Clinical Anesthesia in Neurosurgery

578 Pages·1991·25.49 MB·English

by  Elizabeth A. M. Frost (Eds.)

Clinical
Anesthesia in
Neurosurgery
Second Edition
Edited by
ELIZABETH A. M. FROST, M.B., CH.B
Professor of Anesthesiology, Albert Einstein College of
Medicine, Bronx, New York
With 25 Contributing Authors
Foreword by Paul M. Kornblith, M.D., Professor and
Chairman, Department of Neurosurgery, Montefiore
Medical Center, Bronx, New York
Butterworth-Heinemann
Boston London Singapore Sydney Toronto Wellington
To my four sons . . . Garrett, Ross, Christopher,
and Neil, with love.
Copyright © 1991 by Butterworth-Heinemann, a division of Reed Publishing
(USA) Inc. All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system,
or transmitted, in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without the prior written permission
of the publisher.
Every effort has been made to ensure that the drug dosage schedules within
this text are accurate and conform to standards accepted at time of
publication. However, as treatment recommendations vary in the light of
continuing research and clinical experience, the reader is advised to verify
drug dosage schedules herein with information found on product
information sheets. This is especially true in cases of new or infrequently
used drugs.
Recognizing the importance of preserving what has been written, it is the
policy of Butterworth-Heinemann to have the books it publishes printed on
acid-free paper, and we exert our best efforts to that end.
Library of Congress Cataloging-in-Publication Data
Clinical anesthesia in neurosurgery / edited by Elizabeth A.M. Frost;
with 25 contributing authors ; foreword by Paul M. Kornblith. —2nd
ed.
p. cm.
Includes bibliographical references.
ISBN 0-409-90171-7
1. Nervous system—Surgery. 2. Anesthesia in neurology.
I. Frost, Elizabeth A.M.
[DNLM: 1. Anesthesia. 2. Nervous System—surgery. WO 200
C641]
RD593.C53 1991
617.9'6748—dc20
DNLM/DLC
for Library of Congress 90-1624
CIP
British Library Cataloguing in Publication Data
Clinical anesthesia in neurosurgery.-2nd ed.
1. Man. Nervous system. Anesthesia
I. Frost, Elizabeth A.M.
617.96748
ISBN 0-409-90171-7
Butterworth-Heinemann
80 Montvale Avenue
Stoneham, MA 02180
10 9 8 7 6 5 4 3 21
Printed in the United States of America
Contributing Authors
Steven J. Allen, M.D. Alan Hirschfeld, M.D.
Associate Professor, Department of Anesthe- Assistant Professor of Neurosurgery, Albert Ein­
siology, University of Texas Medical School at stein College of Medicine; Assistant Attending in
Houston, Houston, Texas Neurosurgery, Montefiore Medical Center, Bronx,
New York
Jeffrey Askanazi, M.D.
Associate Professor, Department of Anesthe- Ingrid B. Hollinger, M.D.
siology, Montefiore Medical Center/Albert Ein­ Clinical Director, Montefiore Medical Center; As­
stein College of Medicine, Bronx, New York sociate Professor of Anesthesiology, Assistant Pro­
fessor of Pediatrics, Albert Einstein College of
Robert F. Bedford, M.D. Medicine, Bronx, New York
Professor of Anesthesiology, Cornell Univer­
sity Medical College; Chairman, Department
George B. Jacobs, M.D.
of Anesthesiology and Critical Care Medicine,
Chairman, Department of Neurological Surgery,
Memorial-Sloan Kettering Cancer Center, New
Hackensack Medical Center; Professor of Clinical
York, New York
Neurosurgery, Montefiore Medical Center, Bronx,
New York; Attending Neurosurgeon, Holy Name
F. Harrison Boehm Jr., M.D.
Hospital, Teaneck, New Jersey
Chief Resident, Department of Neurosurgery,
Montefiore Medical Center, Bronx, New York
Jeffrey Katz, M.D.
Professor of Anesthesiology, University of Texas
Richard E. Brennan, Esq.
Medical School at Houston; Director, Neurosur-
Partner, Shanley and Fisher, Esquires, Mor-
gical Anesthesia, Hermann Hospital, Houston,
ristown, New Jersey
Texas
Jonathan S. Daitch, M.D., Capt. (USAF)
Olli Kirvelä, M.D., Ph.D.
