4 Seizure Semiology: Value in Identifying Seizure Origin
4 Cerebral Palsy: Comprehensive Review and Update
4 The Hypotonic Infant: Clinical Approach
4 Updated Overview of Pediatric Headache and Migraine
4 Clinical Approach to Children with Suspected Neurodegenerative Disorders New
4 The Shaken Baby Syndrome New
4 Concise Outline of The Nervous System; Examination for the Generalist New
4 Febrile Seizures; Update and Controversies New
4 Recombinant Tissue Plasminogen Activator for Acute Ischemic Stroke
4 Pediatric Epilepsy
4 Ketogenic Diet
4 Childhood Multiple Sclerosis
4 Communication of Neurological Bad News
4 Reducing Risk of Stroke
4 Stroke
Stroke is the sudden loss of function of the brain. One minute you are normal and the next minute you are paralyzed or numb on one side of the body. You cannot speak and have difficulty walking. 15% of stroke victims do not survive and 50% have a significant neurological problem such as paralysis of half of their body or loss of speech. In Saudi Arabia stroke is the leading cause of long term disability in the adult population.
What causes Stroke?
Stroke is caused by either blockage of an artery supplying the brain or rupture of an artery and hemorrhage into the brain. 80% of strokes result from blockage of one of the many arteries supplying the brain and this type of stroke is called an ischemic stroke. The same problem occurs in the heart but when an artery is blocked in the heart we call it a heart attack. When an artery is blocked in the brain, we call it a stroke. Brain cells, which lose their blood supply, die within a few minutes to a few hours and these cells cannot be replaced. This results in a loss of function in that part of the nervous system where the stroke occurred and usually produces paralysis, loss of feeling, problems with speech, loss of vision or difficulty walking.
Just like heart attacks the most common cause of ischemic strokes is hardening of the arteries or what doctors call atherosclerosis. Atherosclerosis causes narrowing of the arteries and this leads to colt formation and blockage of blood flow to the brain. This hardening and narrowing of the arteries occurs normally with aging but is accelerated by a number of medical condition, the most important of which are high blood pressure, smoking, diabetes, high cholesterol levels, obesity and lack of physical activity. Approximately 50% of all strokes are caused by hardening of the arteries and many of these can be prevented. Approximately 30% of strokes are caused by heart problems where blood colts form in one of the heart chambers or on valve surface. These blood colts break loose and travel into one of the major arteries of the brain where they block blood flow to an area of the brain and cause a stroke.
Unlike arteries in the heart, blood vessels in the brain tend to develop weaknesses in the vessel wall, which can rupture and cause bleeding into the brain. This is known as a hemorrhagic stroke and approximately 205 of all strokes are caused by rupture of an artery and hemorrhage into the brain. The most common underlying cause for a hemorrhagic stroke is untreated high blood pressure.
How do I know when I have had a Stroke?
The major feature of stroke is the sudden onset of the symptoms and the fact that most strokes produce loss of function on one side of the body. The major warnings sings of stroke include:
1- Sudden numbness or weakness of the face, arm, or leg especially on one side of the body.
2- Sudden trouble walking or loss of balance and coordination.
3- Sudden confusion or trouble speaking or understanding.
4- Sudden trouble seeing in one or both eyes.
5- Sudden onset of the worst headache in your life.
These same stroke symptoms sometimes occur for only a brief period of time lasting a few minutes to a few hours. Neurologist calls this a transient ischemia attack or TIA. TIAs are produced by the same process that produces most stokes- blockage of an artery to the brain. Many TIAs represent small strokes and they are a very important warning sign that you may be headed for a big stroke.
What should I do if I have a stroke or TIA?
If you or a family member develops the symptoms of a TIA/stroke, go immediately to the nearest major hospital center. Do not wait to see if the symptoms go away. This wastes valuable time. New forms of treatment are available which can help break up a clot and restore blood flow to the brain, but this treatment can only be given to patients who arrive in the emergency room in the first 1 to 2 hours from the time of onset of their stroke. Stroke is an emergency. Don’t wait, go to the hospital immediately.
What can I do to reduce my risk of stroke?
A number of lifestyle habits and medical conditions contribute hardening of the arteries and the development of heart attacks and stokes. The most important of these conditions are high blood pressure, smoking, diabetes, heart disease, high cholesterol, obesity and physical inactivity.
High blood pressure is the biggest risk factor for heart attacks and stroke. We don’t know what our blood pressure is unless it is measured by a doctor or nurse. For this reason high blood pressure is known as the silent killer. See your doctor and have your blood pressure measured. If the systolic pressure is consistently over 140 mmHg or the diastolic greater than 90 mmHg you should be on a treatment program to reduce your blood pressure.
Diabetes is very common in Saudi Arabia and affects one out of every four people over the age of 65. One out of every ten people over the age of 75 have a heart problem called a trial Fibrillation, which is the most common cardiac cause of stroke. High cholesterol levels increase hardening of the arteries throughout the body and can lead to heart attacks and strokes. An examination by your doctor and a simple blood test can make a diagnosis of all these conditions (hypertension, diabetes, a trial fibrillation, high cholesterol) and give you and your doctor the chance to prevent a stroke. If you have any of these conditions listen to your doctor’s advise and see your doctor regularly to ensure that these conditions are being treated and properly controlled.
A number of factors related to lifestyle can put you at high risk for stroke.
