 Ele ct ro d iag n o st ics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 14.1 Elect roence phalogram (EEG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 14.2 Evoke d p ot e nt ials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 14.3 NCS/ EMG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 Developm ent al Anom alies 15 Prim ary Int racranial Anom alie s . . . . . . . . . . . . . . . . . . . 248 15.1 Arachnoid cyst s, int racranial . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 15.2 Craniofacial developm ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

32 Contents 15.3 Dandy Walker m alform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256 15.4 Aque duct al st e nosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258 15.5 Agene sis of t he corpus callosum . . . . . . . . . . . . . . . . . . . . . . . . . 259 15.6 Absence of t he se pt um pe llucidum . . . . . . . . . . . . . . . . . . . . . . 260 15.7 Int racranial lipom as . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260 15.8 Hypot halam ic ham art om as . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 16 Prim ar y Sp in al An om alie s . . . . . . . . . . . . . . . . . . . . . . . . . 265 16.1 Spinal arachnoid cyst s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 16.2 Spinal dysraphism (spina bifida) . . . . . . . . . . . . . . . . . . . . . . . . . 265 16.3 Klippe l-Fe il syndrom e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 16.4 Tet hered cord syndrom e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272 16.5 Split cord m alform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 16.6 Lum bosacral nerve root anom alie s . . . . . . . . . . . . . . . . . . . . . . 275 17 Prim ary Craniospinal Anom alie s . . . . . . . . . . . . . . . . . . 277 17.1 Chiari m alform at ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 17.2 Ne ural t ube de fe ct s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 17.3 Ne ure n t e ric cyst s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290 Com a and Brain Deat h 18 Co m a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 18.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 18.2 Po st u ring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 18.3 Et iologie s of com a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 18.4 He rniat ion syndrom es . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302 18.5 Hypoxic com a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 19 Brain Deat h and Organ Donat ion . . . . . . . . . . . . . . . . . 307 19.1 Brain de at h in adult s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 19.2 Brain de at h crit e ria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 19.3 Brain deat h in children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312 19.4 Organ and t issue donat ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313

Contents 33 Infect ion 20 Bact erial Infect ions of t he Parenchym a and Me ninge s and Com ple x Infect ions . . . . . . . . . . . . . . . . 318 20.1 Me ning it is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318 20.2 Ce re bral absce ss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 20.3 Su b du ral e m pye m a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 20.4 Neurologic involve m ent in HIV/AIDS . . . . . . . . . . . . . . . . . . . . . 329 20.5 Lym e disease – neurologic m anifest at ions . . . . . . . . . . . . . . . . 334 20.6 Nocardia brain abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 21 Skull, Spine, and Post -Surgical Infect ions . . . . . . . . 339 21.1 Sh u nt in fe ct ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 21.2 Ext ernal vent ricular drain (EVD)-relat ed infect ion . . . . . . . . . 342 21.3 Wou nd infe ct io ns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 21.4 Ost e om yelit is of t he skull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348 21.5 Sp in e infe ct io ns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349 22 Ot h e r No n bact e rial In fe ct io n s . . . . . . . . . . . . . . . . . . . . . 364 22.1 Viral e nce phalit is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364 22.2 Cre ut zfeldt -Jakob disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367 22.3 Parasit ic infect ions of t he CNS . . . . . . . . . . . . . . . . . . . . . . . . . . . 371 22.4 Fungal infect ions of t he CNS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376 22.5 Am e bic infe ct ions of t he CNS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 Hydrocephalus and Cerebrospinal Fluid (CSF) 23 Ce re b ro sp in al Flu id . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382 23.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382 23.2 Prod uct io n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382 23.3 Absorp t io n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382 23.4 CSF co nst it u e n t s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382 23.5 Cranial CSF fist ula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384 23.6 Sp in al CSF fist u la . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386 23.7 Meningit is in CSF fist ula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386

