Functional Neurosurgery

Deep Brain Stimulation

1. Characterize Parkinson disease.		G7 p.532:72mm
a. Best target is the_____ _____	subthalamic nucleus
b. It has similar efficacy to_____	levodopa
c. with fewer_____ _____.	side effects
d. ablative surgery is giving way to _____.	deep brain stimulators	G7 p.534:50mm

Surgical Treatment of Parkinson Disease

2. Matching. Regarding surgical ablative treatment of Parkinson disease and its historical background, match the listed procedures with the appropriate phrase(s) and benefits.		G7 p.532:150mm
Abandoned because:
unpredictable results; tremor did not improve; bradykinesia did not improve; rigidity did not improve; ipsilateral tremor persists; side effects/resistance; only modest benefits Procedure:
a. anterior choroidal artery ligation
b. anterodorsal pallidotomy	,
c. ventrolateral thalamotomy	, ,
d. L-dopa
e. transplantation
3. How beneficial is pallidotomy of globus pallidus interna for the following (percentage)?		G7 p.534:65mm
a. Dyskinesia is _____%.	90%
b. Bradykinesia is _____%.	85%
c. Rigidity is _____%.	75%
d. Tremor is _____%.	57%
4. True or False. The following symptoms improve after anterodorsal pallidotomy:		G7 p.532:157mm
a. tremor ipsilateral	false
b. rigidity	true
c. bradykinesia	false
d. ataxia	false
e. tremor contralateral	false
5. Ventrolateral thalamotomy can improve tremor; it cannot be performed bilaterally because bilateral thalamotomy causes		G7 p.532:162mm
a. d_____ and	dysarthria
b. g_____ d _____.	gait disturbance (Incidence of postoperative dysarthria and gait disturbance is high.)
6. Complete the following about surgical treatment of Parkinson disease:		G7 p.533:165mm
a. The target today is the _____ _____	posteroventral pallidum
b. specifically the
i. _____	GPi—internal segment of the globus pallidus
ii. which blocks the input from the _____	STN—subthalamic nucleus
7. How might pallidotomy work?		G7 p.534:66mm
a. direct destruction of the _____	GPi
b. interrupt _____ fibers	pallidofugal
c. diminish input from the _____	subthalamic nucleus
8. Answer the following about surgical treatment of Parkinson disease:		G7 p.532:150mm
a. What was an early procedure for the treatment of Parkinson disease?	ligation of the anterior choroidal artery
b. What are the mechanisms by which pallidotomy may work?		G7 p.534:65mm
i. destroy _____	GPi or
ii. interrupt p _____ p _____	pallidofugal pathways
iii. reduce input into m _____ p _____	medial pallidum
c. What is the target for the tremor treatment?	ventralis intermedius nucleus (VIM)of the thalamus	G7 p.534:120mm
d. True or False. Pallidotomy is primarily focused on the treatment of motor symptoms.	true
e. What are the most common complications of pallidotomy? Hint: vhid		G7 p.536:62mm
i. v _____	visual field deficit
ii. h _____	hemiparesis
iii. i _____ h _____	intracerebral hemorrhage
iv. d _____	dysarthria
9. Characterize thalamic lesions.		G7 p.536:80mm
a. Lesioning in the thalamic _____ nucleus	intermedius
b. reduces parkinsonian _____.	tremor
c. however it does not improve _____	bradykinesia
d. and may worsen
i. g _____ s _____ and	gait symptoms
ii. s _____ p _____.	speech problems
10. Characterize subthalamatomy.		G7 p.536:105mm
a. Lesions in the STN classically produced _____.	hemiballism
b. Selective lesions may give relief on a par with _____.	pallidotomy
11. Characterize dystonia.		G7 p.536:135mm
a. Stimulationof the _____is the primary surgical treatment for the dystonia.	pallidum
b. Results are better for _____ dyskinesia.	tardive
c. The most common target is _____.	GPi
12. True or False. Stimulation has attracted increasing interest in patients with Parkinson disease who are refractory to medical drug treatment. The deep brain stimulator (the electrode) is placed in which of the following locations? (There are three true answers.)		G7 p.534:83mm
a. zona incerta	false
b. posterior ventral pallidum (PV)	false
c. substantia nigra (SN)	false
d. Forel field (H)	false
e. subthalamic nucleus (STN)	true
f. globus pallidus internus (GPi)	true
g. pedunculopontine nucleus	true	G7 p.534:92mm
13. True or False. Indications for pallidotomy in parkinsonism include		G7 p.534:100mm
a. refractory to drug therapy	true
b. drug-induced dyskinesia	true
c. rigidity	true
d. tremor	false
e. dementia	false
14. Ipsilateral hemianopsia is a contraindication to ventral pallidotomy because one of the side effects of the procedure could be o _____ t _____ i _____ and would cause the patient to be _____.	optic tract injury; blind (Visual field defects could occur in 2.5% of patients; blindness could result.)	G7 p.534:150mm
15. Bilateral pallidotomies carry an increased risk of		G7 p.535:168mm
a. s _____ d _____ and	speech difficulties
b. c _____ d _____.	cognitive decline
16. True or False. What are the benefits for the patient from posteroventral pallidotomy as done currently?		G7 p.536:18mm
a. motor symptoms	true
b. dyskinesia	true
c. rigidity	true
d. bradykinesia	true
e. tremor	true
17. True or False. Common complications of pallidotomy (unilateral) include		G7 p.536:62mm
a. visual field deficit	true
b. dysarthria	true
c. hemisensory deficit	false (Hemisensory deficit is not a common complication.)
d. hemiparesis	true

