Pre- and Post-Surgical Assessment and Treatment of Neurological Conditions

Overview

1. Spinal Disc Herniation

Pathophysiology

Pre-Surgical Assessment

• History: Distribution of radiculopathy (dermatomal pain, paresthesia, weakness), duration, response to conservative management (NSAIDs, physical therapy, epidural steroids)
• Neurological exam: Motor strength grading, sensory testing (dermatomes), deep tendon reflexes; look for foot drop, upper motor neuron signs
• Straight leg raise (SLR) test - positive at <60° suggests L4/L5/S1 nerve root compression
• Imaging: MRI is the gold standard - shows disc herniation, nerve root compression, cord signal change; CT-myelogram if MRI is contraindicated
• Red flags requiring urgent surgery: Cauda equina syndrome (bilateral leg pain, saddle anesthesia, bowel/bladder dysfunction, decreased rectal tone) - surgical emergency requiring decompression within 48 hours

Surgical Options

• Microdiscectomy (posterolateral) - most common for lumbar radiculopathy
• Anterior cervical discectomy and fusion (ACDF) - cervical disc herniation with myelopathy
• Central disc herniation with cauda equina requires urgent surgical decompression

Post-Surgical Assessment

• Monitor for neurological recovery (motor strength, sensory function)
• Watch for surgical complications: hematoma, wound infection, CSF leak, recurrent herniation
• Early mobilization; bowel and bladder function monitoring
• Persistent symptoms may indicate incomplete decompression or fibrosis
• Long-term follow-up: recurrence rate ~5-15%; rehabilitation physiotherapy

2. Spinal Stenosis

Pathophysiology

Pre-Surgical Assessment

• Symptoms: Neurogenic claudication - bilateral buttock, thigh, and calf pain/weakness/numbness provoked by walking and standing (lumbar lordosis increases); relieved by flexion (leaning on shopping cart)
• Differentiate from vascular claudication: Neurogenic worsens with extension, relieved by sitting; vascular claudication relieved by standing still; check peripheral pulses; noninvasive vascular study if needed
• Cervical stenosis causes myelopathy: hyperreflexia, hand clumsiness, gait disturbance - obtain cervical MRI
• Imaging: MRI confirms narrowing of central canal, lateral recesses, and neural foramina; 20-30% of asymptomatic adults >60 have imaging stenosis (clinical correlation essential)
• Conservative trial first: NSAIDs, epidural steroid injections, physical therapy

Surgical Indications

• Failure of 6+ weeks conservative treatment with functional disability
• Progressive neurological deficits
• Decompressive laminectomy ± fusion (if spondylolisthesis or scoliosis co-exists, instrumented fusion required)

Post-Surgical Assessment

• Walking ability and leg symptom relief (primary outcome)
• Monitor for epidural hematoma, neurological deterioration, infection
• Lumbar drain if CSF leak
• Symptoms progress in ~20-33% of untreated patients; surgery results in functional improvement in most

3. Spinal Cord Trauma

Principle: "Time is Spine"

Pre-Surgical Assessment (Acute)

• Scene: Immediate spinal immobilization (rigid cervical collar, backboard with logroll technique) for suspected cervical/thoracic injury
• ATLS protocol: Airway (intubate while maintaining cervical immobilization - ~1/3 of cervical SCI need intubation within 24h), breathing (cervical/thoracic injuries impair diaphragm, intercostal, abdominal muscles - risk of hypoxemia), circulation
• Neurogenic shock (above T6): bradycardia + hypotension from unopposed parasympathetic activity; treat with fluids + vasopressors
• MAP target: Maintain MAP >85 mmHg (or >10 mmHg above baseline) to preserve spinal cord perfusion
• Neurological exam - ASIA Scoring (American Spinal Injury Association):
  • ASIA A: Complete - no motor/sensory function below injury
  • ASIA B: Sensory only preserved below
  • ASIA C: Motor preserved, <50% key muscles grade ≥3
  • ASIA D: Motor preserved, ≥50% key muscles grade ≥3
  • ASIA E: Normal
• GCS, motor level, sensory level, sacral sparing (indicates incomplete injury)
• Imaging: CT spine (bony injury), MRI (cord signal, hemorrhage, ligamentous disruption)

Surgical Indications

• Unstable fracture/dislocation
• Incomplete SCI with imaging compression
• Early decompression (<24h) improves neurological outcomes in incomplete SCI

