Προφορικές & Γραπτές Εξετάσεις Πιστοποίησης Αμερικανικής Επιτροπής Νευροχειρουργών (ABNS),
Επιμέλεια Ιωάννης Καράμπελας MD FAANS

• There is a fine balance between saying little and saying too much, between speaking/reacting speedily and anxiously and presenting your thoughts and answering their questions in a steady pace with confidence.
• Keep talking in an orderly, sequential manner. Maintain the ability to speak out your thoughts in an organized way.
• Do not say too many words; there is a “magic balance” between saying enough but not too much.

• The exam is like an interview: You must sell yourself.
• You have been preparing for this moment for many, many years and now it is the time to demonstrate all your hard work.
• And please, do not read too much into the examiners’ reactions.
• The exam is not a learning experience, you do not want to come out of the oral exam smarter than you went in.

• For each presentation consider: There is no spoon. There are no real patients in peril here.
• Can you bend space/time? Go back in time? Yes, even intra-op, this is not a real situation — bend space/time.
• No one should be trying to trick you, but examiner may want to test your commitment to a diagnostic/treatment plan. Stick to your plan.
• Unless you are way off track, there may be subtle clues about the direction the case needs to go. Slow down. Listen to what the examiner is saying/asking.

• a. History, what more would you like to know? Past history? Co-morbidities?
• b. Remember to ask for vital signs, physical exam findings, meds, family and social history (suspicion for drug addiction? genetic syndrome/phakomatosis?) and review of systems (Skin in particular!).
• c. General physical and neuro exam.
• d. Labs. ALWAYS LABS before surgery!! Especially in emergencies!!
• Ask for tests/imaging → you can get official reads!!
• Remember that imaging usually triggers discussion of surgical management.
• DDx/Plan: They want to see your everyday practice; how do you manage patients. Talk as if you are talking to a colleague. If they want to, the examiners will drive you into more and more details.

• Every case will have a complication.
• What are the possible complications and how you will prevent and deal with them should go through your mind the moment you decide to operate!! You want complications!
• By knowing how to handle them, you gain points, move on quickly, gain momentum and save time.

• Laminotomy/Laminectomy ONLY for thoracic disc herniation
• NOT puttinig an EVD in a case of acute hydrocephalus, no matter how old and sick the person is
• NOT prepping the neck/expose CCA in paraclinoid aneurysms, in some pcomms too
• NOT preserving the STA in a pterional craniotomy for aneurysm clipping
• BIOPSYING a transverse myelitis case (without mentioning it in the DDx or completing a workup of these entities)
• BIOPSYING a lesion suspicious for MS or Sarcoid
• Not doing a time out even in the dearest emergency.

• Meningioma
• High-grade and low-grade gliomas
• Metastasis (particularly to the cerebellum)
• Acoustic neuroma
• Pituitary adenoma
• Colloid cyst

• If there is a major complication or bad outcome, be prepared to discuss how to prevent it or what you would do differently.
• If a poor indication: recognize why it was a poor indication — don’t try to convince them it wasn’t — and describe how your practice has changed accordingly.
• In presenting your own cases, have a clear list of indications for each of them.
• Show the examiners that you have learned from your mistakes.
• If management was not ideal, you can say: “I was early in my career. If I had to do it again, I would probably do it this way.”

• Be methodical and organized. Examiners want to see how you think.
• Perform a thorough medical and neurological workup.
• Be comprehensive. Stay composed and confident without being arrogant.
• Try not to cite literature unless critical.
• Say you would enlist the help of other disciplines (as appropriate).
• Be aggressive with workup and complication management — “Everything is free on the boards.”
• Next slide is the next slide.
• Keep count of cases.
• Rehearse procedure setups and procedures themselves.
• Rehearse complication management.
• Make flash cards to help rehearse content.

• Do not approach this with a negative attitude: “This would never happen… I’ve done this a thousand times…”
• Not the time to “discuss” or “argue” (this applies to all parts of the exam).
• Unless it is an intraoperative event under GA: FIRST EXAMINE THE PATIENT, then describe your approach.
• In any complication: think Neurological, Regional, Systemic.
• In any complication: ALWAYS RESEND LABS (trend + confirm).
• Frame your response: “I think the safest thing to do is…”

• Examine the patient.
• Know the Modified Fisher scale (blood thickness in cisterns/ventricles).
• Nimodipine.
• Balanced fluids; avoid hypotension.
• Rule out other causes: fever/infection, electrolyte imbalance, hydrocephalus (CT), hematomas (CT).

• Proximal control: consider neck exposure/CCA control for ophthalmic/ICA wall aneurysms; sometimes for PCom/ant choroidal if ACP long/ICA trunk short (check CTA pre-op).
• If rupture: suction calmly over area and hold so you can see. Do NOT throw blind clips.
• Apply temporary clips for control.
• If controlled: raise SBP by ~20%, assess need for burst suppression; adenosine PRN; finish dissection and clip.

• Pre-op: assess coagulation status; antiplatelets/anticoagulants/thrombin inhibitors; ETOH abuse; renal failure.
• Examine the patient.
• Imaging: CT head; STAT MRI for spine.

• If in doubt: check beta-2 transferrin; mention halo test/sign.
• Delayed leak: often due to infection or hydrocephalus.
• Labs: CBC with differential, Chem, ESR/CRP.
• If systemic workup negative: CSF needed for studies (via LP or LD).
• Before rushing to obtain CSF: CT head to evaluate hydrocephalus / pneumocephalus.
• If obstructive hydrocephalus: DO NOT PLACE A LUMBAR DRAIN.
• Further tests: MRI w/o & w/ contrast to rule out infection/abscess; CT cisternogram for small leaks; CT myelogram for spinal cases.
• If no obstructive hydrocephalus: place LD, check opening pressure, send CSF studies.
• If leak stops with LD: clamp LD, get patient OOB and reassess for leak.
• If leak recurs: low threshold to return to OR for exploration/repair (pericranium/dural substitute or nasoseptal flap) and leave LD for ~5 days.
• If still leaking after repeat clamp trial: VPS or ETV (if obstructive etiology).
• For headache after intradural surgery: consider blood patch.

• Coordinate with anesthesia: ETT position, ventilation, PO2/PCO2.
• Consider: hematoma (OR ultrasound), draining vein obstruction, major sinus injury/thrombosis, hydrocephalus, air embolism, edema, positional IJ occlusion, seizure.
• Raise HOB (reverse Trendelenburg). Irrigate field.
• Mannitol/diuretics; antiseizure if suspicious seizure activity.
• Decrease PCO2 to ~28–30; get ABG.
• Drain CSF from available cisterns; drain tumor cyst if applicable.
• Intraop CSF diversion plan before start: EVD at Frazier point for PF; LD if indicated; know Payne point for frontal horn puncture.
• Deepen sedation: propofol/paralytics/barbiturates.
• Enlarge craniotomy/dural opening.
• Last resort: frontal/temporal pole resection; consider leaving bone flap off; may need temporalis resection; undermine galea for fast, tensionless closure.

• Examine the patient.
• Ensure no hematoma, residual disc, failure to fuse, etc.
• Often poorly responsive to NSAIDs/steroids/narcotics.
• Preferred: Gabapentin 100 mg TID → titrate to 300 mg TID.
• Side effects: lethargy, peripheral edema.
• Alternative: Lyrica 50 mg TID → titrate to 100 mg TID.
• May need SC stimulator; consider exploration for neuroma.

• Workup: CBC, ESR, CRP, MRI w/o & w/, CT, TTE, U/A, blood/sputum/urine cultures, consider tagged WBC study; LP/CSF studies if indicated.
• Spine: cultures, debridement, washout (e.g., 1 g vanc + 80 mg gent in 1 L if deep).
• Cranial: may need bone flap removed; cranioplasty in 3–6 months.

• ICU diagnosis is challenging; signs have poor predictive value (swelling/pain; hypoxia/tachycardia/dyspnea are non-specific).
• No finding is universal (≈30% can have normal PaO2).
• Imaging: venous doppler, CT PE protocol, V/Q scan.
• ≤10% of those evaluated have PE; only ~50% of PEs have positive venous duplex.

• Examine the patient: deltoid/supraspinatus (abduction), infraspinatus (rotation).
• Timing: immediate vs delayed; incomplete vs complete.
• Rule out hematoma, residual disc, graft displacement, etc.
• Low threshold to take back to OR and explore PRN.
• If delayed: often treat with PT.
• If no function: baseline EMG/NCS at ~3 weeks and ~6 months + MRI/CT myelogram.
• If persistent: consider nerve transfers (spinal accessory → suprascapular; triceps branch radial → deltoid; ulnar fascicle → musculocutaneous).

• Examine the patient: anterior neck incision inflammatory signs, wound drainage.
• CT neck soft tissues w/o & w/ contrast; CBC, ESR, CRP.
• Contrast barium swallow / esophagoscopy.
• ENT consult; flexible/rigid esophagoscopy.
• Direct repair with non-absorbable suture.
• SCM flap between esophagus and graft (incise below CN XI entry point).
• PEG for feeds; antibiotics.
• Be aggressive to avoid mediastinitis.

• Examine the patient and recognize bleeding early.
• Repair intraop if possible; resuscitate with IV fluids/blood; angio immediately post-op if indicated.
• Transsphenoidal resections: CTA navigation imaging; Fogarty catheter in the room.
• VA injury: blunt/monopolar → occlude then angio; sharp → attempt repair. During screw placement: finish screw, pack area, do NOT attempt contralateral screw.
• ACDF: avoid far lateral foraminal bites; evaluate vertebral artery course on MRI (aberrant course possible).
• Lumbar laminectomy: avoid too ventral bite. If hypotensive/tachycardic: close quickly, flip supine, call vascular STAT to repair aorta/iliacs/IVC.
• Post-op LS spine hypotension/tachycardia/flank bruising: call vascular + OR; anterior retroperitoneal approach may be required.