Staff Anesthesiologist, Department of Anesthe­
Senior Staff Anesthesiologist, Turku University
siology, Wright-Patterson Medical Center, Wright-
Central Hospital, Turku, Finland
Patterson Air Force Base, Ohio
Dennis R. Kopaniky, M.D.
R. A. de Los Reyes, M.D.
Professor of Neurosurgery, Department of Surgery,
Associate Professor and Director of Cerebrovas-
cular Surgery, Department of Neurosurgery, Division of Neurosurgery, Texas Medical Center,
Montefiore Medical Center/Albert Einstein Col­ Houston, Texas
lege of Medicine, Bronx, New York
Vladimir Kvetan, M.D.
Philip L. Gildenberg, M.D., Ph.D. Associate Professor, Department of Anesthesia,
Clinical Professor of Neurosurgery, Clinical Pro­ Montefiore Medical Center, Bronx, New York
fessor of Psychiatry and Behavioral Science, Uni­
versity of Texas Medical School at Houston, Hous­ George Lantos, M.D.
ton, Texas Professor of Radiology, Beth Israel Medical Cen­
ter, New York, New York
James T. Goodrich, M.D.
Director of Pediatric Neurosurgery, Montefiore Patrick A. LaSala, M.D.
Medical Center/Albert Einstein College of Medi­ Assistant Professor of Neurosurgery, Albert Ein­
cine, Bronx, New York stein College of Medicine, Bronx, New York
vn
viii Contributing Authors
Alan D. Legatt, M.D., Ph.D. Robert C. Rubin, M.D.
Assistant Professor of Neurology and Neuro- Director, Department of Neurosurgery, Holy Name
science, Albert Einstein College of Medicine; Di­ Hospital, Teaneck, New Jersey; Associate Profes­
rector of Intraoperative Neurophysiology, Depart­ sor of Clinical Neurosurgery, Montefiore Medical
ment of Neurology, Montefiore Medical Center, Center, Bronx, New York; Attending in Neurosur­
Bronx, New York gery, Hackensack Medical Center and Pascack
Valley Hospital, Westwood, New Jersey
Michael E. Miner, M.D., Ph.D.
Professor and Chairman, Division of Neurosur­
gery, Ohio State University, Columbus Kamran Tabaddor, M.D.
Associate Professor of Neurosurgery, Department
Irene P. Osborn, M.D. of Neurosurgery, Montefiore Medical Center/
Assistant Professor, Department of Anesthe­ Albert Einstein College of Medicine, Bronx, New
siology, Montefiore Medical Center, Bronx, New York
York
Richard E. Patt, M.D. Somasundaram Thiagarajah, M.D.
Associate Professor of Anesthesiology and Psy­ Associate Clinical Professor of Anesthesiology,
chiatry, and Coordinator, Cancer Pain Service, Mt. Sinai School of Medicine; Associate At­
University of Rochester Medical Center, Strong tending in Anesthesiology, Beth Israel Medical
Memorial Hospital, Rochester, New York Center, New York, New York
Foreword
Dramatic advances in the field of medicine have In more recent times there have been again two
occurred in the care of the patient with intra- parallel efforts that have converged to signifi­
cranial disease. It is hard to appreciate that it has cantly improve neurosurgical care. In the field of
been only in the past 100 years of humanity's exis­ neurosurgery, the development of microneurosur-
tence that the cranial vault has been safely ex­ gical techniques has revolutionized the approach
plored and major lesions treated successfully. Al­ to major intracranial disease. No longer are tumors
though trephining and various entries into the pushed or pulled or tugged with macroin-
skull had been performed in prior centuries, suc­ struments. Now what is often referred to as "cell
cessful outcomes were rarely achieved. by cell" removal of tumors (such as acoustic
Even looking at the past century, it is even more schwannomas) is the proper routine. The light,
notable that the most remarkable progress in the magnification, and precision of the microneu-
safe and effective management of intracranial dis­ rosurgical armamentarium have decreased blood
ease has occurred in the period since World War loss and damage to normal brain tissues and have
II. This progress rests securely on two major pil­ helped to preserve critical small vessels. These
lars — advances in technical neurosurgery, but as techniques also have permitted anastomoses of
importantly on the advances in the art and science minute cerebral vessels, embolectomies, and clip­
of neuroanesthesia. ping of aneurysms and vascular malformations
This coupling of neurosurgical and neuro- with remarkable safety.