Post-Surgical Assessment

• Serial ASIA scoring for neurological recovery
• Vasopressor weaning, MAP monitoring
• Respiratory support; tracheostomy in high cervical injury
• Bladder/bowel program; pressure sore prevention
• Autonomic dysreflexia surveillance (above T6) - triggered by noxious stimuli below injury level
• Spasticity management; rehabilitation

4. Head Trauma

Classification

• GCS: Mild (14-15), Moderate (9-13), Severe (≤8)
• Injury types: Concussion, contusion, epidural hematoma (EDH), subdural hematoma (SDH), diffuse axonal injury (DAI), intracerebral hemorrhage

Pre-Surgical Assessment

• Primary survey: Airway, breathing, circulation; concurrent spinal injury assumed until cleared
• Neurological: GCS, pupillary responses (unilateral fixed dilated pupil = uncal herniation), lateralizing signs
• CT head (non-contrast): First-line imaging - identifies EDH (biconvex), SDH (crescent), contusions, midline shift, herniation, skull fractures
• Indications for urgent CT: GCS <15, LOC, amnesia, focal deficit, seizure, anticoagulation, age >65
• ICP monitoring: Insert if GCS ≤8 with abnormal CT (Monro-Kellie doctrine; target ICP <20 mmHg, CPP >60-70 mmHg)
• EDH: Classic lucid interval followed by deterioration; associated with middle meningeal artery injury; temporal location most common
• SDH: Bridging vein tear; elderly, anticoagulated patients at risk; chronic SDH may be hygroma

Surgical Indications

• EDH >30 mL, >15 mm thick, or >5 mm midline shift - urgent craniotomy
• Acute SDH with >10 mm thickness or >5 mm midline shift - urgent craniotomy
• Depressed skull fracture (>1 table width, open, contaminated) - debridement/elevation
• Penetrating injuries - debridement

Post-Surgical Assessment (ICU/Neurosurgical)

• Continuous ICP monitoring; maintain CPP
• CT scan at 24-48h post-op to check for re-bleeding
• Seizure prophylaxis (phenytoin/levetiracetam for 7 days in severe TBI)
• Prevent secondary injury: normothermia, normonatremia, normoglycemia, avoid hypoxia/hypotension
• Monitor for post-traumatic hydrocephalus (ventriculomegaly on CT)
• Vasospasm surveillance in severe TBI
• Glasgow Outcome Scale (GOS) at discharge and follow-up

5. Brain Tumors

Classification

• Primary: Glioma (glioblastoma GBM, astrocytoma, oligodendroglioma), meningioma, acoustic neuroma (vestibular schwannoma), pituitary adenoma, medulloblastoma, ependymoma
• Secondary (metastatic): Lung, breast, melanoma, renal, colon

Pre-Surgical Assessment

• Symptoms: Headache (worse in morning, positional), focal neurological deficits, seizures, papilledema, personality change, cognitive decline
• Imaging:
  • MRI with gadolinium contrast - delineates tumor margins from surrounding edema; best for preoperative planning; ring enhancement = high-grade lesion
  • CT scan: calcification, hemorrhage, bone involvement
  • Functional MRI (fMRI) and diffusion tensor imaging (DTI) - eloquent cortex mapping, fiber tract localization for surgical planning
  • MR spectroscopy - tumor metabolic profile (elevated choline, reduced NAA)
• Biopsy/histology essential for treatment planning (WHO grading I-IV)
• Perioperative steroids (dexamethasone) to reduce cerebral edema
• Anticonvulsants if seizures present
• Anesthesia considerations: Awake craniotomy for tumors in eloquent areas (speech, motor cortex)

Surgical Goals

• Complete excision for extra-axial tumors (meningioma, acoustic neuroma) - often curative
• Maximal safe resection for intra-axial tumors (glioma) - improves survival and symptom control
• Biopsy only if eloquent location or medical unfitness

Post-Surgical Assessment

• Neurological exam at emergence from anesthesia (new deficits?)
• MRI within 24-72h to assess extent of resection and complications
• Monitor for edema, re-bleeding, infection (meningitis/abscess), seizures
• Steroids tapered post-operatively
• Oncology referral for adjuvant therapy (radiation ± temozolomide for GBM - Stupp protocol)
• Recurrence monitoring with serial MRI

6. Tumors of the Spine, Spinal Cord, and Peripheral Nerves

Classification

• Extradural (most common ~55%): Metastatic (vertebral body - lung, breast, prostate, renal, lymphoma), primary bone tumors
• Intradural-extramedullary (~40%): Meningioma, schwannoma, neurofibroma
• Intramedullary (~5%): Ependymoma (adults), astrocytoma (children), hemangioblastoma

