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LWBKG-FM[i-xviii] 10/17/08 AM Page i Aptara (PPG-Quark) CLINICAL NEUROANATOMY S E V E N T H E D I T I O N Richard S. Snell. (From Snell, R. S. Clinical Neuroanatomy: A Review with Questions and Explanations [3rd ed., p. 7]. Baltimore: Lippincott Williams & Wilkins.) The negatively. NEUROANATOMY. S E V E N T H E D I T I O N. Richard,M.R.C.S., L.R.C.P., MB, BS, MD, PhD. Emeritus Professor of Anatomy. George Washington .

This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U. Includes bibliographical references and index. ISBN 1. WL Sc ] QM S64

The presence of a hematoma should be confirmed by a computed tomography scan, if possible. Anatomy of the Technique for a Temporal Burr Hole 1. The patient is placed in a supine position with the head rotated so that the side for the burr hole is uppermost.

For example, in a patient with a right-sided fixed and dilated pupil, indicating herniation of the right uncus with pressure on the right oculomotor nerve, a hematoma on the right side must be presumed, and a burr hole is placed on the right side.

The temporal skin is shaved and prepared for surgery in the usual way. A 3-cm vertical skin incision is made two fingerbreadths anterior to the tragus of the ear and three fingerbreadths above this level Fig.

The following structures are then incised: a. Superficial fascia containing small branches of the superficial temporal artery. Deep fascia covering the outer surface of the temporalis muscle. The temporalis muscle is then incised vertically down to the periosteum of the squamous part of the temporal bone Fig.

The temporalis muscle is elevated from its attachment to the skull, and a retractor is positioned some muscular bleeding will be encountered. A small hole is then drilled through the outer and inner tables of the skull at right angles to the skull surface, and the hole is enlarged with a burr unless a blood clot is present between the inner table and the endosteal layer of dura. Figure A-1 Surface landmarks on the right side of the head. The relation of the middle meningeal artery and the brain to the surface of the skull is shown.

The white meningeal layer of dura is flexible and gives slightly on gentle pressure. The hole may be enlarged with a curette, and bleeding from the diploe may be controlled with bone wax. The surgical wound is closed in layers with interrupted sutures placed in the temporalis muscle, the deep fascia covering the temporalis muscle, and the scalp. Burr Hole for Epidural Hematoma Once the inner table of the squamous part of the temporal bone or the anterior inferior angle of the parietal bone is pierced with a small bit and enlarged with a burr, the dark red clotted blood beneath the endosteal layer of dura is usually easily recognized.

However, bright red liquid blood means that the middle meningeal artery or one of its branches is bleeding.

The meningeal artery is located deep to the clot and between the endosteal layer of dura and the meningeal layer of dura or in the substance of the endosteal layer of dura; or it may lie in a tunnel of bone.

Burr Hole for Subdural Hematoma When the squamous part of the temporal bone is penetrated, as described earlier, the endosteal layer of dura will be exposed. In this case, there is no blood clot between the endosteal layer of dura and the meningeal layer of dura, but both fused layers of dura will be dark bluish.

[ Richard S. Snell] Clinical Neuroanatomy ( 7th Ed.)

The dura endosteal and meningeal layers is gently incised to enter the space between the meningeal layer of dura and the arachnoid mater.

The subdural blood usually gushes out, leaving the unprotected brain covered only by arachnoid and pia mater in the depths of the hole. Clinical Neuroanatomy of the Technique of Ventriculostomy Indications for Ventriculostomy Ventriculostomy is indicated in acute hydrocephalus, in which there is a sudden obstruction to the flow of cerebrospinal fluid.

Anatomy of the Technique of Ventriculostomy To perform a ventriculostomy, the needle is inserted into the lateral ventricle through either a frontal or parietal burr hole.

Pdf snell neuroanatomy

The anatomy of these burr holes has been described previously. The needle is inserted through the burr hole using the following anatomical landmarks. Frontal Approach. The needle is inserted through the frontal burr hole and is directed downward and forward in the direction of the inner canthus of the ipsilateral eye Fig. Figure A-2 A: Surface landmarks for a temporal burr hole. B: The vertical incision passes through the temporalis muscle down to bone.

Pdf snell neuroanatomy

The middle meningeal artery lies between the endosteal and meningeal layers of dura and is embedded in the endosteal layer of dura or lies in a bony tunnel.

Figure A-3 Ventriculostomy. Needles passing through frontal or parietal burr holes to enter the lateral ventricle area are shown. The needle is inserted to a depth of about 2 inches 5. Parietal Approach.