• Examine the patient and assess volume status: JVP, edema, skin turgor, I/Os.
• Labs: serum Na, urine Na, creatinine/BUN; review meds (diuretics).
• If Cr/BUN normal: not renal cause → interpret urine Na and urine output.
• If urine Na low: Na loss (vomiting, dehydration, diarrhea, NG tube, third spacing: ascites/pleural effusion).
• If urine Na high + low urine output: SIADH → fluid restriction, salt tabs; hypertonic rarely.
• If urine Na very high + high urine output + low volume: CSW (common in aSAH) → NS IV, salt tabs; hypertonic rarely.
• Do NOT correct more than 12 mEq/day to avoid CPM.

• In craniotomies near SSS (trauma or planned): state prevention and rescue steps explicitly.
• Discuss with anesthesia: TLC to right atrium, precordial doppler U/S, ready to aspirate, positioning maneuvers, resuscitation readiness.

• Surgical pause. Check technical issues.
• Raise MAP > 85 mmHg.
• Steroids? (case-dependent).
• Reverse last maneuver. Check positioning.
• Get radiograph as needed; consider wake-up test (Stagnara).

• You can get any type of complication in any type of procedure.
• Example: posterior fossa meningioma/CPA tumor → AICA injury hemorrhage → post-op basilar vasospasm.
• Example: burr hole for DBS → intraop hypotension + ↓O2 saturation → air embolism.
• VNS complication: hoarseness.

• Imaging: CT, MRI, X-ray (know what you need and why).
• Navigation / monitoring: Decide up front if you need neuronavigation, neuromonitoring, and which modalities.
• Instrumentation planning: What you will use — and what you may need if something unexpected happens.
• Nutritional status assessment.
• Spine instrumentation risks: smoking / depression / osteoporosis assessment (specifically in instrumentation cases).
• Consent (time permitting): extensive discussion with patient and family regarding goals, risks, benefits.
• Code status if possible.
• *SOS* pregnancy test in female of childbearing age.

• Discuss with anesthesiologist: medical status; intraop adverse events; need for transfusion (PRBC), antibiotics, mannitol / dexamethasone / diuretics, neuromuscular blockade / monitoring, cold saline, antiepileptics.
• Scrub nurse / circulating nurse / rep: which instruments/instrumentation; surgeon/assistant/scrub positioning; orientation of table.
• X-ray technician: expected imaging, timing, and what views you will need.
• Pathology: frozen section needs and intraoperative pathology evaluation plan.

• Microscope draped at the start.
• Straight temporary and permanent clips loaded.
• Femoral access for intraop angio.
• Adenosine loaded.
• Retractor in place at start of case (in case of intraoperative rupture).
• Large bore suctions (9×2, ×3).
• ICG.
• Cell saver.

• Be especially careful in MRI of C-spine with edema and spondylotic changes — which can be severe.
• Do not jump to the diagnosis of cervical spondylotic myelopathy.
• Listen to history and physical exam carefully.

• Transverse myelitis: >1 level involved craniocaudally.
• Neuromyelitis Optica (NMO): ask for visual symptoms (optic nerve) and long tract cervical spinal cord symptoms; test AQP4 antibodies; MRI brain (optic nerve changes) + MRI C-spine (cord changes).
• Guillain-Barré syndrome: recent infection / trauma / vaccination.
• Parsonage-Turner brachial plexitis: history of trauma; can occur even after discectomy (surgical trauma).
• ALS / motor neuron disease: ask for tongue fasciculations.

• Intracranial hypotension: subdural hematomas, sagging posterior fossa structures, postural headaches, homogeneously thick dura, possible Chiari. Workup: MRI/CT myelogram spine for nerve root sleeve leaks; CT cisternogram for occult ethmoidal plate leaks. Treatment: fluids, caffeine, analgesics, blood patch. (Surgical management: see spine section.)
• NPH.
• Temporal / granulomatous arteritis: headache, visual loss, tender/palpable temporal artery; check ESR.
• ADEM: history of prior infection (flu/diarrhea) or vaccination.
• PML: think HIV; sexual history (current + PMHx); young male with symptoms. Workup: CSF for toxo, lymphoma cells. DDx: toxoplasma vs lymphoma vs PML.
• MS: brain MRI; also image the whole spine. Check: oligoclonal bands, myelin basic protein, IgG synthesis.
• Herpes simplex encephalitis (esp post-steroids): bilateral temporal lobe + basal frontal edema ± hemorrhage.

• In any stroke: involve your endovascular team STAT.
• Know IV tPA contraindications + time windows.
• Know RCTs supporting thrombectomy: MR CLEAN, SWIFT PRIME, EXTEND-IA, REVASCAT (and others).
• Based on DAWN, endovascular therapy can be considered up to 24 hours in selected patients.

• Mean transit time (MTT) is increased in stroke.
• Cerebral blood flow (CBF) in the area of interest is decreased.
• If cerebral blood volume (CBV) is also decreased → completed infarct (core) within the region.
• If there is a region of increased CBV (with decreased CBF) → penumbra.

• Headache, confusion, seizures, visual loss.
• Associated with malignant hypertension, eclampsia, immunosuppressant/chemotherapy, other meds.
• Etiology: failure of autoregulation → cerebral edema.
• Post-partum day 1 woman with grand mal seizure + high BP → think PRES.
• PRES → control BP.

• Painful ophthalmoplegia.
• Nonspecific inflammation of cavernous sinus or superior orbital fissure.
• Therapy: steroids / immunosuppressants.

• Symptoms depend on inflammation location.
• Cervical lesions (~20%): UMN + LMN signs in arms and legs.
• ~60% idiopathic.
• Can occur with NMO (AQP4 antibodies) or MS; also with bacterial/viral infections and immune disorders.
• If extends ≥3 vertebral segments → LETM, most often in NMO.

• Gradual onset, steadily progressive, initially asymmetric weakness: lower limb 35%, upper limb 30%, bulbar (speech/swallow) 30%.
• UMN and LMN signs in the same territory.
• Death of UMN (motor cortex) and LMN (brainstem/spinal cord).
• Florid fasciculations — ask specifically about tongue fasciculations.
• Absence of significant sensory symptoms — ask.
• Predominantly bulbar form has worse prognosis.
• Familial 15–20%.

• GBS is primarily a clinical diagnosis.
• CSF supportive pattern: elevated protein with <10 cells/mm³.
• Protein usually >40 mg/dL with normal cell counts.
• 10% normal CSF (especially first 1–2 weeks).
• PFTs: abnormal FVC & NIF.
• NCS: delayed F-waves and decreased MAPs.
• May be called for muscle biopsy to rule in/out inflammatory nerve/plexus pathology.

• 2+ sequential seizures without recovery of consciousness in between.
• 30+ minutes of continuous seizure activity.

• Aspirin: platelets
• Plavix / clopidogrel: platelets
• Warfarin: Vit K, FFP, PCC, factor VII
• Heparin: protamine
• Enoxaparin: FFP, protamine
• t-PA: PCC, cryoprecipitate, FFP, TXA
• Direct thrombin (Factor II) inhibitors: idarucizuma
• Direct Factor X inhibitors (X activates prothrombin): 4-factor PCC, andexanet

• In carcinomatous meningitis: DO NOT operate on lumbar lesions; offer radiation and WBRT to brain.
• Venous sinus thrombosis: hydration, heparin gtt, lovenox; be careful if cortical venous reflux with ICH.
• Status post trauma: fat emboli → confusion; treat/reduce long bone fracture + fluid resuscitation.
• NO steroids for spinal cord injury, even post-op. DO NOT mention steroids in trauma case.
• Brain stem death criteria: if you cannot warm the patient, do a vascular study.
• Know propofol infusion syndrome and neuroleptic malignant syndrome (diagnosis approach).
• Basal meningitis (e.g., TB) can present with single or multiple cranial nerve deficits.
• Gower sign indicates proximal muscle weakness.
• Malignant hyperthermia → dantrolene.
• Cabergoline: 0.25 mg PO twice/week initially, up to 1.0 mg twice weekly; side effects: headache, orthostatic hypotension, nausea, constipation; higher doses → valvular disease.
• Pulvinar sign in variant CJD.

• Spinal cord / nerve root compression or lesion
• Lumbar plexus lesion
• GBS
• Botulism / diphtheria
• Electrolyte abnormalities (K, Mg, Ca)
• MS
• Myasthenia gravis
• Polymyositis / dermatomyositis
• SLE

• GCS ≤ 9 → Intubate, then CXR.
• Hemodynamically unstable: resuscitate. (Know what IV fluids you use to resuscitate.)
• Avoid hypotension (SBP ≤ 110, except in 30–69 yr old) and avoid hypoxia (PaO₂ ≤ 60).
• Secondary survey: source of bleeding/hypotension.
• Hemorrhage sources: thoracic, abdominal organ injury, long bone fractures, lacerations (scalp lacerations can bleed profusely — check!).
• Hypotension causes: obstructive (PTX, tamponade), cardiac, neurologic (SCI/spinal shock with bradycardia).