Pre-Surgical Assessment

• Symptoms: Back/neck pain (often nocturnal, constant), radiculopathy, myelopathy (progressive weakness, sensory loss, bowel/bladder dysfunction), cauda equina syndrome
• ASIA classification for myelopathy severity
• Imaging: MRI spine with gadolinium - location (extradural, intradural), cord signal change, extent
• CT with bone windows for bony destruction
• Systemic staging (CT chest/abdomen/pelvis, bone scan/PET) for suspected metastatic disease
• Laboratory: Tumor markers, serum/urine electrophoresis for myeloma; PSA if prostate suspected
• Biopsy if primary unknown (image-guided percutaneous or open)

Surgical Indications (Spinal Metastases)

• NEURNS/Tokuhashi/SINS scores guide surgical decision
• Spinal instability (SINS score ≥7)
• Spinal cord compression with neurological deficit
• Failure of radiation (radioresistant tumors)

Peripheral Nerve Tumors

• Schwannoma/neurofibroma: MRI, electrodiagnostic studies (EMG/NCS) preoperatively
• Malignant peripheral nerve sheath tumors (MPNST) - wide excision

Post-Surgical Assessment

• Serial neurological assessment (ASIA)
• Wound healing; spinal stability
• Adjuvant radiation/chemotherapy
• Rehabilitation for neurological deficits

7. Cerebral Aneurysms

Types

• Saccular ("berry") - most common; at bifurcations of Circle of Willis; rupture causes SAH
• Fusiform - atherosclerotic; rarely rupture
• Mycotic - infectious emboli; peripheral arteries

Pre-Surgical Assessment (Unruptured)

• Incidental on imaging; risk of rupture depends on size (>7mm higher risk), location, morphology, family history
• CTA or MRA - non-invasive screening; 3T MRA for small aneurysms
• 4-vessel digital subtraction angiography (DSA) - gold standard; 3D rotational angiography for treatment planning
• Multidisciplinary decision: surgical clipping vs. endovascular coiling vs. observation
• PHASES score (Population, Hypertension, Age, Size, Earlier SAH, Site) for rupture risk

Pre-Surgical Assessment (Ruptured - SAH)

• Immediate non-contrast CT head (sensitivity ~100% within 3 days)
• Lumbar puncture if CT negative but suspicion high - xanthochromia (develops 2h post-hemorrhage, lasts weeks)
• Hunt-Hess grade (I-V) - severity of SAH; World Federation of Neurosurgical Societies (WFNS) grade
• Fisher Scale (CT blood distribution) - predicts vasospasm risk
• 4-vessel DSA with 3D reconstruction for definitive aneurysm characterization
• Immediate transfer to neurovascular center; nimodipine to reduce vasospasm
• Secure aneurysm early (within 24-72h) to prevent re-bleeding

Treatment

• Surgical clipping: Open craniotomy, clip placed at aneurysm neck
• Endovascular coiling: Minimally invasive; preferred for most posterior circulation aneurysms (ISAT trial: coiling superior to clipping for most ruptured aneurysms)

Post-Surgical/Post-Procedure Assessment

• Neurological monitoring in neurocritical care unit
• Vasospasm (days 4-14): Daily transcranial Doppler (TCD); hypertensive-hypervolemic therapy (Triple-H) if symptomatic; endovascular papaverine or balloon angioplasty for refractory cases
• Delayed cerebral ischemia (DCI) monitoring - most feared complication
• Monitor for hydrocephalus - EVD placement if needed; VP shunt for chronic hydrocephalus
• Hyponatremia (SIADH or cerebral salt wasting) - electrolyte monitoring
• Follow-up DSA at 6 months and 1-2 years (clipping) to confirm aneurysm occlusion; CTA/MRA for coiled aneurysms

8. Subarachnoid Hemorrhage (SAH)

Diagnosis

• Non-contrast CT (NCCT): Highly sensitive (~100% within 3 days, decreasing thereafter) - shows blood in subarachnoid spaces; Fisher Grade predicts vasospasm
  • Grade 1: No blood
  • Grade 2: Thin diffuse blood (<1mm)
  • Grade 3: Thick blood/clots (≥1mm) - highest vasospasm risk
  • Grade 4: Intraparenchymal/intraventricular blood
• LP: Xanthochromia + elevated RBCs if CT negative
• MRI: FLAIR equal to NCCT for acute SAH; GRE sequences detect subacute/chronic SAH
• CTA/MRA - initial non-invasive angiographic evaluation for aneurysm source
• 4-vessel DSA with 3D reconstruction if CTA negative but high suspicion