34 Contents 23.8 Evaluat ion of t he pat ient w it h CSF fist ula . . . . . . . . . . . . . . . . 387 23.9 Tre at m e nt for CSF fist ula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388 23.10 Int racranial hypot ension (spont aneous). . . . . . . . . . . . . . . . . . 389 24 Hydroce phalus – Ge ne ral Aspect s . . . . . . . . . . . . . . . . 394 24.1 Basic d e finit io n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394 24.2 Epide m io lo gy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394 24.3 Et iologies of hydrocephalus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394 24.4 Signs and sym pt om s of HCP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395 24.5 CT/MRI crit eria of hydrocephalus . . . . . . . . . . . . . . . . . . . . . . . . 398 24.6 Di erent ial diagnosis of hydrocephalus . . . . . . . . . . . . . . . . . . 399 24.7 Chro nic HCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400 24.8 Ext ernal hydrocephalus (AKA benign ext ernal hydrocepha- lus) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400 24.9 X-linke d hydrocephalus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401 24.10 “Arre st ed hydrocephalus” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402 24.11 Ent rappe d fourt h ve nt ricle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402 24.12 Norm al pressure hydrocephalus (NPH). . . . . . . . . . . . . . . . . . . 403 24.13 Hydrocephalus and pre gnancy . . . . . . . . . . . . . . . . . . . . . . . . . . 410 25 Tre at m e n t o f Hyd roce p h alus . . . . . . . . . . . . . . . . . . . . . . 414 25.1 Medical t reat m ent of hydrocephalus . . . . . . . . . . . . . . . . . . . . 414 25.2 Spinal t ap s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 25.3 Surg ical. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 25.4 Endoscopic t hird ve nt riculost om y . . . . . . . . . . . . . . . . . . . . . . . 415 25.5 Shu nt s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416 25.6 Shu nt p rob le m s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419 25.7 Spe cific shunt syst em s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427 25.8 Surgical insert ion t echniques . . . . . . . . . . . . . . . . . . . . . . . . . . . 435 25.9 Inst ruct ions t o pat ient s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435

Contents 35 Se izu r e s 26 Seizure Classificat ion and Ant i-Convulsant Ph a rm a co lo g y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440 26.1 Se izure classificat ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440 26.2 Ant ie pile pt ic drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443 27 Sp e cial Type s o f Se izu re s . . . . . . . . . . . . . . . . . . . . . . . . . . . 461 27.1 Ne w onse t se izure s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461 27.2 Post t raum at ic seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462 27.3 Alcohol w it hdraw al seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464 27.4 Nonepilept ic seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464 27.5 Fe b rile se izu re s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467 27.6 St at us e pile pt icus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468 Pain 28 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476 28.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476 28.2 Neuropat hic pain syndrom e s . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476 28.3 Craniofacial pain syndrom es. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477 28.4 Post he rpet ic neuralgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493 28.5 Com plex regional pain syndrom e (CRPS) . . . . . . . . . . . . . . . . . 497 Peripheral Nerves 29 Perip h e ra l Ne r ve s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504 29.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504 29.2 Muscle inne rvat ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506 29.3 Peripheral ne rve injury/surgery. . . . . . . . . . . . . . . . . . . . . . . . . . 509 30 En t rap m e nt Ne u rop at hie s . . . . . . . . . . . . . . . . . . . . . . . . . 515 30.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515 30.2 Me chanism of injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515 30.3 Occipit al ner ve ent rapm ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515

36 Contents 30.4 Median nerve ent rapm ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517 30.5 Ulnar nerve ent rapm ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 526 30.6 Radial nerve injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532 30.7 Axillary nerve injurie s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533 30.8 Suprascapular ne rve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533 30.9 Meralgia parest het ica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534 30.10 Obt urat or nerve ent rapm ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535 30.11 Fem oral nerve ent rapm ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535 30.12 Com m on pe rone al nerve palsy . . . . . . . . . . . . . . . . . . . . . . . . . . 535 30.13 Tarsal t un ne l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 538 31 Non -Ent rapm ent Peripheral Neuropat hies . . . . . . . 541 31.1 De fin it ion s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541 31.2 Et iologies of peripheral neuropat hy . . . . . . . . . . . . . . . . . . . . . 541 31.3 Classificat ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541 31.4 Clinical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 542 31.5 Syndrom es of peripheral neuropat hy . . . . . . . . . . . . . . . . . . . . 542 31.6 Peripheral nerve injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 550 31.7 Missile injuries of peripheral nerves . . . . . . . . . . . . . . . . . . . . . 553 31.8 Thoracic out let syndrom e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 554 Neuropht halm ology and Neurot ology 32 Ne u ro p h t h alm o lo g y. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558 32.1 Nyst ag m u s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558 32.2 Pap ille de m a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558 32.3 Visual fie ld s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559 32.4 Visual fie ld de ficit s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559 32.5 Pupillary diam e t e r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560 32.6 Ext raocular m uscle (EOM) syst e m . . . . . . . . . . . . . . . . . . . . . . . 565 32.7 Ne uropht halm ologic syndrom es . . . . . . . . . . . . . . . . . . . . . . . . 569 32.8 Miscellaneous neuropht halm ologic signs . . . . . . . . . . . . . . . . 570