Spasticity

18. True or False. A spastic bladder will		G7 p.537:40mm
a. have high capacity and empty spontaneously	false
b. have high capacity and empty with difficulty	false
c. have low capacity and empty spontaneously	true (Low capacity and spontaneous emptying are the hallmarks of the spastic bladder.)
d. have low capacity and empty with difficulty	false
19. True or False. The onset of a spastic bladder after spinal cord injury is		G7 p.537:48mm
a. immediate	false
b. delayed	true (Delayed onset is typical because the acute phase of spinal shock is hyporeflexic and hypotonic.)
c. can occur at any time	false
20. True or False. The Ashworth score can grade severity of spasticity. The highest score in this system is given when there is		G7 p.537:80mm
a. no increase in tone (full movement)	false
b. rigidity in all flexors	false
c. rigidity in all extensors	false
d. rigidity in flexion and extension	true
21. The Ashworth score is the clinical grading of the _____ _____ _____.	severity of spasticity	G7 p.537:90mm
22. What are the medications used in the treatment of spasticity?		G7 p.537:140mm
a. b _____	baclofen
b. d _____	diazepam
c. d _____	dantrolene
d. p _____	progabide
23. What are the nonablative procedures used for the treatment of spasticity?		G7 p.538:72mm
a. i _____ b _____	intrathecal baclofen
b. i _____ m _____	intrathecal morphine
c. e _____ e _____ s _____	epidural electrical stimulation
24. What are the ablative procedures with preservation of ambulation used for the treatment of spasticity? Name one.	motor point block, phenol nerve block, selective neurectomy, percutaneous radiofrequency foraminal rhizotomy, Bischof myelotomy, selective dorsal rhizotomy, stereotactic thalamotomy, or dentatotomy	G7 p.538:83mm
25. True or False. Fibers that are more sensitive to radiofrequency rhizotomy are		G7 p.538:120mm
a. small unmyelinated sensory fibers	true
b. large myelinated alpha motor fibers	false
26. What are the ablative procedures with sacrifice of ambulation used for the treatment of spasticity? Name one.	intrathecal injection of phenol, selective anterior rhizotomy, neurectomy, intramuscular neurolysis, cordectomy, cordotomy	G7 p.539:32mm
27. True or False. Spasticity can be treated with intrathecal baclofen pumps. Complications are mainly		G7 p.540:45mm
a. pump underinfusion	false
b. wound complications	false
c. catheter complications	true (Catheter complications may have a frequency of up to 30% in baclofen pumps.)
d. drug resistance	false

Torticollis

28. What is another name for torticollis?	wry neck	G7 p.541:50 mm
29. What muscle is usually affected in spasmodic torticollis?	sternocleidomastoid	G7 p.541:69mm
30. What are the surgical procedures used for the treatment of spasmodic torticollis?		G7 p.541:130mm
a. stimulate _____ _____	dorsal cord
b. inject _____ _____	botulinum toxin
c. cut _____ rhizotomy
d. coagulate _____ _____	Forel’s H1
31. What artery is most commonly implicated in the torticollis of the eleventh nerve origin?	vertebral	G7 p.541:185mm

