CHAPTER Neurosurgery

• Successful management of traumatic brain injury requires rapid assessment, diagnosis, and treatment of primary in­ juries and avoidance of secondary injuries from hypoxia, hypotension, increased intracranial pressure, and seizures. • Progressive obtundation, pupillary abnormalities, or other lateralizing neurologic findings in combination with intra­ cranial lesions such as epidural hematoma, subdural hematoma, and intracranial hemorrhage causing patho­ logic brain shift are generally surgical emergencies. • All patients with significant trauma should be considered to have spinal injury until proven otherwise. Clearance of the spine requires negative x-rays and clinical clearance by palpation for pain, swelling, and step-ofts of the spine. • Helical computerized tomography has generally sup­ planted plain film x-rays for assessing cervical spine injury with magnetic resonance imaging utilized to evaluate patients with suspected ligamentous injury. • Degeneration of the joints of the spine leads to compres­ sion of the neural elements from disk herniations, bone spurs, ligamentous hypertrophy, malalignment, and possi­ ble instability. Acute compression of the lumbosacral nerve roots (cauda equina) can lead to a cauda equina syndrome, which is a surgical emergency. • Metastases are by far the most common brain tumor in adults. Tumors that commonly metastasize to the brain include lung, breast, melanoma, and renal cell carcinoma. • High-grade gliomas are the most common primary brain tumor in adults and overall have a poor prognosis. • In the acute setting, attempted repair of a peripheral nerve is only appropriate in the setting of sharp penetrating injuries.