• Assess clinically and radiographically the WHOLE SPINE in every case.
• Spine precautions in all cranial trauma cases.
• Rule out atlanto-occipital dislocation before applying traction for cervical fracture deformity (jumped/perched facet).
• MRI before closed reduction for traumatic disc herniation / disco-ligamentous complex? Value debated; differences of opinion on priority.
• Chance fractures: bony only, ligamentous only, or combined (Jewett hyperextension brace applies here).

• Review C2 pedicle/transarticular/pars screw entry points + trajectories. Ask for thin-cut CT before finalizing trajectory. Check vertebral artery position.
• Severe spondylosis ± myelopathy + traumatic fracture/dislocation with incomplete SCI: think/ask for fiber optic intubation.
• Incomplete SCI due to unilateral facet fracture/dislocation: skip the MRI → take straight to OR for an anterior approach.
• Maintain good BP/perfusion in spine trauma cases with incomplete SCI.
• Discuss with senior: anterior vs posterior for thoracolumbar burst fractures. When is posterior-only enough? Do we always supplement anterior with posterior instrumentation? Role of PLC integrity and MRI status? Role of neuro exam?
• Costotransversectomy for thoracic vertebrectomy: use pedicle as a guide to the VB; use contralateral temporary rod for stability during drilling.
• Stay short of anterior and posterior VB cortex to protect viscera/aorta anteriorly and cord posteriorly. This is why pedicle screws go first, then corpectomy.
• Ask and record potentials post-intubation, pre-positioning, post-positioning in neurologically intact or incomplete spine fracture trauma cases.
• ACDF retractor tip: deflate ETT cuff to level just above air leak when placing the retractor.

• Use of rescue screw.
• Use PMMA: wait for exothermic reaction to harden PMMA placed in hole, then place a screw into hardened PMMA.
• Try placing a pedicle screw.
• Extend fusion one level ipsilaterally.

• Is the PLC disrupted?
• Neuro status: intact vs incomplete vs complete SCI.
• PLC disruption: best on MRI, but infer on CT with: splaying spinous processes; avulsion/fracture of contiguous spinous processes; widening facet joints; empty “naked” facets; perched/dislocated facets; vertebral translation/rotation.
• Do not be carried away by canal compromise images — always ask: “Is the patient neurologically intact?” If yes, options vary.

• Know: TBI guidelines, skull fractures (esp over sagittal sinus), status epilepticus management (Levi book p.70).
• Hypotension is worse than hypoxia in TBI; both together is disastrous.
• CPP range 50–70. Ideal CPP: minimum 60, no more than 70 — raising BP too much with high ICP can cause ARDS.
• HOB at 30°. SBP ≥ 90. ICP control for GCS ≤ 8.
• Avoid fever; target serum Na ≥ 140; glucose 80–140; seizure control; early CT; PbO₂ ≥ 15.
• Early decompressive surgery if indicated.

• Consider precipitating event: ruptured aneurysm SAH, ruptured AVM, stroke, spontaneous ICH, tumor bleed → then trauma.
• If CT atypical: ask more history: acute severe headache before accident? history of headache/seizure? hypertensive? illicit drugs?

• Oxidized cellulose: Surgicell
• Microfibrillar collagen: Avitene
• Gelatin sponge: Gelfoam (soaked in thrombin)
• Cotton balls soaked in hydrogen peroxide
• Warm irrigation
• Gelatin matrix + thrombin: Floseal, Surgiflo

• Be careful with cerebellar intraparenchymal hematomas: tumor bleed? AVM? dural AVF? coagulopathy?
• Prepare for EVD.
• Wide posterior fossa craniectomy: take air embolism precautions: wax edges, triple lumen catheter, precordial Doppler.
• If sudden/more swelling: flood wound with saline; use ultrasound to see if hematoma expanding in depth.

• Dural sinus injury: plan craniotomy around suspected injury.
• Depressed skull fracture: isolate circumferentially, evaluate. Have Fogarty catheter ready.
• Assess size of rent. Primary repair with 4-0 Neurolon, Weck hemostatic clips.
• Duroplasty with graft: patch of artificial dura/pericardium/muscle/Gore-Tex.
• First steps in sinus bleeding: 1) tamponade (gelfoam + cottonoid) 2) elevate HOB.

• Consider need for PEG, tracheostomy, and early nutrition post-DC.
• Fungating/herniating brain during decompressive hemicraniectomy: see salvage maneuvers (Cranial Tricks of the Trade, pages 507 & 509).
• Complications post-DC and post-cranioplasty: see pages 509–510 (Cranial Tricks of the Trade).

• Obtain CTA/CTV.
• Tell anesthesia: precordial Doppler, type & cross.
• Wide craniotomy.
• Assess risk for traumatic pseudoaneurysms and CSF leaks from basal skull fractures.
• ALWAYS give tetanus toxoid!

• In every trauma case: check aspirin, coumadin, thrombin inhibitors, Factor X inhibitors.
• Qualitative platelet dysfunction from kidney/liver failure? Check PT/PTT/INR.
• Give Pneumovax for frontal sinus fractures.
• Even in acute trauma, don’t fail to address fusion inhibitors: diabetes, smoking, NSAIDs, malnutrition.

• EDH: surgery if ≥ 30 cc. Non-surgical if ≤ 30 mL, ≤ 1.5 cm thickness, ≤ 0.5 cm shift, GCS > 8.
• SDH: thickness ≥ 1 cm or shift ≥ 0.5 cm. If smaller but GCS drop ≥ 2, or ICP ≥ 20, or pupillary change → operate.
• ICH: surgery if ≥ 50 cc, or > 20 cc with ≥ 0.5 cm shift, GCS 6–8, refractory ICP, cisternal compression.
• Posterior fossa hemorrhage: surgery for mass effect, cisternal compression, obstructive hydrocephalus, neuro dysfunction.
• Open depressed skull fracture: surgery for displacement ≥ skull thickness, associated hematoma, infection, apparent deformity, crossing frontal sinus (relative).

• If symptomatic with mass effect → surgery.
• Twist drill vs burr holes vs craniotomy. Recurrence up to ~20%.
• Always put a subdural drain.
• Consider: one burr hole or two? HOB elevation? Do not keep flat if very elderly with major medical issues.
• Steroids decrease recurrence but increase mortality.
• Role of MMA embolization? Follow recent trials.

• Agitated/confused/tachypneic, desaturation ~85% after severe trauma with long bone fractures.
• Fat in urine; petechiae upper chest/face.
• Fat embolizes to pulmonary + cerebral circulation → confusion.
• Treatment: fluids/supportive therapy; reduce/stabilize long bone fractures.

• Infection (UTI, pneumonia, wound)
• Metabolic (hyponatremia)
• Seizures
• Stroke
• Sundowning
• Hydrocephalus
• Post-trephination syndrome (weeks later)
• Trauma complications: abscess, hyper/hypothermia
• Trauma evaluation: physical exam, labs, radiographs, additional studies as needed

• In every trauma patient, think possibility of vascular injury.
• Heparin IV for cerebral venous sinus thrombosis.

• If lateral ventricle edge cannot be avoided: safer to go medial and traverse through ventricle at ~90° angle; tangential ependyma skimming carries high hemorrhage risk.
• Good starting point: 3–3.5 cm lateral to midline, just in front of coronal suture.
• Avoid traversing caudate nucleus (suspected postoperative confusion).
• Use tissue sealant + absorbable gelatin sponge over burr hole to minimize CSF loss and brain shift.
• Compensating for brain shift is a main argument for iMRI-guided DBS.

• For VIM DBS / thalamotomy: patient comes to surgery off anti-tremor meds.
• Use antihypertensives that do not interfere with MER during electrode placement.
• Does MER improve DBS outcomes? NO.
• Verification with stimulation (VIM): (1) tremor improves; (2) paresthesias from sensory thalamus habituate within 10 seconds; (3) no tightening from internal capsule stimulation.
• Thalamus somatotopy: legs lateral, face medial.
• STN determination: indirect (AC/PC intercommissural line); direct: find anterior border of red nucleus, go lateral.
• Evidence exists for PPN DBS for PD gait disturbance and postural instability.

• V1 TN: consider V1 peripheral neuropathy.
• V1+V2+V3 TN: percutaneous balloon compression is a good option.
• Balloon compression also good for MS-related TN.

• RF cases: don’t raise temperature > 85°C or treat > 90 seconds.
• Balloon trigeminal ganglion compression: don’t use > 1 mL contrast; don’t keep inflated > 3 minutes.
• During percutaneous trigeminal gangliolysis, if carotid punctured: withdraw cannula, gently tamponade, abort procedure.

• Rule out seizures in hemifacial spasm.
• Useful read: Citow/Spinner pages 139–141.
• Delayed facial palsy after MVD (10–14 days): inflammatory response or herpes zoster reactivation.
• Immediate post-op hearing loss: middle ear effusion.
• Treatment: oral antiseizure meds (largely ineffective), serial Botox injections (units questionable), microvascular decompression.
• Complications: intraop similar to TN; post-op facial weakness, lower CN weakness.

• DREZ indicated for deafferentation pain after injuries causing root avulsion.
• Risk: ipsilateral leg weakness due to spread to corticospinal tract.
• Therapy for chronic pain after brachial plexus avulsion: DREZ, motor cortex stimulation, DBS (PAG/PVG).
• DREZ targets: Lissauer’s tract, substantia gelatinosa, nucleus proprius (Rexed laminae I–V).
• During case: SSEPs to prevent posteromedial directionality that risks posterior columns.
• Technique: sharp bipolar coagulation every 2–3 mm, depth 3 mm under microscope. Imaginary line connecting normal posterior rootlets above/below intended lesion.
• Angles: cervical lesions ventromedial 35°; lumbar lesions ventromedial 45°.
• Always stimulate ventral and dorsal roots and identify levels.
• S1–S2 level estimate: ~30 mm above coccygeal nerve exit; conus/cauda root ID is difficult.
• In general: consider SCS or motor cortex stimulation or DBS before DREZ (lesioning).