Contents 37 33 Ne u ro t o lo g y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572 33.1 Dizzine ss and ve rt igo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572 33.2 Me nie re’s dise ase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573 33.3 Facial ne r ve p alsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 576 33.4 He aring loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580 Prim ary Tum ors of t he Nervous and Relat ed Syst em s: Tum ors of Neuroepit helial Tissue 34 General Inform at ion, Classificat ion and Tum or Ma rke rs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584 34.1 Classificat ion of nervous syst em t um ors . . . . . . . . . . . . . . . . . 584 34.2 Brain t um ors – general clinical aspect s . . . . . . . . . . . . . . . . . . . 590 34.3 Pediat ric brain t um ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593 34.4 Medicat ions for brain t um ors. . . . . . . . . . . . . . . . . . . . . . . . . . . . 594 34.5 Chem ot herapy for brain t um ors . . . . . . . . . . . . . . . . . . . . . . . . . 595 34.6 Int raoperat ive pat hology consult at ions (“frozen sect ion”). 596 34.7 Select com m only ut ilized st ains in neuropat hology . . . . . . . 598 35 Syn d ro m e s Invo lvin g Tu m ors . . . . . . . . . . . . . . . . . . . . . . 603 35.1 Neurocut aneous disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 603 35.2 Fam ilial t um or syndrom es . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610 36 Ast ro cyt o m a s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612 36.1 Incidence, risk fact ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612 36.2 Classificat ion and grading of ast rocyt ic t um ors . . . . . . . . . . . 612 36.3 Molecular gene t ics and epige net ics . . . . . . . . . . . . . . . . . . . . . . 616 36.4 Miscellaneous pat hological feat ures . . . . . . . . . . . . . . . . . . . . . 617 36.5 Neuroradiological grading and findings . . . . . . . . . . . . . . . . . . 617 36.6 Sp re ad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618 36.7 Mult ip le glio m as . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619 36.8 Tre at m e n t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619 36.9 Out co m e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624

38 Contents 37 Ot h e r Ast ro cyt ic Tu m o rs . . . . . . . . . . . . . . . . . . . . . . . . . . . 629 37.1 Pilocyt ic ast rocyt om as . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629 37.2 Pleom orphic xant hoast rocyt om a (PXA) . . . . . . . . . . . . . . . . . . 635 38 Oligodendroglial Tum ors and Tum ors of t he 638 Ependym a, Choroid Plexus, and Ot her 38.1 Ne uro e p it h e lial Tu m o rs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638 38.2 641 38.3 Oligodendroglial t um ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642 38.4 Oligoast rocyt ic t um ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 645 38.5 Epe nd ym al t u m o rs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 648 38.6 Ne uronal and m ixed glial t um ors . . . . . . . . . . . . . . . . . . . . . . . . 649 Choroid plexus t um ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Ot her neuroepit helial t um ors . . . . . . . . . . . . . . . . . . . . . . . . . . . 39.1 Neuronal and Mixed Neuronal-Glial Tum ors . . . . . 651 39.2 39.3 Gan glio glio m a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651 Paragan glio m a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 652 40 Ne uro blast o m as . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 657 40.1 Pineal Region and Em bryonal Tum ors . . . . . . . . . . . . 658 40.2 Pine al re gion t um ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 658 41 Em b r yon al t um ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663 41.1 Tum ors of Cranial, Spinal and Peripheral Nerves 670 41.2 Ve st ibular schw annom a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 670 42 Tum ors of peripheral nerves: Perineuriom a . . . . . . . . . . . . . . 687 42.1 Me n in g io m a s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690 42.2 42.3 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690 42.4 Epide m io lo gy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690 42.5 Com m o n lo cat io ns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690 42.6 Pat holog y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693 Pre se nt at io n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 695 Evaluat io n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 695