Management

Post-SAH Assessment

• Neurological observation every 1-2 hours; transcranial Doppler daily for vasospasm
• Nimodipine 60mg q4h for 21 days (oral/NG) - reduces ischemic deficits (not angiographic vasospasm)
• Euvolemia, avoid hypotension
• Monitor: ICP, hydrocephalus (EVD), cardiac arrhythmias (SAH causes ECG changes - Wellens, ST changes, prolonged QT)
• Seizure prophylaxis
• Sedation/analgesia; strict bed rest until aneurysm secured

9. Epilepsy (Surgical Management)

Patient Selection for Surgery

• Medically refractory epilepsy: failure of 2+ appropriate anticonvulsants at therapeutic doses
• ~25% of all epilepsy patients are candidates for surgery; over 50% may benefit
• Patients often wait too long - surgery should be considered when 2 drugs fail (only ~60% respond to first drug; few benefit from 3rd drug)

Pre-Surgical Assessment (Comprehensive Epilepsy Evaluation)

1. Clinical seizure semiology - careful characterization
2. EEG/long-term video-EEG monitoring - capture ictal and interictal activity; localize seizure focus
3. High-resolution MRI (3T) - structural lesion (hippocampal sclerosis, focal cortical dysplasia, tumor, vascular malformation)
4. Functional imaging:
   • PET (interictal hypometabolism in seizure focus)
   • SPECT (ictal hyperperfusion)
   • MEG (magnetoencephalography)
5. Intracranial EEG (SEEG depth electrodes, subdural grid/strip electrodes) - if non-invasive localization inconclusive
6. Wada test (intracarotid amobarbital) or fMRI - language/memory lateralization; essential pre-temporal lobectomy
7. Neuropsychological testing - baseline cognitive function

Surgical Options

• Temporal lobectomy (anterior temporal lobe + amygdala + hippocampus) - best results: 58% seizure-free at 1 year (vs. 8% medical); >50% still seizure-free at 10 years
• Lesionectomy - extratemporal lesion removal; ~50% seizure-free
• Corpus callosotomy - palliative; best for atonic drop attacks
• Hemispherectomy - severe unilateral cerebral disease (Rasmussen encephalitis, Sturge-Weber, large porencephalic cyst)
• Vagal nerve stimulation (VNS) - neuromodulation for non-resectable epilepsy
• Responsive neurostimulation (RNS) - closed-loop stimulation

Post-Surgical Assessment

• Video-EEG monitoring post-operatively
• Engel outcome scale (Class I = seizure free)
• Continue anticonvulsants (most still require medication even if seizure-free)
• Neuropsychological follow-up (verbal memory decline after dominant temporal lobectomy)
• Visual field testing (superior quadrantanopia common after temporal lobectomy)

10. Parkinson's Disease (Surgical Treatment)

Indication for Surgery

• Advanced Parkinson's disease with motor fluctuations (on-off), dyskinesias, or tremor refractory to optimal medical therapy (levodopa/carbidopa, dopamine agonists, MAO-B inhibitors)
• Good candidates: Levodopa-responsive motor symptoms, no dementia, no major psychiatric illness, young-onset PD

Pre-Surgical Assessment

• Comprehensive motor assessment: UPDRS (Unified Parkinson's Disease Rating Scale) - on and off medication
• Levodopa challenge test - motor improvement predicts DBS response (aim for >30% improvement)
• MRI brain - rule out structural pathology; DBS targeting of subthalamic nucleus (STN) or globus pallidus interna (GPi)
• Neuropsychological testing - rule out dementia
• Psychiatric evaluation - depression, impulse control disorders
• Speech/swallowing assessment

Surgical Options - Deep Brain Stimulation (DBS)

• Subthalamic nucleus (STN) DBS - most common target; improves tremor, rigidity, bradykinesia; reduces medication needs
• Globus pallidus interna (GPi) DBS - improves dyskinesias; less medication reduction
• Thalamic (VIM) DBS - primarily for tremor only

Post-Surgical Assessment

• DBS programming (neurologist + programmer) over several visits - optimize stimulation parameters
• Medication adjustment (often reduced after STN DBS)
• Monitor for hardware complications: lead migration, infection, impedance changes
• Complications: perioperative stroke, hemorrhage, infection, speech/cognitive decline (rare)
• Continued UPDRS monitoring