Neurovascular Compression Syndromes

32. Characterize root entry zone.		G7 p.542:35mm
a. Syndromes due to compression of
i. _____ _____	cranial nerves
ii. at the _____ _____ _____	root entry zone
b. This site, also known as the _____- _____ zone,	Obersteiner-Redlich
c. is the point where the central myelin from the _____ cells.	oligodendroglial
d. Changes to the peripheral myelin of the _____ cells	Schwann
33. True or False. Hemifacial spasm (HFS) starts from the lower half of the face and spreads to the upper half of the face.	false (starts with the orbicularis oculi)	G7 p.542:98mm
34. Complete the following about neurovascular compression syndromes:		G7 p.542:110mm
a. On what side is HFS more common?	left
b. What is the age and gender predilection?	women, after the teen ages
c. What is the most commonly involved artery?	AICA
d. True or False. Carbamazepine and phenytoin are generally effective treatment.	false
e. What is the material used as a cushion in the microvascular decompression (MVD)?	Ivalon, polyvinyl formyl alcohol foam
35. What is the only other involuntary movement disorder besides HFS that persists during sleep?	palatal myoclonus	G7 p.542:125mm
36. What distinguishes HFS from blepharospasm?		G7 p.542:155mm
a. HFS is _____.	unilateral
b. Blepharospasm is _____.	bilateral
37. What distinguishes HFS from facial myokymia (FM)?		G7 p.542:172mm
a. Hemifacial spasm (HFS) is _____.	intermittent
b. Facial myokymia (FM) is _____.	continuous
38. True or False. The vessel most commonly associated with hemifacial spasm is		G7 p.543:15mm
a. posterior inferior cerebellar artery (PICA)	false
b. superior cerebellar artery (SCA)	false
c. anterior inferior cerebellar artery (AICA)	true
d. posterior cerebral artery (PCA)	false
e. vertebral artery	false
f. basilar artery	false
39. Hemifacial spasm		G7 p.543:48mm
a. is caused by compression at the _____ _____ _____	root entry zone
b. of the _____ _____	facial nerve
c. by the	AICA
d. This does not cause _____ conduction but	ephaptic
e. produces _____	kindling
f. and _____.	synkinesis
40. Synkinesis is a phenomenon where		G7 p.543:57mm
a. stimulation of _____ _____ of the facial nerve	one branch
b. results in _____ _____	delayed discharges
c. through _____ _____.	another branch
41. True or False. Postoperatively after microvascular decompression for hemifacial spasm the patient can expect		G7 p.543:145mm
a. immediate cessation of facial spasms	false
b. reduction starting 2 to 3 days later	true
c. better results the longer the patient has had HFS	false
d. better results the older the patient is	false
e. complete resolution of spasms eventually	true (in 81 to 93% of patients)
f. possible relapse even if free of spasms for a full 2 years	false (relapse after 2 years only1%)
42. Complications of hemifacial spasm (HFS) surgery include the following:		G7 p.544:70mm
Hint: hemifacial s
i. h _____	hoarseness
ii. e _____	elderly do less well
iii. m _____	meningitis (aseptic)
iv. i _____	ipsilateral hearing loss
v. f _____	facial weakness
vi. a _____	ataxia
vii. c _____	CSF rhinorrhea
viii. i _____	incomplete relief-
ix. a _____	aseptic meningitis
x. l _____	lip (perioral) herpes
xi. s _____	swallowing (dysphagia)

Hyperhidrosis

43. Complete the following statements about hyperhidrosis:		G7 p.544:132mm
a. It is due to overactivity of the _____ _____ glands.	eccrine sweat
b. These glands are under control of the _____ _____ _____.	sympathetic nervous system
c. The neurotransmitter is _____.	acetylcholine	G7 p.544:140mm
d. Most _____ end organs are _____.	sympathetic; adrenergic
e. Some cases warrant _____ _____.	surgical sympathectomy

Sympathectomy

44. Name five indications for upper extremity (UE) sympathectomy.		G7 p.545:75mm
Hint: “crash” the sympathetic ganglia
a. c _____	causalgia major primary
b. R _____	Raynaud disease
c. a _____	intractable angina
d. s _____	shoulder-hand syndrome
e. h _____	hyperhidrosis
45. Complete the following statements about sympathectomy:		G7 p.545:60mm
a. What is the level for cardiac sympathectomy?	from stellate ganglion
b. What is the level for UE sympathectomy?	second thoracic ganglia T2	G7 p.545:82mm
c. What is the level for lumbar sympathectomy?	L2 and L3 sympathetic ganglia	G7 p.545:147mm
d. What is the most commonly used approach for lumbar sympathectomy?	retroperitoneal
46. What are the complications of UE sympathectomy?		G7 p.545:100mm
a. p _____	pneumothorax
b. i _____ n _____	intercostal neuralgia
c. s _____ c _____ i _____	spinal cord injury
d. H _____ s _____	Horner syndrome