Contents 39 42.7 Tre at m e n t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 696 42.8 Out co m e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 698 43 Ot her Tum ors Relat ed t o t he Meninges . . . . . . . . . . 701 43.1 Mesenchym al, non -m eningot helial t um ors . . . . . . . . . . . . . . . 701 43.2 Prim ar y m elanocyt ic le sions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701 43.3 He m angioblast om a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701 Tum ors Involving Non-Neural Origin: Met ast ases, Lym phom as, Chordom as 44 Lym phom as and Hem at opoiet ic Neoplasm s . . . . . 710 44.1 CNS lym ph o m a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 710 44.2 Mult ip le m ye lo m a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 714 44.3 Plasm acyt om a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 716 45 Pit uit ary Tum ors – General Inform at ion and Cla ssifica t io n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 718 45.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 718 45.2 Ge ne ral t um or t ype s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 718 45.3 Ep id e m io lo gy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 718 45.4 Di erent ial diagnosis of pit uit ary t um ors . . . . . . . . . . . . . . . . 718 45.5 Clinical present at ion of pit uit ary t um ors . . . . . . . . . . . . . . . . . 719 45.6 Specific t ype s of pit uit ary t um ors . . . . . . . . . . . . . . . . . . . . . . . . 721 46 Pit uit ary Adenom as – Evaluat ion and No nsu rgical Man ag e m e n t . . . . . . . . . . . . . . . . . . . . . . . . . 730 46.1 Evalu at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 730 46.2 Managem ent /t reat m ent recom m endat ions . . . . . . . . . . . . . . 737 46.3 Radiat ion t herapy for pit uit ary adenom as . . . . . . . . . . . . . . . . 744 47 Pit uit ary Adenom as – Surgical Managem ent , Out com e, and Recurrence Managem ent . . . . . . . . . 747 47.1 Surgical t reat m ent for pit uit ary adenom as . . . . . . . . . . . . . . . 747 47.2 Out com e follow ing t ranssphenoidal surgery . . . . . . . . . . . . . 753 47.3 Managem ent of recurrent pit uit ary adenom as . . . . . . . . . . . . 755

40 Contents 48 Cyst s an d Tu m o r-Like Le sion s . . . . . . . . . . . . . . . . . . . . . 756 48.1 Rat hke’s cleft cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 756 48.2 Collo id cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 756 48.3 Epiderm oid and derm oid t um ors . . . . . . . . . . . . . . . . . . . . . . . . 760 48.4 Craniopharyngiom a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 763 49 Pseudot um or Cerebri and Em pt y Sella Syn d ro m e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 766 49.1 Pseudot um or cerebri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 766 49.2 Em pt y sella syndrom e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 773 50 Tum ors and Tum or-Like Lesions of t he Skull. . . . . 775 50.1 Skull t u m o rs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775 50.2 Non -ne oplast ic skull le sions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 779 51 Tum ors of t he Spine and Spinal Cord . . . . . . . . . . . . . 783 51.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 783 51.2 Com part m ent al locat ions of spinal t um ors . . . . . . . . . . . . . . . 783 51.3 Di erent ial diagnosis: spine and spinal cord t um ors . . . . . . 783 51.4 Int radural ext ram edullary spinal cord t um ors . . . . . . . . . . . . 785 51.5 Int ram edullar y spinal cord t um ors . . . . . . . . . . . . . . . . . . . . . . 787 51.6 Prim ar y bone t um ors of t he spine . . . . . . . . . . . . . . . . . . . . . . . 792 52 Ce re b ral Me t ast ase s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800 52.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800 52.2 Met ast ases t o t he brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800 52.3 Met ast ases of prim ary CNS t um ors . . . . . . . . . . . . . . . . . . . . . . 800 52.4 Locat ion of cerebral m et s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801 52.5 Prim ary cancers in pat ient s w it h cerebral m et ast ases . . . . . 801 52.6 Clinical present at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 805 52.7 Evaluat io n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 806 52.8 Managem ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 806 52.9 Ou t com e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 810 52.10 Carcinom at ous m eningit is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811