• Failed back surgery syndrome
• CRPS I and II
• Peripheral neuropathic pain
• Postherpetic neuralgia
• Phantom limb syndrome
• Root injury or SCI/lesion pain
• Peripheral vascular disease
• Angina

• Consider SDR in children with CP and spasticity.
• Criteria include: age 3–7, non-progressive disease, some strength to sustain walking, not wheelchair bound, and others.
• Alternatives: IT baclofen pump, botox IM injections, medications, orthopedic procedures.

• Central sulcus confirmed by SSEP phase reversal.
• Presence of a D-wave in corticospinal MEP (requires spinal epidural electrode).

• Complete callosotomy: craniotomy flap centered on coronal suture (not 2/3 in front, 1/3 behind). Typical flap 4×8 cm.
• Technical tips: neuronavigation to avoid bridging veins; slight Trendelenburg; tilt microscope anteriorly (vision directed posteriorly) because splenium “makes away”.
• Contraindicated in cross-dominance individuals (speech/hand dominance opposite hemispheres).
• Absolutely contraindicated in partial seizures.
• Risk of transient mutism from retraction on cingulate gyrus during callosotomy or any interhemispheric approach.

• ECoG (esp for language) must be performed during stimulation to determine after-discharge threshold to avoid propagated depolarization and false negatives/positives.
• ECoG via carbon tip electrodes 10–20 mm apart or strip electrodes at exposure edges.
• When mapping motor (frontal) speech: identify face motor cortex first — stimulation can block speech and mimic speech area.
• Excellent cortical mapping chapter: Cranial Tricks of the Trade, page 608.
• Resections near eloquent cortex can cause delayed dysfunction from swelling.

• Workup: WADA, memory testing, EEG, subdural or stereotactically placed intraparenchymal electrodes.
• RCT supports temporal lobectomy/temporal ablation surgery.
• Standard vs selective resection for TLE.
• If temporal lobectomy → seizure-free period → seizures recur at 2 months: Do not go straight to surgery. Repeat the full workup as if from the start.
• Classes: diagnostic procedures vs therapeutic surgery.
• Non-invasive tests: FDG-PET, MRI, stereoEEG.
• Diagnostic procedures: subdural grid, SEEG.

• Posterior extent of skin incision: mastoid-to-vertex line.
• Do not coagulate choroid plexus (risk to anterior choroidal artery).
• Extend neck so hippocampus becomes more horizontal and AP length is more visible.
• Anterior limit of amygdala: pia covering M1 bifurcation as it swings around temporal stem/limen insulae. Connect this to the choroidal point → limit of amygdalectomy.
• Pia covering knee of MCA lies on cortex of middle temporal gyrus; connecting to choroidal defines amygdala.
• Do not resect basal white matter too far back (occipitotemporal fasciculus / fusiform gyrus WM) to avoid basal language deficits.
• Retract choroid plexus toward thalamus. Intralimbic gyrus faces brainstem.
• CUSA helps protect arachnoid planes.
• Landmark: absolute posterior limit of hippocampal resection is the tectum.

• Rheumatoid arthritis, basilar invagination
• C1–C2 fractures; subaxial fracture/dislocation
• Radiculopathy, myelopathy
• OPLL (and OPLL surgical decision-making)
• Demyelinating diseases
• Metastatic + intradural tumors
• Infection/osteomyelitis
• Acute spinal cord injury management
• C8 vs ulnar nerve DDx
• Ankylosing spondylitis

• Occipito-cervical fusion
• C1/C2 fusion; C1–C2 screw/wiring concepts
• ACDF
• Anterior cervical corpectomy
• Laminectomy / foraminotomy
• Laminoplasty
• Lateral mass screw placement

• Lumbar stenosis; spondylosis
• Spondylolisthesis (degenerative vs isthmic)
• Facet joint cyst
• Herniated nucleus pulposus (HNP) + radiculopathy
• Infection/abscess; trauma
• Intradural + extradural tumors
• Tethered cord
• L5 vs common peroneal nerve DDx

• Laminectomy
• Microdiscectomy
• Posterolateral fusion
• Instrumented fusion
• Sacral fixation to S1

• HNP; centrally herniated calcified thoracic disc
• OPLL
• Tumor; infection
• Ankylosing spondylitis
• Thoracolumbar burst fracture management
• Vascular lesions (dural AV fistulas)

• Anterolateral thoracotomy
• Posterior: transpedicular / facet / costotransversectomy approaches
• Thoracolumbar fusion; corpectomy; posterior fusion techniques

• Multiple sclerosis (MS)
• Neuromyelitis optica (NMO)
• Motor neuron disease
• Guillain–Barré syndrome
• Transverse myelitis

• ABC / ATLS; assess for other internal injuries
• Maintain perfusion: SBP to keep MAP > 70 (and SCI protocol MAP targets below)
• Repeat detailed neuro exam; document baseline
• ASIA score: acknowledge formal scoring timing (often 24–48+ hrs), but still document deficits now

• If patient is awake and examinable: attempt closed reduction
• Assess facet status on CT (perched vs jumped facets)
• If intubated: obtain MRI before reduction (especially if concern for disc herniation)

• First reduce manually, then obtain MRI

• Emergency OR
• Manual traction quickly to restore alignment
• Reduction + ACDF (bicortical screws if possible)
• Do not oversize the graft

• MRI first, then reduction

• CTA if front/back surgery is needed

• Spine precautions
• External stabilization: C-collar, sandbags as appropriate
• MAP > 85 (often target 90) for 5 days (some protocols 7)
• Cooling: used at some centers (extrapolated from TBI data)
• High-dose steroids: NOT recommended (pneumonia risk)

• Dopamine: β-inotrope at 2–10 mcg/kg/min; >10 mcg/kg/min adds vasoconstriction
• Norepinephrine: α1,2 > β1 → vasoconstriction + β avoids reflex bradycardia
• Dopamine and norepinephrine are good options for neurogenic spinal shock
• Phenylephrine: pure sympathomimetic → NOT recommended for spinal shock

• Transient reflex depression (“concussion of spinal cord”)
• Loss of anal tone/reflexes/autonomic control within 24–72 hours
• Flaccid bladder/bowel
• Lasts days until reflex arcs recover
• Lack of bulbocavernosus reflex

• Type I
• Type II
• Type IIa
• Type III

• Anterior C2–3 plating: higher failure + dysphagia
• Loss of rotational ability (upper cervical constructs)
• Ascendi classification mentioned in your notes (know it)
• If pars fracture present → instability is anterior column → treat via C1–4 fusion (per your notes)

High-yield oral trap: After a VA injury, do NOT attempt to place the contralateral screw. You will be asked about this.

• Immediately inform anesthesia; anticipate significant blood loss → transfuse as needed
• Attempt hemostasis with large hemostatic agents (avoid intravascular embolization)
• Attempt screw tamponade (if feasible)
• Once stable: abort procedure (do not proceed to other side)
• Transfer STAT to IR/angiography suite for angiogram + treatment
• Definitive therapy ranges from antiplatelet therapy to vessel sacrifice

• Check leads/connections; eliminate interference
• Reverse the last maneuver that precipitated change
• Assess for residual compression/need more decompression
• Check hypotension, hypothermia, inhalational anesthetics

• Anatomic: re-evaluate field; relax retraction; unclamp vessels; irrigate warm NS; local vasodilators (papaverine)
• Physiologic: raise BP; replace blood loss; re-evaluate anesthetic regimen
• Technical: check electrodes/impedance/amplifier/computer
• Salvage: remove instrumentation; Stagnara wake-up test; administer steroids; abort

• T1/T2 hypointensity behind cervical vertebral bodies → OPLL
• T1/T2 hypointensity at disc level → calcified disc
• Assess autofused segments, calcified ligamentum flavum, facets, bony anatomy/quality

• Always CT to determine calcification

• Acute hypoxia → STAT CXR for pneumothorax (esp after costotransversectomy)
• Acute new neuro deficit → consider anterior spinal artery infarct

Always say you distinguish vascular vs neurogenic claudication. Always do a whole-spine neuro exam (even in “lumbar” complaints).

• Advocate conservative measures first: PT, epidural injections, NSAIDs, etc.

• Back pain: NSAIDs, short oral steroid course, muscle relaxants, heat/massage, biofeedback, epidural interlaminar injections
• Radicular/neuropathic pain: gabapentin/pregabalin, antidepressants, PT/OT, chiropractor, epidural/foraminal/facet injections, TENS, weight loss
• Assess neuropsychologic background in every pain case

• Radicular pain vs axial back pain vs instability?
• Other pain generators: facets, SI joints, piriformis syndrome, fibromyalgia, etc.