The needle is inserted through the parietal burr hole and is directed downward and forward in the direction of the pupil of the ipsilateral eye Fig. Vertebral Numbers and Spinal Cord Segments Table A-1 relates which vertebral body is related to a particular spinal cord segment.

Table A-1 Cervical vertebrae Upper thoracic vertebrae Lower thoracic vertebrae 79 Add 1 Add 2 Add 3 Tenth thoracic vertebra Eleventh thoracic vertebra Twelfth thoracic vertebra First lumbar vertebra L cord segments L cord segments L5 cord segment Sacral and coccygeal cord segments Segmental Innervation of Muscles It is possible to test for the integrity of the segmental innervation of muscles by performing the following simple muscle reflexes on the patient.

Biceps brachii tendon reflex C flexion of the elbow joint by tapping the biceps tendon.

Clinical Neuroanatomy

Bottom: Oblique coronal section of the brain. Figure CA-6 Top: Inferior view of the brain showing cranial nerves. The abducent and facial nerves cannot be seen.

Bottom: Enlarged inferior view of the central part of the brain.

Neuroanatomy pdf snell

Figure CA-7 Top: Posterior view of the brainstem. The greater part of the cerebellum had been removed to expose the floor of the fourth ventricle.

Middle: Superior view of the cerebellum showing the vermis and right and left cerebellar hemispheres. Bottom: Inferior view of the cerebellum showing the vermis and right and left cerebellar hemispheres. Figure CA-8 Enlarged medial view of the right side of the brain following median sagittal section, showing the continuity of the central canal, fourth ventricle, cerebral aqueduct, and the third ventricle and entrance into the lateral ventricle through the interverntricular foramen.

On examination in the emergency department of the local hospital, he had a fracture dislocation of the seventh thoracic vertebra, with signs and symptoms of severe damage to the spinal cord. Later, he was found to have paralysis of the left leg.

Neuroanatomy pdf snell

Testing of cutaneous sensibility revealed a band of cutaneous hyperesthesia increased sensitivity extending around the abdominal wall on the left side at the level of the umbilicus. Just below this, he had a narrow band of anesthesia and analgesia. On the right side, he had total analgesia, thermoanesthesia, and partial loss of the sensation of touch of the skin of the abdominal wall below the level of the umbilicus and involving the whole of the right leg.

With knowledge of anatomy, a physician knows that a fracture dislocation of the 7th thoracic vertebra would result in severe damage to the 10th thoracic segment of the spinal cord. Because of the small size of the vertebral foramen in the thoracic region, such an injury inevitably results in damage to the spinal cord. Knowledge of the vertebral levels of the various segments of the spinal cord enables the physician to determine the likely neurologic deficits.

The unequal sensory and motor losses on the two sides indicate a left hemisection of the cord. The band of anesthesia and analgesia was caused by the destruction of the cord on the left side at the level of the 10th thoracic segment; all afferent nerve fibers entering the cord at that point were interrupted. The loss of pain and thermal sensibilities and the loss of light touch below the level of the umbilicus on the right side were caused by the interruption of the lateral and anterior spinothalamic tracts on the left side of the cord.

To comprehend what has happened to this patient, a knowledge of the relationship between the spinal cord and its surrounding vertebral column must be understood. The various neurologic deficits will become easier to understand after the reader has learned how the nervous pathways pass up and down the spinal cord.

This information will be discussed in Chapter 4.

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Chapter Objectives To understand the basic organization of the main structures that form the nervous system To gain a three-dimensional appreciation of the parts of the brain and their relative positions to one another. The nervous system and the endocrine system control the functions of the body. The nervous system is composed basically of specialized cells, whose function is to receive sensory stimuli and to transmit them to effector organs, whether muscular or glandular Fig.

The sensory stimuli that arise either outside or inside the body are correlated within the nervous system, and the efferent impulses are coordinated so that the effector organs work harmoniously together for the well-being of the individual. In addition, the nervous system of higher species has the ability to store sensory information received during past experiences. This information, when appropriate, is integrated with other nervous impulses and channeled into the common efferent pathway.

Central and Peripheral Nervous Systems The nervous system is divided into two main parts, for purposes of description: the central nervous system Fig. For the subject of Neuroanatomy, this book scores the highest number for medical students and for medical professionals who wish to understand this most important subject of neuroanatomy as it is always associated with every other subject and every operation of the human body. The study of neuroanatomy is described best by this snell book and its 8th edition proves the amount of importance it has for students.

Download it now along with the gross anatomy snell. Splittgerber is an amazing anatomist. A great resource for learning anatomy! Helps keep everybody upbeat as well — he is always in a good mood. Click it to start your free download.

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