Contents 41 53 Sp in al Epidu ral Me t ast ase s . . . . . . . . . . . . . . . . . . . . . . . . 814 53.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 814 53.2 Prim ary t um ors t hat m et ast asize t o t he spine . . . . . . . . . . . . 814 53.3 Pre se n t at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 814 53.4 Evaluat ion and m anagem ent of epidural spinal m et ast ases 815 Head Traum a 54 General Inform at ion, Grading, Init ial Man ag e m e n t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824 54.1 54.2 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824 54.3 Grading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824 54.4 Transfer of t raum a pat ient s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 825 54.5 Manage m e n t in E/R. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 826 54.6 Radiographic evaluat ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 832 54.7 Adm it t ing orders for m inor or m oderat e head injury. . . . . . 834 54.8 Pat ient s w it h associat ed severe syst em ic injuries . . . . . . . . . 834 Explorat or y burr holes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 836 55 Concussion, High-Alt it ude Cerebral Edem a, Ce re b rovascu lar In jurie s . . . . . . . . . . . . . . . . . . . . . . . . . . . 841 55.1 55.2 Con cussio n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 841 55.3 Ot her TBI definit ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 848 55.4 High -alt it ude cerebral e dem a . . . . . . . . . . . . . . . . . . . . . . . . . . . 848 Traum at ic cervical art ery dissect ions . . . . . . . . . . . . . . . . . . . . . 849 56 Ne u ro m o n it o rin g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 856 56.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 856 56.2 Int racranial pressure (ICP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 856 56.3 Adjunct s t o ICP m onit oring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 865 56.4 Treat m ent m easures for elevat ed ICP . . . . . . . . . . . . . . . . . . . . 866 57 Sku ll Fra ct u re s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 882 57.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 882 57.2 Linear skull fract ures over t he convexit y . . . . . . . . . . . . . . . . . 882

42 Contents 57.3 De pressed skull fract ures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 882 57.4 Basal skull fract ures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 884 57.5 Craniofacial fract ures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 886 57.6 Pn e um oce ph alu s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 887 58 Traum at ic He m orrhagic Condit ions . . . . . . . . . . . . . . 891 58.1 Post t raum at ic parenchym al injuries . . . . . . . . . . . . . . . . . . . . . 891 58.2 He m orrhagic cont usion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 891 58.3 Epidural he m at om a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 892 58.4 Acut e subdural hem at om a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 895 58.5 Chronic subdural hem at om a . . . . . . . . . . . . . . . . . . . . . . . . . . . . 898 58.6 Spont aneous subdural hem at om a . . . . . . . . . . . . . . . . . . . . . . . 901 58.7 Traum at ic subdural hygrom a . . . . . . . . . . . . . . . . . . . . . . . . . . . . 902 58.8 Ext raaxial fluid collect ions in children. . . . . . . . . . . . . . . . . . . . 903 58.9 Traum at ic post erior fossa m ass lesions . . . . . . . . . . . . . . . . . . 905 59 Gunshot Wounds and Non-Missile Penet rat ing 908 Bra in In ju rie s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59.1 908 59.2 Gunshot w ounds t o t he he ad . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911 Non -m issile pe net rat ing t raum a . . . . . . . . . . . . . . . . . . . . . . . . . 60 Ped iat ric He ad In ju r y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 913 60.1 60.2 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 913 60.3 Managem ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 913 60.4 Ou t com e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 914 60.5 Ce p halhe m at o m a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 914 60.6 Skull fract ure s in pe diat ric pat ient s . . . . . . . . . . . . . . . . . . . . . . 914 Nonaccident al t raum a (NAT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 916 61 Head Injury: Long-Term Managem ent , 61.1 Co m p licat io n s, Out com e . . . . . . . . . . . . . . . . . . . . . . . . . . 918 61.2 61.3 Airw ay m anage m e nt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 918 Deep -vein t hrom bosis (DVT) prophylaxis . . . . . . . . . . . . . . . . 918 Nut rit ion in t he head-injured pat ient . . . . . . . . . . . . . . . . . . . . 918