anesthetic progress and its combined impact on All of these wonderful technical advances have
patient care is the essence of this book. been completely dependent upon the concomitant
The history of the two fields, neurosurgery and development of what might be seen as the exten­
neuroanesthesia, are so intimately intertwined sion of Cushing's concept of a quantitative ap­
that the figures of importance in their progress proach to neuroanesthesia. Precise, second-by-
have come to be seen as part of a unified effort to second monitoring of all the clinical parame­
improve care. ters— pulse, blood pressure, respiratory rate —
It was Sir William Macewen, a Glasgow neuro- has now been extended to instantaneous monitor­
surgeon, who in 1878 carried out the first endo- ing of blood gases and blood chemistries. Regula­
tracheal anesthesia using chloroform. Sir Victor tion of delivery of anesthetic agents is now ultra-
Horsley noted that ether caused a rise in blood precise, and the appropriate combinations can be
pressure and should not be used in neurosurgery. custom designed to fulfill the special needs of a
He felt strongly that precise concentrations of the particular patient. As the microsurgical proce­
anesthetic agents needed to be regulated to dures often take many hours, meticulous regula­
achieve the proper degree of safety. Fedor Krause tion of fluid and electrolyte balance as well as an
from Germany emphasized the relative insensi- appropriate level of cerebral dehydration becomes
tivity to pain of the brain tissue itself and the role absolutely essential.
that local anesthesia could play in reducing the All of these developments in neuroanesthesia
pain from scalp and meningeal manipulation. and how they interdigitate with modern neurosur­
Harvey Cushing, even as a medical student, was gical practice are thoroughly reviewed by Dr. Frost
concerned about the problems of anesthesia and and her colleagues in this book. Dr. Frost is one of
pioneered the development of quantitative record­ those extremely rare individuals who combines a
ing of the clinical parameters of the patient under historical perspective of the field, a personal mas­
anesthesia. These major historical figures cer­ tery of the clinical arena, and involvement with
tainly helped to establish the field of neurosur­ the most up-to-date techniques with a true aca­
gery, and their interest in neuroanesthesia was demic interest in seeing that the field advance. In
critical in their early successes. this edition of Clinical Anesthesia in Neurosur-
IX
x Foreword
gery the remarkable evolution of the field of neuro- help in laying the foundation for future advances
anesthesia is integrated with the major areas of as well as describing the current state of the art.
neurosurgical activity to give the reader the re­
quired perspective and requisite information to Paul M. Kornblith, M.D.
Preface to Second Edition
Six years have passed since the appearance of the ting position, the present trend is toward a prone
first edition of this book. In considering the broad or lateral position, thus preventing or minimiz­
field of anesthesiology, one might note that over ing complications.
this relatively short period of time, there have Brain tumors, once thought to be synonymous
been no major new discoveries of anesthetic with death, are now often successfully treated
agents or techniques. Thus, one might rationally with several different therapies. A new chapter
assume that there are probably few changes in a has been assigned to this topic.
subspecialty area such as neuroanesthesia. Noth­ New frontiers are being forged in the care of
ing could be further from the truth. In preparing children with congenital neurologic abnormali­
this second edition, not only have several chapters ties. Teams of specialists are forming to better un­
been added, but preexisting chapters have often derstand and care for these babies. In this edition,
been completely rewritten and major thrusts a pediatric anesthesiologist and a pediatric neuro-
redirected. surgeon have collaborated to present a state-of-
Much new information has emerged concern­ the-art view of the exciting subspecialty of pediat­
ing cerebral hemodynamics and metabolism. With ric neuroanesthesia.
the now widespread use of exciting radiologic Seizure surgery and stereotactic surgery remain
techniques incorporating magnetic imaging and important aspects of neurosurgical care. An an­
isotopes, our understanding of cranial function is esthesiologist has joined with a neurosurgeon to
expanding rapidly. The blood-brain barrier, now present an updated view of these areas.
defined, is affected by many chemical situations Pain therapy requires a team approach. A new,
and anesthetic techniques. expansive chapter has been added in this edition
Electrophysiologic monitoring, in its infancy in to review the therapeutic options and outline the
1984, is now standard technique in most operating roles of the several specialists.
suites, with rapidly expanding uses in neurosur- Central nervous system trauma remains one
gery. So much has been learned of the effects of the of the most devastating medico-socio-economic
anesthetic agents on intracranial dynamics over problems of our society. Again updated neurosur­
the past few years that discussion of this topic gical and anesthetic views are presented.
