Common Neurosurgical Procedures

Surgeries performed on the CNS

Purpose: Prevent neurological deficits

Therapeutic Precautions: 

• Check order set; Confirm lifting restrictions

• Avoid prolonged bending over and Valsalva maneuvers

• Monitor vital signs: BP, HR, and O2

• Check for elevated ICP

• Monitor for reperfusion injuries

Procedure to open blocked coronary arteries

Purpose: Restore blood flow due to arterial occlusions. May be done in combination with IV tPA or angioplasty. Indicated for patients who present >6 hrs. after onset, patients who have contraindications to or don’t improve after IV tPA. Work well for large clots.

Therapeutic Precautions: May require bed rest for up to 8 hrs. after procedure. Check with the team for activity orders. The primary issue may be the closure method or the presence of a femoral sheath.

Tiny hole drilled into the skull

Purpose: Remove localized fluid collection

Therapeutic Precautions: See general neurosurgical precautions

Surgical removal of plaque buildup inside the carotid artery.

Purpose: Treat carotid artery disease

Therapeutic Precautions: Usually have tight BP parameters post-op to avoid reperfusion injury (i.e., SBP 120-160)

Catheter is inserted into an artery in the groin (occasionally an artery in the arm or neck are used) and contrast dye is injected. Following which x-rays are taken to show blood flow to the brain.

Purpose: Investigate or examine blood vessels of the brain, head, or neck

Precautions: Following the procedure, patients are generally on bed rest for 6-8 hours with involved limb (hip/knee/arm) immobilized for ~6-8 hours. If neck used, watch for signs of hoarseness, breathing problems, pain, or difficulty swallowing. Defer mobility until the femoral sheath is removed and activity orders are advanced.

A portion of the skull is removed, then placed into a subcutaneous pocket in the abdomen or a flap in the subgaleal space, a deep freeze, or is discarded

Purpose: Relieve pressure, reduce ICP, reduce intracranial hypertension, or allow for unrestricted brain swelling

Therapeutic Precautions:

• Helmets are generally recommended when the patient is OOB. However, this practice is neurosurgeon/facility-specific due to potential compression

  • **If no helmet is used, be cautious not to apply pressure to the areas with no bone.

• When ordering helmets, measure the circumference of the head ~1 in above the ears

• Ensure the helmet is not compressing the area with no bone

• Do not roll the patient onto the side with the craniectomy as it will put pressure on the portion of the brain that is unprotected.

• Restrict the patient from bending forward with ADL or mobility

• For further reading visit the Pandit et al., 2022 article listed in the reference section

Replacement of the bone flap in the skull

Purpose: restore protection for the brain cosmetic

Therapeutic Precautions: See general neurosurgical precautions

Removal of a portion of the skull (bone flap) and subsequent opening of the dura. The skull is then replaced.

Purpose: Remove a tumor, Relieve pressure, Drain blood from a hemorrhagic area, or Repair damaged area

Therapeutic Precautions: See general neurosurgical precautions

Small metal clip placed around the base of an aneurysm

Purpose: Isolate aneurysm from normal blood flow to prevent rupture

Therapeutic Precautions: See general neurosurgical precautions

Surgical excision of a CNS mass

Purpose: Remove as much of the tumor as possible to reduce neurological deficits & improve quality of life

Therapeutic Precautions: See general neurosurgical precautions

Coils are placed in an aneurysm or vascular area via a catheter. The body responds by forming a blood clot around the coil, blocking off the aneurysm.

Purpose: Block an aneurysm. Block vascularity that may rupture during a surgery (i.e., in prep for tumor debulking)

Therapeutic Precautions: See general neurosurgical precautions

Usually done in conjunction with a burr hole, craniectomy, or craniotomy to remove excess intracerebral blood or a clot

Purpose: Reduce ICP from bleeding in the brain either via a burr hole or craniotomy

Therapeutic Precautions: See general neurosurgical precautions

A needle is inserted between two lumbar bones (vertebrae) to remove a CSF sample

Purpose: diagnose disease of the CNS (brain & spine) and to provide short-term relief of hydrocephalus

Therapeutic Precautions: Bed rest for 2-4 hours following procedure (might be patient or facility-specific)

Short term complications and indications to hold therapy until cleared for OOB activity: headache, backache, bleeding at the site, CSF leak, voiding difficulty, and fever

Device used to retrieve & remove clots or insert IA thrombolytics to achieve primary reperfusion

Purpose: Restore blood flow due to arterial occlusions; may be done in combination with IV tPA or angioplasty. Indicated for patients who: present >6 hrs. after onset or have contraindications to/don’t improve after IV tPA & caused by MCA occlusion

Therapeutic Precautions: Arterial closure system sometimes develops a “leak” & must be monitored. Typically, entry site is the femoral artery. Can also be done through the radial artery. Watch for hematoma formation for frank bleeding. If frank bleeding occurs, hold pressure and cease activity.

Surgical procedure done trans nasally

Purpose: Removal of pituitary tumor

Therapeutic Precautions:

Do not remove nasal packing:

• Keep head of bed at 30°

• Avoid Valsalva maneuvers

• If clear, thin fluid is draining from the nose, alert staff immediately; could be CSF

Sinus Precautions in place for ~4-6 weeks (check with the surgeon):

• Do no bend/lean forward at the waist

• Do not drink from straws

• Do not sneeze through the nose

• Do not sniffle

• Do not pick nose

• Do not blow nose

Surgical management of excess CSF.

Purpose: Provides an alternate path to redirect excess CSF from one area to another using an implanted tube. With an overall goal of relieving elevated ICP from excess CSF

Location: a catheter is passed from the ventricles to the abdomen to directly drain CSF (MedlinePlus, 2021). The drip chamber is located inside the abdominal cavity. 

Precautions: doesn’t require leveling or clamping. Craniotomy precautions. Gradual elevation of HOB and activity orders are generally ordered on post-op day 1. Patients may complain of headache and stomachache. Do not push on the shunt that is visible on the head.