11. Chorea

Key Causes

• Huntington's disease (autosomal dominant, CAG repeat >36 on chromosome 4)
• Sydenham's chorea (post-streptococcal, rheumatic fever - Group A Strep)
• Drug-induced (antipsychotics - tardive dyskinesia)
• Lupus (antiphospholipid antibody syndrome)
• Chorea gravidarum (pregnancy)
• Benign hereditary chorea
• Metabolic: hyperthyroidism, hyper/hypoglycemia

Surgical Relevance

• Pallidotomy or GPi DBS - for severe, medically refractory chorea in Huntington's disease
• Pre-surgical assessment includes genetic confirmation, cognitive/psychiatric evaluation, advanced disease stage
• Post-procedure: monitoring of involuntary movements, cognitive status

Assessment

• Characteristic irregular, flowing, unpredictable limb movements
• UHDRS (Unified Huntington's Disease Rating Scale) for Huntington's
• MRI: caudate atrophy in Huntington's
• ASO titers, throat culture in Sydenham's

12. Hemiballism

Definition

Common Causes

• Lacunar stroke/infarction in STN (most common)
• Hyperglycemic hemiballism
• AVM, tumor, encephalitis

Assessment and Treatment

• Brain MRI/CT - identify STN lesion (usually small infarct)
• Most cases are self-limiting (weeks to months) and respond to:
  • Haloperidol, tetrabenazine, or valproate
• Surgical/interventional (rare, refractory): Pallidotomy or GPi DBS

13. Psychiatric Disorders (Neurosurgical Interventions)

Indications for Neurosurgery

• Obsessive-Compulsive Disorder (OCD)
• Major Depressive Disorder (MDD)
• Treatment-resistant anxiety disorders
• Tourette's syndrome

Surgical Options

• DBS (FDA approved for refractory OCD - anterior limb of internal capsule/NAcc target)
• Anterior cingulotomy / capsulotomy (stereotactic ablation) - historical; OCD, severe MDD
• Gamma Knife radiosurgery - capsulotomy/cingulotomy

Pre-Surgical Assessment

• Exhausted pharmacotherapy (multiple antidepressants/antipsychotics/augmentation strategies)
• Psychotherapy failure
• Multidisciplinary team review (psychiatry, neurosurgery, ethics, psychology)
• Detailed neuropsychological baseline
• No active substance abuse, no significant cognitive impairment
• Yale-Brown Obsessive Compulsive Scale (Y-BOCS), HAM-D, MADRS scores

Post-Surgical Assessment

• Serial psychiatric rating scales
• DBS programming adjustments
• Monitoring for emotional/behavioral changes, cognitive effects
• Ongoing psychiatric follow-up essential

14. Malformations of the Nervous System

Types Relevant to Surgery

• Chiari malformations (I, II) - cerebellar tonsillar herniation below foramen magnum
• Dandy-Walker malformation - cystic posterior fossa, hypoplastic cerebellum
• Arachnoid cysts - extra-axial fluid collections
• Tethered spinal cord - low-lying conus with fatty filum

Pre-Surgical Assessment

• MRI brain and spine (full craniospinal axis)
• Chiari I: syrinx (syringomyelia), symptoms of suboccipital headache, myelopathy
• Hydrocephalus severity - head circumference, fontanelle, ventricular size on imaging
• Neurological exam in children: developmental milestones, cranial nerve function
• Genetic/chromosomal evaluation (Dandy-Walker associated with trisomies)

Surgical Options

• Chiari I: Posterior fossa decompression (suboccipital craniectomy ± duraplasty)
• Dandy-Walker/Hydrocephalus: VP shunt or endoscopic third ventriculostomy (ETV)
• Tethered cord: Untethering surgery

Post-Surgical Assessment

• Serial MRI to check syrinx resolution, shunt function
• Developmental and neurological follow-up
• Shunt malfunction signs: headache, vomiting, altered consciousness, bulging fontanelle

15. Carotid Artery Stenosis

Pathophysiology

Pre-Surgical Assessment

• Clinical: TIA or stroke history, amaurosis fugax; carotid bruit
• Duplex ultrasound - first-line; measures degree of stenosis (velocity criteria)
• CTA or MRA - extent, plaque morphology, aortic arch anatomy
• Cerebral angiography (DSA) - gold standard for planning; reserved for complex cases
• Cardiac evaluation - concurrent coronary artery disease common; perioperative cardiac risk
• Risk factor optimization: antiplatelets (aspirin/clopidogrel), statins, antihypertensives