Contents 43 61.4 Post t raum at ic hydrocephalus . . . . . . . . . . . . . . . . . . . . . . . . . . . 920 61.5 Out com e from he ad t raum a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 920 61.6 Lat e com plicat ions from t raum at ic brain injury . . . . . . . . . . . 923 Spine Traum a 62 General Inform at ion, Neurologic Assessm ent , 930 Whiplash and Sport s-Relat ed Injuries, Pediat ric 62.1 Sp in e In ju rie s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62.2 62.3 Int ro du ct io n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 930 62.4 Te rm in olog y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 930 62.5 Whiplash -associat ed disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 931 62.6 Pediat ric spine injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 933 62.7 Ce r vical bracin g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 935 62.8 Follow -up sche dule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 935 62.9 Sport s-relat ed cervical spine injuries . . . . . . . . . . . . . . . . . . . . . 935 Neurological asse ssm ent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939 Spinal cord injurie s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 943 63 Managem ent of Spinal Cord Injury. . . . . . . . . . . . . . . . 949 63.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 949 63.2 Managem ent in t he fie ld . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 949 63.3 Managem ent in t he hospit al. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 950 63.4 Radiographic evaluat ion and init ial C-spine im m obilizat ion 952 63.5 Tract ion/reduct ion of cervical spine injuries . . . . . . . . . . . . . . 957 63.6 Indicat ions for em ergency decom pressive surgery . . . . . . . . 960 64 Occipt oat lant oaxial Injuries (Occiput t o C2) . . . . . 963 64.1 At lant o -occipit al dislocat ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 963 64.2 Occipit al condyle fract ure s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 966 64.3 At lant oaxial subluxat ion/dislocat ion . . . . . . . . . . . . . . . . . . . . . 968 64.4 At las (C1) fract ure s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 971 64.5 Axis (C2) fract ure s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 972 64.6 Com binat ion C1–2 injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 982

44 Contents 65 Subaxial (C3 t hrough C7) Injuries / Fract ures . . . . 986 65.1 Classificat ion syst em s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 986 65.2 Clay shoveler’s fract ure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 988 65.3 Ve rt ical com pression injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . 989 65.4 Flexion injuries of t he subaxial cervical spine . . . . . . . . . . . . . 989 65.5 Dist ract ion fle xion injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 991 65.6 Ext ension injuries of t he subaxial cervical spine . . . . . . . . . . 994 65.7 Treat m ent of subaxial cervical spine fract ures . . . . . . . . . . . . 996 65.8 Spinal cord injury w it hout radiographic abnorm alit y (SCIWORA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 999 66 Thoracic, Lum bar and Sacral Spine Fract ures . . . . 1002 66.1 Assessm ent and m anagem ent of t horacolum bar fract ures 1002 66.2 Surgical t re at m e nt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007 66.3 Ost eoporot ic spine fract ure s . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1008 66.4 Sacral fract u re s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1014 67 Penet rat ing Spine Injuries and Long Term Manag e m e n t / Co m plicat io ns . . . . . . . . . . . . . . . . . . . . . 1017 67.1 Gunshot w ounds t o t he spine . . . . . . . . . . . . . . . . . . . . . . . . . . . 1017 67.2 Penet rat ing t raum a t o t he ne ck . . . . . . . . . . . . . . . . . . . . . . . . . 1017 67.3 De layed cervical inst abilit y. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1019 67.4 Delayed det eriorat ion follow ing spinal cord injuries . . . . . . 1019 67.5 Chronic m anagem ent issues w it h spinal cord injuries . . . . . 1020 Spine and Spinal Cord 68 Low Back Pain and Radiculopat hy . . . . . . . . . . . . . . . . 1024 68.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1024 68.2 Int e rve rt e bral disc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1024 68.3 Nom e nclat ure for disc pat hology . . . . . . . . . . . . . . . . . . . . . . . . 1024 68.4 Ve rt e bral body m arrow changes . . . . . . . . . . . . . . . . . . . . . . . . 1025 68.5 Clinical t e rm s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1025 68.6 Disabilit y, pain and out com e det erm inat ions . . . . . . . . . . . . . 1026