• Can be pain source → try facet blocks; if positive → RF ablation

• Scan the whole spine

• X-ray is gold standard for dynamic worsening
• Obtain AP, lateral, oblique + flexion/extension views + CT for bony anatomy

• Translational degree of slip
• Does spinous process “follow” vertebral body? (degenerative slip sign)
• Ligamentum flavum thickening
• Subarticular and/or foraminal stenosis (axial/parasagittal cuts)
• Cauda equina clumping above stenosis → ↑ risk intraop CSF leak
• Bone quality + masses + vascular abnormality/infection signs

• Correlate physical findings with imaging
• X-rays, CT, MRI, discography, bone scan, myelogram inform decision-making
• Hyperintense facet joints → consider instability → order flex/ext films
• Always obtain standing lumbar X-rays; consider 36-inch films for sagittal balance

• Do CT myelogram to better characterize nerve root impingement + stenosis anatomy
• Also evaluate if disc is calcified
• Concept: disc highest protrusion point lateral to thecal sac → minimize cord manipulation

• Use to check radiculopathy symptom exacerbation

• Always assess for extraforaminal disc in radiculopathy
• L5 radiculopathy: can be L4/5 paracentral or L5/S1 intra/extraforaminal

• C1 lateral mass
• C2 transpedicular
• C2 translaminar
• C1–C2 transarticular
• Brooks vs Gallie vs Sonntag wiring differences
• Thoracic + lumbar pedicle screw entry points + inclinations by level

• Entry: 1 mm inferolateral to center of lateral mass
• Trajectory: ~30° cranial (avoid exiting nerve)
• Trajectory: ~20–35° mediolateral (avoid vertebral artery)

• T1–T10: intersection of (1) horizontal line along superior edge of TP and (2) vertical line bisecting facet joint
• T11–T12: horizontal line bisects transverse process
• Often near base of superior facet
• Anatomic trajectory decreases pullout resistance; straight/parallel to superior endplate may increase resistance (controversy acknowledged)

• ~30° for T1–T3
• ~15–10° mid-thoracic
• ~5° at T10
• No inclination T11–T12

• If not self-tapping: tap diameter 0.5–1.0 mm smaller than screw
• Small pedicles: “in–out–in” technique may be used intentionally

• “Safe” max breach ~4 mm (2 mm epidural + 2 mm subarachnoid)
• >4 mm → revise

• ~5–10° @ L1
• Up to ~25–30° @ L5
• Approx +5° each level from L1 → L5

• L4: 0° (straight)
• L3: 5–10° rostral
• L5: 5–10° caudal
• Gearshift is curved aiming toward anterosuperior VB corner

• Sagittal plane entry: junction of lateral facet and transverse process
• L4: midline of TP approximates pedicle entry
• Above L4: TP midline is slightly rostral to ideal entry
• Below L4 (L5): TP midline slightly caudal to ideal entry

• S1 entry: just inferior and lateral to superior articular process
• Size screws to ~70% pedicle diameter
• Depth into VB: ~50–80%
• If you go straight AP instead of aiming medially ~25° and perforate anterior cortex → can injure lumbosacral trunk

• ~1.5 cm incision; entry point ~3–5 cm lateral to spinous process at level above planned fusion
• Aim enter lateral pedicle margin and exit lateral to its medial margin
• Pre-op planning begins before day of surgery with detailed imaging review + plan

• Use fiberoptic intubation + neuromonitoring
• “Double ossicle sign” on CT → ossified dura → very high CSF leak risk
• Know OPLL types (per your notes)
• Anterior vs posterior approach: use K-line guidance; consider kyphosis vs lordosis
• “Eggshell out” OPLL; consider corpectomy; consider intraop lumbar drain depending on risk

• Parainfectious/postinfectious etiologies
• Systemic autoimmune diseases
• Paraneoplastic syndromes
• MS
• Neuromyelitis optica

• Remove cartilaginous endplate first
• During drill/osteophyte trimming: use Luken’s trap to collect bone dust for autograft

• Esophageal injury
• Recurrent laryngeal nerve injury
• Carotid artery injury
• Graft dislodgement
• Pseudoarthrosis
• Adjacent level degeneration/disease
• Wound infection
• CSF leak

• Diagnosis: barium swallow; soft tissue CT neck
• Endoscopic evaluation down esophagus
• Repair: ENT + remove plate; repair wall defect; SCM or pectoralis flap options

• Dysphagia ~71% in repeat ACDF vs ~23% first surgery
• SCOPE before revision ACDF

• Rule of thumb: 50% facetectomy one side or 25% bilaterally may be feasible without fixation/fusion

• Avoid excessive Bovie on decorticated facets → devascularization
• Bone wax prevents bony bridging
• Principle: maximize vascularized bony surface area for arthrodesis

• Anemia, infection, malnutrition
• Osteoporosis
• Renal/hepatic dysfunction
• Anti-inflammatory drug usage
• Tobacco; vape use
• Comorbidities + psychological status

• After positioning: lateral X-ray to ensure not in overkyphosis/overlordosis

• Brachial plexus, axilla
• Cubital/carpal tunnel
• Knee
• Peroneal nerve/fibular head
• Hip-thigh
• Ankle

• Remove lamina via drill; avoid Kerrison footplate pressure pushing anteriorly on cord

• Degenerative: disc herniation; cervical/lumbar spondylosis; stenosis; neurogenic claudication
• Infection: discitis/osteomyelitis; abscess; meningitis
• Neoplastic: primary intradural tumors (± hemorrhage): schwannoma, meningioma, neurofibroma, myxopapillary ependymoma, paraganglioma (extramedullary), astrocytoma, ependymoma, hemangioblastoma (intramedullary); secondary extradural metastases
• Hematoma: epidural/subdural (anticoagulants)
• Fracture: traumatic, osteoporotic, pathologic
• Bony tumor: primary/metastatic
• Syringomyelia: Chiari 1, post-traumatic, tumor-associated, malformation-associated
• Congenital: Chiari, dysraphism
• Vascular: AVM, AV fistula, cavernoma, resolving hematoma
• Inflammatory/metabolic/neurologic: MS, transverse myelitis, NMO, SCDC/B12 deficiency, motor neuron disease, GBS
• Muscular: polymyositis
• Traumatic: syrinx

• Dural tail
• Foraminal extension
• Dumbbell shape

• May be attached to anterior spinal artery
• Think nerve roots + vessels when dissecting/resecting

• Have fixation instrumentation available in the OR (may need more bone removal → instability)
• Another reason to get CT: bony anatomy/quality (in addition to hemorrhage evaluation)

• Remove en bloc; do not debulk
• Deprive arterial supply before venous drainage (AVM-like logic)

• Muscle MEPs + epidural D-wave MEPs during resection

• Standard checks (connections/anesthesia/BP/MAP) + raise MAP
• Warm saline or papaverine-soaked cotton in cavity
• Change site/strategy; consider stopping procedure

• T2 hyperintensity suggesting hemorrhage → likely ependymoma (per your note)
• Look for associated syrinx + cysts above/below mass

• Branches of anterior spinal artery penetrating via ventral median raphe
• Coagulate/divide vessels as encountered on ventral surface
• Use 7-0 Prolene for pial retraction

• Multiple myeloma
• Ewing
• Hemangioma
• Chordoma
• Osteosarcoma

• Meningioma, schwannoma, neurofibroma
• Obtain CTA for VA position/dominance relative to mass
• MRI rest of spine for drop mets
• CT C-spine for bony anatomy / possible instrumentation
• Use intraop ultrasound, neuromonitoring, microdoppler for VA recognition

• Consider paraganglioma, myxopapillary ependymoma, ganglioneuroma
• Consider drop mets and systemic primary metastasis (rare intradural)
• Scan cervical + thoracic spine + brain to rule out drop metastasis
• Basic systemic workup if indicated: CXR, CT C/A/P, PSA, mammogram

• Meningioma
• Calcified ligamentum flavum

• Neoplasm
• Abscess
• Inflammatory lesion
• Multiple myeloma

• If hemangioma / aneurysmal bone cyst suspected → expect blood loss; consider preop embolization
• If biopsy is possible: first consider vascular lesion → angiogram ± embolize
• If embolize spinal cord tumor and plan surgery → take to surgery immediately after embolization
• Identify Adamkiewicz; ask IR to place a marker for localization if helpful
• Embolize preop renal cell or melanoma spine metastasis (hypervascular)

• Neuromonitoring: SSEPs + MEPs
• Intraop ultrasound
• Maintain BP / MAP ≥ 90
• Laminoplasty if possible
• Possible need for instrumentation
• Steroids
• Find midline via: dorsal root entry zones bilaterally; midline vein

• Central tumor: midline raphe; look for midline dorsal medullary vein; if distorted, estimate midpoint between DREZs; monitor dorsal columns if reliable
• Eccentric tumor: myelotomy along dorsal root entry zone
• Tumor reaches surface: enter at surface

• May maintain prone or alternate lateral positioning to reduce pial/dural scarring (per note)
• Confusion/AMS after surgery → consider subdural hematoma from CSF loss

• Consider SRS
• Tokuhashi and Tomita scales for surgical decision-making
• Dexamethasone for SC compression: 100 mg IV stat, then 10 mg q6h (per your notes)
• Steroid therapy for primary/metastatic vertebral tumors leading to cord compression (state it explicitly)

• Use neuromonitoring for nerve roots; avoid paralytics
• Resect filum terminale to avoid traction on conus
• Assess if cysts are truly neoplastic: do they enhance on MRI?