now requires its own chapter. Deleterious ef­ I received several requests after the first edition
fects of nitrous oxide on the injured brain have of this book appeared: "What do you do with the
been confirmed. Sufentanil may also be contra- head-injured patient, cleared for abdominal sur­
indicated in specific situations and alfentanil gery?" "How do you manage the patient with a
indicated. stroke for hip replacement?" Thus, yet another
Recently, the importance of appropriate and chapter was added on the care of the patient
adequate fluid management of the neurosurgical with neurologic disease who presents for non-
patient in ensuring optimal outcome has been em­ neurosurgical surgery.
phasized. A new chapter, written by a neurosur- One of the major exciting advances in postoper­
geon, addresses these pertinent issues. ative and intensive care has involved hyperali-
In the arena of cerebrovascular disease, results mentation. Although many new drugs and tech­
of multi-institutional studies have required that niques have been advanced to improve outcome
we revise our previous approach to therapy of after brain insult, no clear therapeutic approaches
ischemic cerebral disorders. No longer are extra- have been established. However, our understand­
cranial to intracranial bypasses and carotid endar- ing of the changes caused by hypoxic and is­
terectomies routine procedures. Rather, much chemic insults are much clearer, and with under­
more vigorous standards must be applied. standing may come healing.
Whereas lesions in the posterior fossa were Finally, the latest court rulings applying to the
commonly operated with the patient in the sit­ definition of cerebral death are summarized.
xi
xii Pre/ace to Second Edition
Again, as in the first edition, this book is pre­ ing on their laurels, but rather, with remarkable
sented by anesthesiologists and neurosurgeons, intensity, striving to further define neurologic,
most of whom work together on a daily basis. Even pathophysiologic, and appropriate anesthetic
as pathologic processes become more clearly de­ management
fined, rigid management plans are still not delin­ As before, I thank the contributors for all their
eated. Rather, rational approaches to prudent an­ hard work and the secretarial staff of Montefiore
esthetic care are presented — bearing in mind that Medical Center and Bronx Municipal Hospi­
there are many different situations in this world, tal, who worked long hours to complete manu­
and strict adherence to a single technique is unfea­ scripts. My gratitude is also extended to the staff
sible, unrealistic, and usually not necessary. at Butterworth-Heinemann for help and en­
I am proud to see the advances that the spe­ couragement through both editions.
cialty of neuroanesthesia has made in these six
years. Neuroanesthesiologists are not as yet rest­ Elizabeth A. M. Frost
Preface to First Edition
Just as there is no standard central nervous system volved and suggest rational approaches to anes­
lesion, there is no single best choice in neuro- thetic care. Both anesthesiologist and neurosur-
anesthesia. Rather, over the years, there has been a geon should be aware, for example, of the hazards
gradual evolution, albeit rather peripatetic, in of anesthesia in the patient with peripheral nerve
neuroanesthetic care, dictated in part by neuro- trauma who has just eaten, or the difficulty of
surgical advances. Early craniotomies were per­ intubating a patient with cervical spine injury.
formed without any anesthesia. Subsequent local The chapters describing seizure surgery, percuta­
anesthetic techniques employed ice, ether as a neous ablative procedures, and stereotactic tech­
spray jet, and cocaine. Toward the end of the nine­ niques might suggest a limited role for the
teenth century, a balanced technique using an in­ anesthesiologist. These topics have been in­
halation anesthetic (chloroform) and a narcotic cluded, however, since in many parts of the world,
(morphine) was in vogue. Increased understand­ many of these procedures are either done under
ing of intracranial dynamics led to the adoption of general anesthesia or actually performed by the
intravenous anesthesia, a technique that was less anesthesiologist.
likely to increase intracranial pressure. More re­ For the most part, neurosurgical disease pro­
cently, with the growing awareness of the possible cesses have been considered in separate chapters.
deleterious effects of nitrous oxide and the devel­ Supratentorial tumors and adult hydrocephalus
opment of better agents, the trend again is to use are characterized mainly by raised intracranial
an inhalational agent (isoflurane) combined with a pressure; since the anesthetic management in­
narcotic (sufentanil). volves principles rather than specific care, these
The state of the art in neurosurgery is such that diseases have been covered in Chapter 3, Physiol­
operative intervention of many more and complex ogy of Intracranial Pressure.
disease processes is possible. Intracranial func­ The section on intensive care is not intended as
tion is influenced not only by anesthetic agents a reference for the intensivist but rather as a guide
and techniques but is also acutely sensitive to ab­ for the practitioner who, as part of a team, must see
normalities of other organ systems. Thus, optimal the patient through a critical period following
outcome after any neurosurgical procedure must trauma or surgery.