Contents 45 68.7 Di erent ial diagnosis of low back pain . . . . . . . . . . . . . . . . . . . 1026 68.8 Init ial assessm ent of t he pat ient w it h back pain . . . . . . . . . . 1026 68.9 Radiographic evaluat ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1029 68.10 Elect rodiagnost ics for low back problem s . . . . . . . . . . . . . . . . 1032 68.11 Bone scan for low back problem s . . . . . . . . . . . . . . . . . . . . . . . . 1032 68.12 Therm ography for low back problem s . . . . . . . . . . . . . . . . . . . 1033 68.13 Psychosocial fact ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1033 68.14 Tre at m e n t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1033 68.15 Chronic low back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1037 68.16 Coccyd yn ia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1038 68.17 Failed back surgery syndrom e . . . . . . . . . . . . . . . . . . . . . . . . . . . 1039 69 Lum bar and Thoracic Int ervert ebral Disk He rn iat io n / Rad icu lo p at hy . . . . . . . . . . . . . . . . . . . . . . . . 1046 69.1 Lum bar disc herniat ion and lum bar radiculopat hy . . . . . . . . 1046 69.2 Thoracic disc herniat ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1061 70 Ce r vical Disc He rniat io n . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1069 70.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1069 70.2 Cervical nerve root syndrom es (cervical radiculopat hy) . . . 1069 70.3 Cervical m yelopat hy and SCI due t o cervical disc h e rniat io n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1069 70.4 Di ere nt ial diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1070 70.5 Physical exam for cervical disc herniat ion . . . . . . . . . . . . . . . . 1070 70.6 Radiologic evaluat ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1070 70.7 Tre at m e n t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1071 71 Degenerat ive Cervical Disc Disease and Cervical Mye lo p a t h y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1083 71.1 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1083 71.2 Pat hop hysio lo gy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1083 71.3 Clin ical. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1084 71.4 Di ere nt ial diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1086 71.5 Evalu at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1088 71.6 Tre at m e n t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1090 71.7 Coincident cervical and lum bar spinal st enosis. . . . . . . . . . . . 1093

46 Contents 72 Thoracic and Lum bar Degenerat ive Disc Disease 1096 72.1 General inform at ion about degenerat ive disc disease 1096 (DDD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1096 72.2 Anat om ic subst rat e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1099 72.3 Risk fact ors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1099 72.4 Associat e d condit ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1099 72.5 Clinical present at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1101 72.6 Di erent ial diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1101 72.7 Diagnost ic evaluat ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1103 72.8 Tre at m e nt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1108 72.9 Ou t com e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Adult Spinal Deform it y and Degenerat ive Sco lio sis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1111 73.1 73.2 Ge ne ral inform at ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1111 73.3 Epide m io lo gy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1111 73.4 Clinical e valuat ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1111 73.5 Diagnost ic t e st ing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1111 73.6 Pert ine nt spine m easurem e nt s . . . . . . . . . . . . . . . . . . . . . . . . . . 1112 73.7 SRS-Schw ab classificat ion of adult spinal deform it y. . . . . . . 1112 Tre at m e nt /m anagem e nt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1113 74 Spe cial Condit ions A e ct ing t he Spine . . . . . . . . . . . 1120 74.1 74.2 Paget ’s disease of t he spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1120 74.3 Ankylosing spondylit is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1123 74.4 Ossificat ion of t he post erior longit udinal ligam ent (OPLL) . 1127 74.5 Ossificat ion of t he ant erior longit udinal ligam ent (OALL). . 1129 74.6 Di use idiopat hic skelet al hyperost osis (DISH) . . . . . . . . . . . 1129 74.7 Scheuerm ann’s kyphosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1130 74.8 Spinal epidural hem at om a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1131 Spinal subdural hem at om a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1131