• Treat only if symptomatic: XRT, embolization, vertebroplasty; rarely surgical resection
• Large neoplastic lesions → consider preop embolization

• CT C/A/P to look for intrathoracic/intraabdominal abscesses, psoas/paraspinal abscess
• If only lumbar MRI was done: assess whole spinal axis (cervical abscesses possible)
• First assess symptoms: some can do well initially on antibiotics

• Diabetes
• Immunosuppression / steroids / immunosuppressants
• Cancer
• Chronic renal/hepatic failure
• Multiple medical illnesses
• Morbid obesity
• Alcoholism
• IV drug use
• Infectious processes (urosepsis, pneumonia)
• HIV

• Can use radiopaque silicone catheter for lavage after verifying position by X-ray

• Epidural abscess presenting with paraplegia: ~18% recovery rate

• Useful in questionable discitis/osteomyelitis

• Neurologic deficit
• Impending spinal cord compromise
• Intractable pain
• Establish diagnosis / specify microbe
• Progression despite antibiotics

• ~15–35%

• Is patient stable for surgery?
• Neuro deficits?
• Threshold to operate depends on level (cervicothoracic vs lumbar)
• Consider venous ± arterial thrombosis of spinal cord supply as paralysis mechanism
• These are sick patients → treat aggressively whether medical or surgical

• GET spine imaging
• Fungi/TB can involve vertebral bodies + paraspinal muscles + intrathoracic space
• Drain chest abscesses, IV antibiotics, treat infection, then stabilize spine

• Starts lower thoracic/upper lumbar
• Often ≥2 vertebral bodies; spreads to disk space → caseation and necrosis
• Think if recent travel abroad (Asia/Africa) or immunosuppression risk

• Clinical exam
• Inflammatory markers: CRP/ESR/WBC
• Radiology lags behind clinical improvement

• Discuss graft/instrumentation staying vs removal
• Acute setting → washout
• Acute-on-chronic (>4 weeks) discitis/osteomyelitis → remove instrumentation, do posterior instrumentation (per your note)

• <50% anterolisthesis → likely unilateral jumped facet
• >50% → likely bilateral jumped facets

• PLC status assessment is difficult
• PLC on MRI: ligamentum flavum tear, interspinous ligament tear, facet capsule dilation, increased water content

• Diffuseness of STIR signal
• Anterior only vs anterior+posterior collapse
• Retropulsion
• Widened interpeduncular distance

• Short posterior constructs won’t hold → need longer construct (example in notes: severe burst at L3 without deficit)

• Ventral anterolateral/retroperitoneal approach
• Posterior open approach with ligamentotaxis + pedicle screws
• Lateral MIS corpectomy

• Drill from truly lateral direction, not oblique, or posterolateral residual bone remains

• Sacral sensation/motor implies dorsolateral cord function preserved → recovery potential nearby corticospinal tract

• CTA in the great majority of C-spine fractures (per notes)
• VA injury often not treated; posterior fossa strokes may be delayed; manage MAP goals 5–7 days

• Anterior vs posterior approach (be ready to discuss both)

• Spinal cord herniation through dural defect → look for pulsatile artifact behind cord
• Dorsal arachnoid cyst → CT myelogram filling defect

• Odontoid screw: preserves atlantoaxial motion; requires reduced odontoid, intact transverse ligament (MRI), favorable fracture line orientation
• Posterior C1–2 screws: allows open reduction; prone; loss of atlantoaxial motion; longer operative time

• Need horizontal dens fracture + intact transverse ligament for odontoid screw to work
• Oblique dens fracture → odontoid screw fixation performs poorly
• Elderly + osteoporosis → higher pseudoarthrosis with odontoid screw

• Do not go >15 mm from midline along C1 posterior arch when placing C1 lateral mass screw
• Evaluate C2 anatomy: pars vs pedicle vs transarticular vs translaminar options
• C2 pedicle screw: start higher on posterior inferior articular process and more medially; aim cranially → dissect further caudal to achieve trajectory
• Beware VA relationship to C2 lateral mass; grooving can make screws risky
• C2 transarticular follows pars trajectory but longer; aim toward anterior tubercle of C1 on lateral fluoro
• Translaminar C2 screws and C2 pars screws do not prevent A–P motion at C1/C2 articulation (per your note)

• If insufficient bone laid around construct / no bone bridging occiput margin of foramen magnum to C1 → high nonunion risk

• Temporarily occlude with aneurysm clips while monitoring SSEPs/MEPs
• If no changes after 5 minutes → ligate the segmental artery
• Adamkiewicz: usually left side, T8–L1

• Curettes + rongeurs (Kerrison, pituitary) + drills
• Free bone fragments gently pushed into central cavity with Epstein “down-going” curette
• Good decompression when contralateral pedicle reached

• Exothermic reaction
• Barrier (e.g., Gelfoam) between PMMA and thecal sac

• Bone scan or T2/FLAIR MRI
• If active → may be amenable to vertebroplasty/kyphoplasty

• Schanz pin in iliac crest for anchoring reference arc for iCT in lumbosacral surgery

• On approach side, remove all bone pedicle-to-pedicle

• Have I identified the nerve root / thecal sac?

• Do not place cage
• Fill disc space with bone auto/allograft + add pedicle screws

• Retraction injury to L5 during graft placement
• Malpositioned pedicle screw
• Hematoma
• Disc fragment
• Bone chips backing out
• Obtain CT/MRI to differentiate

• Decompression + 3-column fixation of lumbosacral spine
• Lumbar disc degeneration (as appropriate)
• Recurrent disc herniation
• Grade I/II spondylolisthesis
• Lumbar stenosis
• Segmental instability
• Lateral/subarticular stenosis

• Discitis/osteomyelitis
• Osteoporosis
• Morbid obesity
• Vertebral body or endplate fracture

• Limit TLIF to max 3 levels
• Poor candidates: need bilateral decompression, central canal stenosis, trauma, neoplasm, morbid obesity, infection

• If redo discectomies fail → do fusion

• Acute: PSWs, fibrillations, decreased recruitment in affected muscles
• Chronic: ↑ MUAP amplitude/duration/phases

• L5–S1 ALIF failure: return anterior, larger cage + supplement posterior pedicle screws
• Failed fusions/ALIF at L3–4 or L4–5: lateral approach (XLIF), retrieve prior cage and replace with new one

• L1–2, L2–3, L3–4: middle posterior quarter of vertebral body
• L4–5: midpoint of vertebral body
• L4–5: too posterior → femoral nerve injury; too anterior → iliolumbar vessels

• Several % following multilevel anterior or posterior cervical operations
• Presentation: no shoulder abduction
• Management: PT + serial exams; many recover over ~2 years
• If no clinical/electrical recovery at ~9 months: consider nerve transfers
• Transfers: spinal accessory → suprascapular + triceps branch → axillary nerve

• Type I: dural AV fistula
• Type II: intramedullary glomus AVM
• Type III: juvenile AVM
• Type IV: intradural perimedullary pial AV fistula

• Always look for ASA contribution: “hairpin” sign

• Confirm correct level (critical)
• Ask IR for gold smear/cement marker or place a coil in the appropriate pedicle for localization
• Use intraop ICG before and after clipping

• Usually left T8–L1
• Use SSEPs/MEPs; place temporary clip and wait 5–10 minutes
• If no changes → tie off nerve root sleeve with silk
• If MEPs/SSEPs drop → remove clip, allow recovery, attempt clipping more distally

• May have cutaneous angioma on back
• Can present with spinal SAH, excruciating sudden back pain (“coup de poignard of Michon”)

• Whole-spine exam + symptoms/signs (even if “lumbar” complaint)
• Vascular vs neurogenic claudication distinction
• Conservative management first for spondylotic issues when appropriate
• Osteoporosis/smoking/infection/comorbidities/psychological status if planning fusion
• Pad all pressure points

• Intraop durotomy
• Post-op CSF leak
• Post-op infection ± instrumentation; graft stay vs remove
• Wound dehiscence ± exposed instrumentation
• Intraop electrophysiology change
• New post-op neuro deficit; delayed deficit
• Vascular injury intraop
• Approach-related complications
• Post-op neuropathic pain
• Post-op hematoma
• Screw fracture / joint violation
• Pseudoarthrosis
• Instrumentation failure
• Delayed deformity
• Adjacent segment degeneration/disease
• Proximal junctional failure

• Severe osteoporosis → more fixation points, anterior supplementation, possible cement augmentation
• Small pedicles → consider navigation/fluoro/direct visualization; hooks if needed
• Steroids/immunomodulators → higher pseudarthrosis risk; autograft is good option
• Plan for CSF leak possibility; consider lumbar drain even preop when high risk

• Cervical microdiscectomy with bright red bleeding from right side of disc space → VA injury management steps (pack, protect cord, anesthesia coordination, blood, neurointerventional help, repair vs sacrifice)

• LL–PI mismatch ≥ 12° → increased ALDx risk
• Cervical: ACDF increases biomechanical stress
• ~14.2% post-ACDF develop ALDx
• Annual rate ~2.9%/yr
• Higher risk if construct adjacent to but does not include C5–6 or C6–7
• 1–2 level ACDF higher ALDx risk than ≥3 levels

• Observation
• Laminoplasty
• Decompression alone
• Arthroplasty
• Stabilization/fusion (anterior, posterior, or both)

• Posterior cervical approaches offer some lordosis correction; anterior approaches better
• Lordosis correction reduces neck pain
• ALIF is ideal for increasing lumbar lordosis

• PI = PT + SS (PI fixed)
• Target: lumbar lordosis matches PI
• Natural history: loss of lumbar lordosis
• SVA ≤ 5 cm → good quality of life; SVA ≥ 9 cm → severe disability

• Treat conservatively first; X-ray/CT/DEXA; PT; strengthen paraspinals

• In cervical myelopathy needing surgery: MRI + CT + CTA for VA anatomy/OPLL
• Cervical myelopathy scale helps baseline and decisions
• If C6–C7 fused: extend posterior fusion to T2
• Know RCTs for spondylolisthesis (per your note)
• Think DVT/PE in post C-spine surgery patients
• Cervical CSF drain for big lumbar/thoracic CSF leaks: keep ~5 days
• T12 subcostal nerve injury → flank bulge
• In cervical intramedullary tumors: consider osteoplastic cervical laminoplasty to reduce delayed kyphosis
• In thoracic AVF surgery: level confirmation is critical; use IR markers/coil; ICG pre/post

In cases of carpal tunnel syndrome (CTS), besides the obvious role of repetitive hand movements, ask about social and work history:

You must rule out underlying diseases such as acromegaly, amyloid, multiple myeloma, hypothyroidism, diabetes, mucopolysaccharidosis, rheumatoid arthritis and the condition of pregnancy.

