Comprehensive management of traumatic HNP.pptx

Comprehensive management of traumatic herniated nucleus pulposus

1. 3 BROCA rd BALI NEUROSURGERY CLINICAL UPDATE Comprehensive Management of Traumatic Herniated Nucleus Pulposus Neurosurgery Division, Department of Surgery, Faculty of Medicine, Udayana University, Prof. Dr. IGNG Ngoerah General Hospital, Denpasar, Bali, Indonesia dr. I Nyoman Gde Wahyudana , Sp.BS , Subsp.TB , FINSS MULTIDISCIPLINARY APPROACH TO NEUROTRAUMA Emphasizing the Importance of Collaboration Between Neurosurgeons, General Practitioners, and Other Specialists in the Effective Management of Neurotrauma Cases September 21-22, 2024

2. Anatomy of The Cervical Spine

3. Anatomy of The Thoracic Spine

4. Anatomy of The Lumbar Spine

5. Anatomy of The Sacral Spine

6. Dermatomes

7. Mechanisms of Injury

8. Definition

9. Clinical Presentation

10. Physical Findings

11. Imaging

12. Imaging MRI: The gold standard for assessing soft tissue injuries, including herniated discs, ligamentous injuries, and spinal cord compression. It provides detailed images of the intervertebral discs and neural structures, making it critical for diagnosing traumatic HNP.

13. Classification

14. Classification

15. Primary Survey Oxygenation NG tube to suction: prevent vomiting, aspiration, decompress abdomen Indwelling urinary catheter Temperature regulation --> cooling blanket Treat electrolyte imbalance Proceed to Secondary Survey After Primary survey completed ABCDEs are reassessed Vital functions are returning to normal

16. Initial Management

17. Conservative Treatment

18. Indication for Surgery

19. Surgery

20. Instrumentation

21. Instrumentation

22. Instrumentation

23. Instrumentation 1. Bone awl  Perforate outer cortex of pedicle 2. Pedicle probe  as path finder to open pedicle canal 3. Sound probe  ensure path is surrounded by bone

24. Instrumentation Taps Wrench

25. ACDF

26. Position and Incision Supine position, with the shoulders elevated and the head maintained in a central position and slightly extended backwards Superficial landmarks include: • Hyoid C3 • Thyroid cartilage C4–5 • Cricoid C6

27. Incision Isolation and transverse or longitudinal incision of the platysma

28. ACDF Neurovasculature of the anterior cervical investing layer of deep cervical fascia

29. Dissection Retract the platysma to expose the investing layer of deep cervical fascia

30. Dissection Deep layer neurovasculature of the anterior cervical region

31. Dissection Blunt dissection of the investing layer of deep cervical fascia between the trachea, esophagus and carotid sheath medial to the sternocleidomastoid muscle

32. Dissection Deep layer neurovasculature of the left anterior cervical region with the common carotid artery retracted laterally

33. Dissection Deep layer neurovasculature of the left anterior cervical region

34. Carotid sheath, trachea and esophagus stretched apart by retractors to expose the prevertebral fascia

35. ACDF Implantation of the Caspar retractor and Incision to remove of the anterior longitudinal ligament and the annulus fibrosus outer layer of the intervertebral disc

36. ACDF Removal of osteophytes from the anterior border of the vertebral body Removal of the intervertebral disc tissue and cartilaginous Complete decompression of the spinal cord after resection of the posterior longitudinal ligament

37. ACDF Placement of the interbody cage

38. ACDF Placement of the anterior cervical titanium plate followed by screw fixation and locking

39. Lateral Mass Screw

40. Lateral Mass Screw Posterior bony structure of cervical spine

41. Lateral Mass Screw Entry points of pedicle screw and lateral mass screw

42. Lateral Mass Screw Entrance point and trajectory of three commonly used lateral mass screw placement technique

43. Lateral Mass Screw Subperiosteal exposure is performed Extending out to the lateral edge of the lateral mass.

44. Lateral Mass Screw Starting point should be created with a high-speed burr. – The center of the lateral mass is burred first. – The drill is then directed 20° cephalad and lateral, thereby avoiding the ver - tebral artery and nerve root.

45. Lateral Mass Screw

46. Lateral Mass Screw The lateral mass screws are then placed and rods are secured in place A cross connector can be applied to increase torsional rigidity

47. Lumbar Pedicle Screw

48. Lumbar Pedicle Screw Position and incision

49. Lumbar Pedicle Screw Screw placement and projection

50. Lumbar Pedicle Screw Screw placement and projection

51. Lumbar Pedicle Screw The initial exposure should involve subperiosteal dissection of the muscle to the facet joint.

52. Lumbar Pedicle Screw Tapping insertion point with Awl

53. Lumbar Pedicle Screw With gentle pressure, use probe to advance through the pedicle

54. Lumbar Pedicle Screw Use ball tip to probe the four side of the pedicle cavity Make sure there is no breach into the neural cavity

55. Lumbar Pedicle Screw The pedicle tract is tappered

56. Lumbar Pedicle Screw Insert the pedicle screw

57. Lumbar Pedicle Screw Fluoroscopy evaluation after screw insertion

58. Transforaminal Lumbar Interbody Fusion

59. Transforaminal Lumbar Interbody Fusion

60. Transforaminal Lumbar Interbody Fusion Exposure of the posterior structure of the lumbar spine L4 vertebral lamina Temporarily stabilizing the involved segments by installing connecting rod

61. Transforaminal Lumbar Interbody Fusion The inferior facet of the superior vertebra is resected with an osteotome L5 superior facet Exposure of the lateral recess and intervertebral disc

62. Transforaminal Lumbar Interbody Fusion Graft bed preparation Placement of an intervertebral fusion cage

63. Transforaminal Lumbar Interbody Fusion Place the connecting rod on the fusion side and compress the intervertebral space

64. Thank You