depend on a team approach. Careful preoperative Finally, from two disciplines, neither of which
evaluation and stabilization of multisystem dis­ allows room for compromise, the views from both
ease are essential. With a knowledge of the pathol­ sides of the ether screen have been presented in
ogy involved and the operative approach and re­ the belief (to paraphrase Antoine de Saint Ex-
quirements, the anesthesiologist can then make a upery) that "Progress does not consist in gazing at
rational and appropriate choice of technique. each other but in looking outward together in the
This book is a collaborative effort by anesthe­ same direction."
siologists and neurosurgeons to collate their expe­ The editor thanks the contributors for their pa­
riences and survey the extensive literature that tience, Carolyn Burke Giles for her secretarial
has flooded the academic scene of the neuroscien- help, and Nancy Megley of Butterworth-
ces over the past few years. The intent has not Heinemann for her advice and encouragement.
been to advocate rigid management plans for each
situation but rather to present the pathology in­ Elizabeth A. M. Frost
xiii
1
Introduction Elizabeth A. M. Frost
All anesthesia concerns itself with the interrup­ system. Responsibility for maintaining this stable
tion of pain perception by higher cortical centers environment during operation and resuscitation
within the central nervous system. In that sense, it from any neurosurgical experience and well into
might be argued that all anesthesia is neuro- the postoperative period rests with the anesthe­
anesthesia, although in fact the subspecialty of siologist.
neuroanesthesia has become firmly established as The primary problem in neuroanesthesia is to
the anesthetic care of patients with central ner­ regulate brain volume and pressure. Whether it is
vous system disease. done by controlling respiratory patterns and blood
gas tensions, administering diuretic or hypoten-
sive agents, draining cerebrospinal fluid, or any
other means, changes critical to the successful
outcome of a case will be realized immediately.
REQUIREMENTS OF THE DISCIPLINE
The second major problem is to control hemor­
rhage. The anesthesiologist profoundly influences
Anesthesia for neurologic surgery occupies a blood loss through choice of anesthetics and con­
unique place within the larger field of anesthe- trol of blood pressure and ventilation. The third
siology. Admittedly, overlap exists, as for example critical task is to protect nervous tissue from is-
in the anesthetic management of a patient with chemic and surgical injury. Regeneration of the
head injury who is having emergency splenec- central nervous system is slow and limited: apart
tomy. In essence, though, a patient with preexis­ from Purkinje cells, no new cells are formed; mini­
ting neurologic disease is undergoing neurosur- mal repair facilities are available; existing neurons
gical intervention under the influence of centrally do not hypertrophy. Whereas skin, bone, or liver
acting depressant anesthetic drugs. A clear under­ will regenerate, the central nervous system can­
standing of the situation and the ability to balance
not, and extreme efforts must be made to protect
all three factors are essential for the successful
existing tissue.
outcome of any neurosurgical procedure. Thus, it
Of course, numerous lesser problems also arise
is apparent that major problems unique to neuro-
during neurosurgical anesthesia. Access to the
surgery must be fully understood and solved by
head is difficult; the positioning required tends to
anesthesiologists.
obstruct the airway; temperature, fluid, and elec­
The brain appears to have a certain redundancy trolyte control are essential. Matters are compli­
of circuitry and plasticity of function that become cated by the uncommonly painstaking techniques,
lost as the organ matures. Perhaps it is because the initiated by Halsted and widely practiced by Cus-
brain has so little capability for repair that it is so hing, that often result in very lengthy operations
uniquely protected, both physically and physio­ and, thus, greatly prolonged anesthetic time. Inev­
logically: it has its own container, the skull, and is itably, neuroanesthesia appeals to a relatively
biochemically isolated by the blood-brain barrier; small number of anesthesiologists of unusual pa­
the brain also most probably has its own waste tience who possess an almost pathologic ad­
disposal system in the cerebrospinal fluid circu­ herence to meticulous detail in technique, for
lation. Sometimes these protective features are a there is no room for compromise.
mixed blessing, as when the skull is confining the
swollen brain and intracranial pressure increases,
or the cerebrospinal fluid passages are blocked
AnciJJary RoJes of the NeuroanesthesioJogist
and hydrocephalus results. But this uniquely con­
trolled environment permits the central nervous With the introduction of diathermy, the operating
system to function and, in turn, to monitor and microscope, ultrasonic devices to detect and re­
control the environment for the rest of the organ move lesions, high-speed drills, LASER probes to
1