The diagnosis of CTS is easy when there is a classic history:

• Paresthesiae in the radial 3 ½ digits
• Nocturanal symptoms (improved with + shaking)
• Positional symptoms (e.g. driving a car)

Be mindful of Martin – Gruber anastomosis (median to ulnar n., in the forearm) and Riche – Cannieu anastomosis (ulnar to median n. in the hand), which may present with a clinical picture of ulnar neuropathy. However, the pathologic entrapment may be along the course of the median nerve (and vice versa).

• Cervical rib/neurogenic thoracic outlet syndrome
• Pancoast tumor
• ulnar nerve compression at Guyon canal.
• Cervical radiculopathies at C8 and T1
• Double crash injury: nerve compressed at the elbow and roots compressed at the cervical spinal canal.

Before closure in cubital tunnel release case, besides thorough irrigation with antibiotic containing solution and hemostasis, it is mandatory to perform flexion and extension movements of the arm to confirm the release of the nerve and exclude any subluxation, tension or kinking of it.

• Postoperative weakness: rule out anesthetic blockade → observe
• Ulnar nerve injury from retraction, at Guyon’s canal or at cubital tunnel due to positioning → Observe
• Injury to the median n. or isolated injury to recurrent motor branch of media-n nerve → re-exposure and repair.
• Pain, numbness in the hand: injury to the palmar cutaneous branch of median n., palmar cutaneous neuroma
• Injury to the superficial palmar arch:
  • Intraoperatively, apply pressure +/- stitch repair
  • Post operatively expanding Hematoma → re Explore and evacuate.
• Wound dehiscence, infection (deep infection): Oral antibiotics, wound care, washout
• Always there is a risk of CRPS

• Wartenberg sign: abduction of the little finger due to paralysis of the third palmar interosseous muscle in ulnar n. palsy
• Wartenberg syndrome: Cheiralgia Paresthetica. Palsy of the superficial (sensory) radial n. branch due to compression by a band between brachioradialis and extensor carpi radialis longus muscles.
• Differentiate between Posterior Interosseous Nerve (PIN) entrapment due to arcade of Frohse and radial tunnel syndrome that looks like tennis elbow/lateral epicondylitis but, characteristically, and in contrast to PIN neuropathy, has no muscle weakness, only pain.

• Parsonage-Turner syndrome can give rise to CRPS
• Nerves that are affected in isolation or in combination; Long thoracic, suprascapular, axillary, posterior interosseous, anterior interosseous. Can give rise to CRPS.
• In contradistinction to suprascapular nerve palsy, Parsonage – Turner syndrome has also findings in distal nerve distribution areas, e.g. forearm, hand.

• Medical (manage pain so that patients can participate in →), PT, Steroids (?).

• think about wrist pain, think about cyclists, mechanics, carpenters. And do not forget to think about ALS!!

• Acute chronic reinnervation: Polyphasic potentials, Recruitment
• Stable chronic reinnervation: Large MUPs, Recruitment
• Acute denervation: Fibrillation and Positive Sharp Waves.

• Increased latency reflects demyelination.
• Decreased amplitude reflects loss of axons.

• Increased latency reflects demyelination.
• Decreased amplitude reflects loss of axons.

• Peroneal nerve palsy at fibular neck
• L5 radiculopathy (+ weakness in inversion from tibialis posterior getting L5)
• Motor neuron disease
• Spinal cord compression
• Parasagittal meningioma

• L5 radiculopathy affects both inversion and eversion (both tibialis anterior and posterior receive L5 contribution).
• Pain usually radiates from low lumbar area to thigh and foot. Positive SLR, no Tinel at fibular neck, EMG: Fibs in Posterior Tibial, paraspinals and gluteals. MRI of L spine usually abnormal.

• Foot drop from peroneal n. palsy has preserved inversion as tibialis posterior muscle is still normal (posterior tibial n. intact, receiving L5 root contribution).
• Pain usually from knee level down, normal inversion, Tinel positive at fibular neck, EMG/NCS: slowing at level of fibular neck, get MRI of peroneal n → rule out a mass.

• Intra-neural: related to a non-articular branch of the parent nerve (excision of brand cyst required)
• Extra-neural: caused by extrinsic pressure.

• Decompress the nerve
• Drain the cyst
• Disconnect the articular branch
• Drill the superior tibio-fibular joint (resect or fuse)

• Reactive lesions (traumatic neuroma, etc.)
• Cysts, intraneural (ganglion, synovial)
• Inflammatory, infectious and miscellaneous lesion simulating PNTs
• Hyperplastic lesions
• Hamartomas, Teratomas
• Schwannoma
• Neurofibroma/Neurofibromatosis type I
• Benign neurogenic tumors (ganglioneuroma)
• Benign and Malignant non-neurogenic tumors
• MPNST
• Secondary neoplasia

• NF1 associated, most often
• Rapidly enlarging mass, usually very painful
• Motor loss early and often progressive (which is rare for benign tumors)
• Often non-mobile, feels fixed
• Imaging features: heterogenous, necrosis, invasion of surrounding compartments (none is diagnostic)
• Surgery: Firm, indurated, “no good planes”

• If highly suspected preop → do percutaneous or limited open bx, no quick/ frozen section, close. Wait for final pathology report before planning next step.
• If suspicious at the time of surgery (no good planes… etc), do a quick frozen section and wait. If pathologist is confident that the tumor is benign, resect completely. If pathologist is uncertain or favors malignancy, close and wait for final path report, Get a 2nd opinion from pathology expert, if needed.
• Stage the MPNST (PET, CT C/A/P, Bone scan, etc) check for metastasis in lung, bone, pleura, etc
• Multidisciplinary approach to therapy: Discuss at tumor board surgery (wide resection or limb amputation) in combination with chemo, radiation therapy preop and/or postop
• Always stage a suspicious lesion before surgery with CT of Che/Abd/Pel scan and whole-body PET scan
• Always think to exclude MPNST in a case of peripheral nerve tumor.
• Clinical features include history of neurofibromatosis type 1 (ASK for features of NF1!), rapid growth over weeks or months, increased refractory pain, large size, and most important, significant motor deficits at presentation. (most benign tumors present with paresthesias and pain that is less severe.)
• Radiologic features that may support the diagnosis of MPNST include irregular borders, irregular enhancement, necrosis on MRI, increased avidity on PET.
• However, you cannot definitely differentiate Schwannoma – Neurofibroma – MPNST preoperatively. Bring the case at multidisciplinary sarcoma board, and – remember- stage MPNST.

• If there are enlarging, symptomatic, large lesions, and if there is uncertain pathology.

• Is the nerve in continuity?
• a. If not, then proceed depending on the nature of the injury (clean/sharp versus tissue destructive/ragged ends)
• b. If nerve is in continuity, then:
  • 1. Will it recover on its own with time?
  • 2. How much should we wait before exploring it?
• (Here is important the role of clinical and electrodiagnostic follow up evaluations)

• A. Sharp transections, e.g., clean knife, are repaired in less than three days. Clean lacerations, ends can be found. If distance between the nerve ends is more than 3 cm, then probably a graft is needed. State word by word that you will perform “a tension free repair using 8/0 or 9/0 stitches, use the microscope to line up the fascicles with each other”. In case of complete disruption of nerve/nerve branches, trim the edges to viable fascicles.
• B. Blunt transections, e.g., propeller blade, nerve contused, epineurium ragged → tack edges to adjacent tissue planes, secondary repair at 3 weeks after neuroma is allowed to form, facilitating discernment of healthy fascicular ends to reapproximate. Contaminated wound, ragging ends, no clean cut.
• C. Blunt injuries, (no transection), nerve remains in continuity, lesion due to stretch/contusion/compression induced by kinetic energy, ischemic, electric, injection or iatrogenic injury are treated after three to six months if there is failure to improve based on clinical and nerve conduction studies. If no recovery → explore, repair/reconstruct with intraoperative monitoring no earlier than 3 months.
• Remember, as an example of C., the possibility of injury to the lateral cord of brachial plexus after pacemaker placement.
• Examination, and ancillary studies compatible with lateral cord injury → infraclavicular exposure to release suture distorting the lateral cord of the brachial plexus.

• resect neuroma in continuity. Then options include:

• a. C5 → Suprascapular nerve + Posterior division of Upper trunk
  {shoulder function}
• b. C6 → anterior division of Upper trunk {elbow flexor function}
• c. C7 → posterior division of Middle trunk {extensor function}

• a. Distal Spinal Accessory to Suprascapular n.
• b. Branch of triceps (from radial n) to Axillary {Leechavengon’s procedure}
• c. Branch of Ulnar n. (not the br. to interossei!!) to Musculocutaneous {Oberlin procedure}.

• Normal shape and duration 65 m/sec
• Regeneration; altered shape, 30 m/sec
• If NAP is absent in case of neuroma, then resect it and perform graft repair

• For shoulder: spinal accessory to suprascapular nerve, radial nerve branch to long head of triceps transfer to axillary nerve.
• For elbow: ulnar n, fascicle to flexor carpi ulnaris to musculocutaneous nerve.