Contents 47 75 Ot her Non-Spine Condit ions w it h Spine Im p lica t io n s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1134 75.1 Rheum at oid art hrit is. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1134 75.2 Do w n syn dro m e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1138 75.3 Morb id ob e sit y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1139 76 Special Condit ions A ect ing t he Spinal Cord . . . . 1140 76.1 Spinal vascular m alform at ions . . . . . . . . . . . . . . . . . . . . . . . . . . . 1140 76.2 Spinal m eninge al cyst s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1142 76.3 Juxt aface t cyst s of t he lum bar spine . . . . . . . . . . . . . . . . . . . . . 1143 76.4 Syrin go m ye lia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1144 76.5 Post t raum at ic syringom yelia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1148 76.6 Spinal cord herniat ion (idiopat hic) . . . . . . . . . . . . . . . . . . . . . . . 1150 76.7 Spinal epidural lipom at osis (SEL). . . . . . . . . . . . . . . . . . . . . . . . . 1150 76.8 Craniocervical junct ion and upper cervical spine ab n orm alit ie s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1151 SAH and Aneurysm s 77 Int roduct ion and General Inform at ion, Grading, Medical Managem ent , Special Condit ions . . . . . . . 1156 77.1 Int roduct ion and overvie w . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1156 77.2 Et iolog ie s o f SAH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1156 77.3 Incid e n ce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1157 77.4 Risk fact ors for SAH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1157 77.5 Clin ical fe at ure s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1157 77.6 Work-up of suspect e d SAH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1159 77.7 Grading SAH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1162 77.8 Init ial m anagem ent of SAH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1163 77.9 Re ble e ding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1167 77.10 Pregnancy and int racranial hem orrhage . . . . . . . . . . . . . . . . . . 1169 77.11 Hydrocephalus aft e r SAH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1170

48 Contents 78 Crit ical Care of Aneurysm Pat ient s . . . . . . . . . . . . . . . 1177 78.1 Neurogenic st ress cardiom yopat hy (NSC) . . . . . . . . . . . . . . . . 1177 78.2 Ne urogenic pulm onar y edem a . . . . . . . . . . . . . . . . . . . . . . . . . . 1178 78.3 Vasospasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1178 78.4 Post -op orders for aneurysm clipping . . . . . . . . . . . . . . . . . . . . 1186 79 SAH from Cerebral Ane urysm Rupt ure . . . . . . . . . . . 1191 79.1 Epidem iology of cerebral aneurysm s . . . . . . . . . . . . . . . . . . . . 1191 79.2 Et iology of cerebral aneuysm s. . . . . . . . . . . . . . . . . . . . . . . . . . . 1191 79.3 Locat ion of cerebral ane urysm s . . . . . . . . . . . . . . . . . . . . . . . . . 1191 79.4 Prese nt at ion of cerebral aneurysm s . . . . . . . . . . . . . . . . . . . . . 1191 79.5 Condit ions associat ed w it h aneurysm s. . . . . . . . . . . . . . . . . . . 1193 79.6 Tre at m e nt opt ions for ane urysm s . . . . . . . . . . . . . . . . . . . . . . . 1194 79.7 Tim ing of aneur ysm surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1199 79.8 General t echnical considerat ions of aneurysm surgery . . . . 1200 80 An e u r ysm Type by Locat ion . . . . . . . . . . . . . . . . . . . . . . . 1210 80.1 Ant erior com m unicat ing art ery aneurysm s . . . . . . . . . . . . . . 1210 80.2 Dist al ant erior cerebral art ery aneurysm s . . . . . . . . . . . . . . . . 1211 80.3 Post erior com m unicat ing art ery aneurysm s. . . . . . . . . . . . . . 1212 80.4 Carot id t erm inus (bifurcat ion) aneurysm s. . . . . . . . . . . . . . . . 1213 80.5 Middle cerebral art ery (MCA) aneurysm s . . . . . . . . . . . . . . . . 1213 80.6 Supraclinoid aneurysm s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1214 80.7 Post erior circulat ion ane urysm s . . . . . . . . . . . . . . . . . . . . . . . . . 1215 81 Special Aneurysm s and Non-Aneurysm al SAH. . . 1222 81.1 Unrupt ured aneur ysm s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1222 81.2 Mult iple ane urysm s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1226 81.3 Fam ilial ane urysm s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1226 81.4 Traum at ic ane ur ysm s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1227 81.5 Mycot ic ane urysm s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1228 81.6 Giant an e ur ysm s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1229 81.7 Cort ical subarachnoid he m orrhage . . . . . . . . . . . . . . . . . . . . . . 1230 81.8 SAH of unknow n et iology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1230 81.9 Pret runcal nonaneurysm al SAH (PNSAH) . . . . . . . . . . . . . . . . . 1231