Surgical Options

• Carotid endarterectomy (CEA) - surgical plaque removal; gold standard for symptomatic 70-99% stenosis (NASCET criteria)
• Carotid artery stenting (CAS) - for high surgical risk patients; higher restenosis rate than CEA

Post-Surgical Assessment (CEA)

• Surveillance duplex ultrasound: at 30 days post-op, then 3 months, 6 months, 1 year
• More frequent if: 50%+ ipsilateral restenosis, primary arterial closure, high atherosclerotic risk
• Contralateral progression more common than ipsilateral restenosis - bilateral surveillance
• Post-CAS: Velocity criteria differ (stent affects readings); same surveillance schedule
• 50-70% restenosis: duplex every 6 months

• 70-80% restenosis: CTA/MRA or DSA for reintervention planning

• Ongoing risk factor control (statin, antiplatelet, BP, smoking cessation)

16. Arteriovenous Malformations (AVM)

Definition

Pre-Surgical Assessment

• Presentation: Hemorrhage (intracerebral or SAH), seizures, headache, focal deficit, incidental
• MRI brain - nidus location, relationship to eloquent cortex, prior hemorrhage
• CTA - fast evaluation; identifies nidus, feeding arteries, draining veins
• 4-vessel DSA - gold standard; characterizes angioarchitecture (nidus size, deep vs. superficial venous drainage, eloquent location), feeding pedicles, associated aneurysms
• Spetzler-Martin (SM) Grading (I-V) - guides surgical risk: size (≤3cm=1, 3-6cm=2, >6cm=3) + eloquence of adjacent cortex (0/1) + deep venous drainage (0/1)
  • Grade I-II: low risk surgery; Grade III: intermediate; Grade IV-V: high risk, consider non-surgical management

Treatment Options

• Surgical resection - SM Grade I-II; definitive cure
• Stereotactic radiosurgery (Gamma Knife) - small (<3cm) AVMs in eloquent/deep locations; obliteration takes 2-3 years
• Endovascular embolization - preoperative reduction of AVM volume; rarely curative alone
• Combination (embolization + surgery or radiosurgery)

Post-Surgical Assessment

• DSA at 6 months post-resection - confirm obliteration (residual AVM has ongoing hemorrhage risk)
• MRI at 3 months and annually
• Seizure monitoring; antiepileptics continued post-op
• After radiosurgery: annual MRI × 3 years; DSA at 3 years to confirm obliteration
• Radiation-induced complications: radiation necrosis (symptomatic ~5%), cyst formation (delayed)

17. Spina Bifida

Classification

• Spina bifida occulta - incomplete fusion of vertebral arch, no neural tissue herniation; usually asymptomatic
• Meningocele - meninges herniate through defect; no neural tissue; good prognosis
• Myelomeningocele (MMC) - spinal cord + nerve roots herniate; most serious; associated with Chiari II malformation and hydrocephalus
• Myeloschisis - open neural placode, no covering membrane

Pre-Surgical Assessment (Prenatal/Neonatal)

• Prenatal diagnosis: Elevated maternal serum AFP (MSAFP), detailed ultrasound (open defect, "lemon" sign, "banana" sign, ventriculomegaly), fetal MRI
• At birth: Level of lesion, neurological function below lesion, sac intact vs. ruptured, associated hydrocephalus
• Imaging: Head ultrasound/MRI - hydrocephalus, Chiari II; spine MRI - tethered cord
• Latex allergy precautions (MMC patients have high latex sensitization rates)

Surgical Management

• Fetal surgery (MOMS trial) - prenatal MMC repair at 19-25 weeks gestation reduces hindbrain herniation, need for VP shunt, improves motor outcomes
• Postnatal repair: Within 24-72 hours of birth to prevent infection and further neurological loss
• VP shunt for associated hydrocephalus (needed in ~80-90% of MMC)
• Untethering surgery if tethered cord develops

Post-Surgical Assessment

• Neurological function monitoring (motor, sensory level)
• Bladder function (clean intermittent catheterization program - neurogenic bladder common)
• Bowel program
• Hydrocephalus surveillance: head circumference, fontanelle, MRI/CT
• Shunt function checks
• Latex precautions maintained throughout care
• Long-term: orthopedic care (scoliosis, hip dislocation), developmental support

Summary Table: Key Pre/Post-Surgical Pearls