SurgSpace / Specialties / Neurosurgery
Neurosurgery
Brain and spine: the physics of a rigid box, where pressure is the common enemy, haematomas measured against the clock, hydrocephalus drained by hydrostatics, and spinal cord compression where hours decide function for decades.
After, and when it goes wrong
Post-op & Emergencies
The expected course, the ward reads, and the calls that cannot wait.
The expected course and the ward reads, then the complications and the calls that cannot wait.
On the ward
Three boards, three reads
Night shift · head injury observation
GCS 14 at 22:00, 13 at 01:00, 12 now
Pupils equal, sluggish left
BP rising, pulse 58
What do these three lines mean together?
The read
Deterioration with early Cushing's physiology: a two-point GCS fall is already an alarm, and hypertension with bradycardia says pressure is climbing toward herniation. This is an immediate scan-and-neurosurgery call, with the airway plan made before transfer, because a GCS heading through 8 will need protecting.
Day 2 · external ventricular drain
EVD at 10 cm above tragus
Drained 210 mL/24h
CSF clearing, no fever
Transducer re-zeroed after transfer
What are the rules of this device?
The read
The EVD is a column of physics: its height sets the pressure at which CSF spills, so the level is prescribed like a drug, re-zeroed after every move, and never left open during transfers. Sudden over-drainage collapses ventricles and tears veins; sudden blockage recreates the hydrocephalus. Volume, colour and clarity get charted every shift, and a blocked or disconnected drain is an urgent call, not a note.
POD 1 · burr-hole drainage of chronic subdural
Drain in, 90 mL dark fluid
GCS 15, brighter than admission
Lying flat as instructed
Apixaban still held
What does success look like, and what spoils it?
The read
Success is this board: an awake patient, a draining collection, and a brain given time to re-expand, which is why these patients often lie flat for the first day. The spoilers are recollection (the symptoms creeping back after the drain comes out), pneumocephalus, and the unfinished anticoagulation decision, which needs an owner and a date rather than an indefinite hold.
Emergencies
The calls that cannot wait
The deteriorating head injury
Recognise: A falling GCS, then a unilateral fixed dilated pupil: the third nerve is being crushed by herniating brain, and minutes remain.
First move: Airway, osmotherapy as a bridge, and theatre or scanner by the shortest safe route: this is the specialty's crash call, and the treatment is removing the clot.
Acute hydrocephalus
Recognise: Headache, vomiting and falling consciousness with ballooning ventricles: after haemorrhage, with a blocked shunt, or from an obstructing mass.
First move: CSF diversion is the treatment and the EVD is the instrument: escalate to neurosurgery immediately, because this deterioration is fast and fully reversible in the same hour.
Cauda equina syndrome
Recognise: Saddle anaesthesia, urinary retention or overflow, bilateral leg deficit: the roots that run bladder, bowel and legs are being crushed.
First move: Bladder scan, rectal examination, document, and emergency MRI: the pathway to decompression is measured in hours, and every undocumented hour belongs to the deficit.
Rebleed after subarachnoid haemorrhage
Recognise: A secured-not-yet aneurysm patient with sudden new headache, collapse or a crashing GCS: the sac has gone again, and the second bleed is deadlier than the first.
First move: Resuscitate, image, and escalate to the neurovascular team for emergency securing: prevention beforehand, blood pressure control and early coiling, was always the real treatment.
Hub shaped by the Surgical Specialties Lead with the Neurosurgery reviewer (open seat). Images and videos carry their source; educational use for supervised learning, not clinical guidance.