• For shoulder:
  • C5 to suprascapular nerve transfer,
  • C5 to posterior division of upper trunk (targeting the axillary nerve).
• For elbow:
  • C6 to anterior division of upper trunk (targeting the musculocutaneous nerve).

• Median nerve and musculocutaneous nerve combined injuries; suspect lateral cord injury. e.g. pacemaker placement injury. Tx: Infraclavicular- deltopectoral groove approach.
• When you see a combined median and ulnar n. palsy, think of Thoracic outlet, Pancoast tumor.
• In a lateral femoral cutaneous n. (Meralgia Paresthetica) case, search for the tunnel and decompress it inferolateral to anterior superior iliac spine and under origin of sartorius.

• For cervical root avulsion case consider DREZ or spinal cord stimulator.

• Know symptoms/signs of PIN syndrome (motor only- supinator) and its causes.
• AIN: check for trauma, tumor vs compression of AIN. AIN palsy → most of the time inflammatory. DO NOT operate unless it is traumatic, or there is a tumor within the nerve. Other times there may be entrapment. Get EMG, rule out masses with MRI.
• Median n. injury: differentiating it from an AIN injury:
  • a) Thumb cannot flex
  • b) High median n → SENSORY findings as well.
• Complete Median N. trauma: Which muscles go out as the lesion goes higher?
• High level Ulnar n. palsy → Pancoast tumor, Thoracic Outlet syndrome (in the latter, there is usually a little bit of median n. supplied muscle weakness due to plexus fibers mixing)
• Stab in the arm:
  • Brachial artery injury + Median n. injury
• Spiral fracture of the humerus leading to radial nerve injury: Wait three to six months if no clinical electrical recovery after closed fracture → intervene.

• Use neuromonitoring
• NAPs are better than EMG in prognostication
• Monitoring: SSEP, MEP, NAP, EMG
• Therapies: Neurolysis, Nerve repair, nerve graft, nerve transfer
• Always consider vascular surgery assistance when you go in for brachial plexus repair.
• Pre-op both sides for sural nerve graft harvest.

• How to distinguish lumbar radiculopathy from femoral neuropathy? Test the adductors. Sensory dermatomes differ. Test paraspinals on EMG also.
• Always check for paraspinal m. fibrillations in EMG that signify nerve root problem.
• Progress of re-innervation: 1 mm/day ≈ 1 inch /month.

• Exam
• Conservative management
• Image (U/S, MRI)
• Neuroma will develop!
• Resection, re-implantation within the muscle. If this does not work → SCS

• Several % following multilevel anterior or posterior cervical operations
• – Would follow with PT and serial exams
• – May regain function over 2 years
• – Controversial. If no clinical/ electrical recovery at 9 months, would consider nerve transfers.
• a. Spinal accessory to suprascapular and
• b. Triceps branch to axillary nerve.

• Serratus anterior (long thoracic nerve), think about inflammation
• Trapezius (spinal accessory nerve), think previous surgery, e.g. neck lymph node biopsy.
• Rhomboids (dorsal scapular nerve), rare cause

• When symptomatic, growing, or large (or concern for malignancy) → resect

• 1. Often improves symptoms
• 2. Treats tumor
• 3. Decreases (does not eliminate) interval for follow up
• 4. Surgery is safer, easier with smaller tumors
• 5. Tumors tend to grow over lifetime
• 6. Definitive tissue diagnosis
• 7. Neurofibromas can transform (small risk though).

• Microscope or loupes
• 7/0 to 9/0 non absorbable suture (prolene or nylon)
• Tension free technique
• Try to match fascicle size, blood vessels
• Epineurial or perineurial approximation
• Flat (square) knots
• Not too tight knots

• Direct repair
• Grafting:
  • a. Autograft (donors: sural nerves or superficial radial nerves)
  • b. Allografts
• Tubes, glue
• Nerve transfers
• Free muscle flaps
• Tendon transfers

• No shoulder abduction, no elbow flexion, strong elbow extension, normal grip and grasp, waiter’s tip position
• Summary
• Know basics about C5,6 upper pattern plexus injury and C5 injury
• Know mechanism of waiter’s tip posture position
• Know surgical options and timing in babies and adults
• Know about sural nerve management for neuroma pain at other sites (leg, hand, groin, etc)

• 1. Proximal and distal control
• 2. Save the date!
• 3. 80-90 % nerve function preserving

• Entrapment – common and a few uncommon
• Injury – acute (laceration); chronic (stretch/contusion)
• Tumor – benign vs malignant PNST
• Pain (neuroma or avulsion)
• Inflammation (Parsonage – Turner Syndrome)

• History, Physical exam, EMG, Imaging
• Nerves do 3 things: Motor, Sensory, Pain. Ask and examine these 3 components.
• More important question- Where does pain start? Pain/provocative tests localize (Find +, confirm -)
• Then image that region if atypical site!
• DDx: peripheral vs spinal

• Know the basic anatomy and examination
• Keep nerves in your differential: if the spine does not explain the findings, keep peripheral nerve pathology in your differential
• Know the indications for surgery and the basic nerve exposures
• If you suspect NERVES as the problem, ask for:
• Tinel sign, EMG/NCS, Imaging: U/S, MRI

There is an important role of the position of the deep veinous system relative to the pineal gland when choosing an approach to the region:

• If the venous system is dorsal to the mass, an infratentorial supracerebellar approach is indicated.
• If it is ventral to the mass, then a supratentorial approach, such as a posterior transcallosal or occipital transtentorial approach is indicated.

• Germinoma: Placental Alkaline Phosphatase, c kit, OCT 4
• Teratoma: Alpha Feto Protein (aFP) +
• Embryonal Carcinoma: aFP ++, beta Chorionic Gonadotropin (bHGTbHCG)
• Choriocarcinoma: bHGTbHCG +++, Human Placental Lactogen ++
• Pinealocytoma: Melatonin +
• Pinealoblastoma: Melatonin +++
• Papillary Tumor: Cytokeratin ++

• Always assess cardiac and renal abnormalities in a myelomeningocele case.
• They might be lethal.
• Always check respiratory status, possible apnea in these cases.

• Medulloblastoma surgery: importance of not violating the floor. Even tumor traction can cause neurological deficits if floor is invaded.
• Check for pituitary “bright spot” in suprasellar masses. Its presence usually excludes pituitary gland tumor or craniopharyngioma.

• Craniopharyngioma
• Optic glioma
• Hypothalamic Hamartoma
• Supracellar Arachnoid Cyst
• Dermoid, epidermoid, teratoma
• Pituitary tumor
• Germ cell tumor (check pineal region concurrent mass): germinoma/ nongerminoma

“VGMA” Vein of Galen Malformation is a true persistence of the median prosencephalic vein of Markowicz.

• 1) Primary type 1: Choroidal (direct)
  • High flow shunting within the wall of venous aneurysm
  • Anterior pericallosal
  • Posterior pericallosal
  • Posterior cerebral arteries, all three feed into Vein of Galen wall
• 2) Primary type 2: Mural (indirect)
  Thalomoperforating vessels → interposed network in quadrigeminal cistern → → vein of Galen
• 3) Combination of type 1 + 2 : High Flow
• 4) Parenchymal diffuse AV with primary drainage into vein of Galen (vein of Galen aneurysmal dilatation)

• Observation
• Fundoscopy to check for papilledema
• Shuntogram: nuclear study to check flow
• Place ICP monitor
• Shunt exploration

• Multiple prior orthopedic procedures
• Scoliosis
• Progressive neurologic disease (choreoathetosis)
• Double hemiplegia
• Cognitive problems
• Dislocated hips
• Inability to collaborate with physical therapists

• Planning for biopsy/ resection of pontine tumor through 4th ventricle:
• Brainstem auditory evoked responses
• SSEPs
• Motor potentials (including lower cranial nerves)
• Intraoperative MRI suite
• Mapping of 4th floor with electrodes
• Always assess preoperatively the lower cranial nerves
• Perform an overnight sleep study and vocal cord assessment in medulla oblongata tumors

• Hydrocephalus
• Increased intracranial pressure (morning headache, nausea, vomiting, papilledema, extraocular muscle dysfunction)
• Direct brainstem compression
• A. Parinaud syndrome (superior tectum involvement)
• B. Downward gaze palsy ptosis (periaqueductal gray or third ventricle involvement)
• C. Rare causes of tectal deafness (inferior colliculus involvement)
• Direct cerebellar compression (ataxia, dysmetria, superior cerebellar peduncle or cerebellorubro fibers involvement)
• Endocrine dysfunction
• A. Hypothalamic dysfunction
• B. Precocious Pseudopuberty (male patients with beta HCG producing tumors)
• Pineal apoplexy syndrome — acute presentation

• Always watch for blood loss, CSF leak and hypothermia
• In sagittal synostosis suturectomy: postoperative fever common due to blood resorption
• Incidence of sepsis is very low
• CSF leak after craniosynostosis:
  • Keep drains, no suction
  • Remove drains early
  • Non-tight head bandage
  • Rare lumbar drain
• SIADH not uncommon after sagittal craniosynostosis correction
• In unilateral/bilateral lambdoid synostosis: obtain MRV to assess transverse sinus and torculus
• Radiologic Chiari I + headache only → be cautious about surgery

• Always think anatomy first
• Hydrocephalus is the most common presentation
• Markers and syndromes are exam favorites
• Over-aggression in pediatric cases is punished
• Safety, physiology, and judgment score points

Due to its size and exam-level depth, Chapter 10 is provided as a standalone downloadable document.

Note: This material is intended for physician education and board-level preparation. Not for direct patient education.