Smoking is a major cause of heart attack and strokes. If you smoke, stop now. Inhaled smoke kills the cells that line your blood vessels and greatly increases hardening of the arteries and formation of blood clots. A 50-year-old man who has smoked for 20 years can expect to have the arteries of 70-year-old man who does not smoke.
If you are significantly overweight, you are at high risk for the development of adult onset diabetes, hypertension and hypercholesterolemia, all of which increase your risk of stroke. Weight loss is one of the most effective ways of reducing your chance of having a stroke. Exercise is also an important component of a healthy lifestyle and helps reduce blood pressure, cholesterol levels and improve heart function. A heavy diet low in fats and high in fiber and vegetables plus 30-40 minutes of physical activity, four times a week involving walking, running, cycling or swimming are important components of a general health program to reduce the risk of stroke and heart attacks.
Remember, many strokes can be prevented. You can reduce your risk of stroke and heart attacks by having regular checkups with your doctor and following his advice and treatment plan. Develop a healthy lifestyle; stop smoking, lose weight and make physical activity part of every day. No one wants to have a stroke, so start today for a better future tomorrow.
Live smart, live better, live longer!!
Introduction
This information has been provided to help you understand what will be involved with the surgery your physician has recommended. It is not intended to take the place of the physician’s explanation, but by knowing what to expect should help you to prepare for your role in the recovery process. Your surgeon has the expertise to treat the physical deficits; however, it is important for you to approach the surgery with confidence, a positive attitude and clear understanding of the anticipated outcome, as both your physical condition and your mental attitude will help determine your recovery progress. Setting goals with members of the health care team and working to achieve these will greatly aid the speed of your recovery and reduce the risk of related problems in the future.
It is expected that you will be discharged home on the third day following the operation. However, please remember that no two operations are exactly the same, some patients may be discharged earlier and some patients may need an extra day or two in hospital. Please prepare for some one to be able to collect you on the third day after surgery, unless your physician informs you otherwise.
Please ask questions about anything you don’t understand.
Lumbar Diskectomy
This is an operation on the lower section of your spine to relieve pressure on one or more nerve roots. Individual bones, called Vertebrae, make up the spine and in between each of these are cushioned pads called disks, which act as shock absorbers for the bony spine. As a result of wear and tear on the spine, the disk may begin to protrude or collapse and put pressure on the nerve root(s) often called “nerve root compression” or a “pinched nerve” this can lead to varying problems which may include:
4Low back pain
4Pain and numbness in the buttock and one or both legs.
4Weakness of the muscles in one or both legs.
4Loss of bladder or bowel function
The goal of surgery is to improve these symptoms; the amount and speed of improvement can vary depending on the severity of the problem.
Risks
All operations have risks. Complications occur rarely, but can include:
4Bleeding
4Infection
4Nerve damage
4Blood clots
4Spinal fluid leak
4Adverse reaction to the anesthetic
Before Admission to Hospital
Your surgeon will see you as an outpatient to perform the following tests and procedures:
4History of your illness
4Physical examination
4Blood tests
4Any diagnostic tests required, e.g. ECG (a heart tracing) and chest X-Ray
4Urine test
4The results of the physical examination, or the presence of a pre-existing medical condition, may necessitate further tests or consultation with another physician.
4Consent- this is a legal document and it is important that you understand the procedure and its risks before signing, which the surgeon will explain to you.
4The physician may instruct you to stop taking some medications before surgery such as aspirin.
4If you smoke you should preferably stop or at least cut down several weeks before surgery.
4If blood might be required for the surgery, a family member will be asked to donate the estimated amount.
Following this assessment, arrangements will be made for you to be seen in the pre-anesthetic clinic and then admitted on the day of surgery. However, occasionally a patient will have another medical condition that will necessitate admission prior to the day of surgery.
Pre-anesthetic clinic
4Here, you will meet the anesthetist, who will examine you. He will also discuss anesthetic technique, risks, complications and alternatives with you.
4Your medical history and results from tests will be reviewed and if a concern is identified, the anesthetist may refer you to another medical specialty for consultation before admission.
You must not eat or drink any thing after midnight the night before surgery.
If you are normally taking important medications such as blood pressure or heart pills, often the doctor will want you to take these as usual with just a sip of water. Check with the doctor if any medications should be taken the morning of your surgery.
Admission to Hospital
4Nursing staff need to perform an admission assessment- this will entail asking you some questions, performing a physical assessment, taking your blood pressure, pulse temperature, height and weight.
4If you are admitted the night before surgery, the anesthetist will see before surgery.
Day of Surgery
Pre-operatively
You must not eat or drink anything before the operation, except your regular medications with a sip of water. It is important that you shower before the operation to remove bacteria from the skin. Before the operation, the nurse will insert a small, narrow needle into an arm vein. This allows repeated injections to be given without the need for more needles. An antibiotic may be given through this and it is also how the anesthetic will be given.
Post-operative
After the operation you will be transferred to the recovery room until awake from the anesthesia and then back to your own room.
4The nurse will assess you, first in the recovery room and then on return to the unit and will monitor your progress – checking your blood pressure, pulse, temperature, movement and sensation of your legs, and the wound at frequent intervals.
4You will be recovering fluid through the small tube in your arm and possibly an infusion of a painkiller, which allows on demand pain relief within safe limits.
4Pain is expected after surgery and you may also experience muscle spasms across the back and down your legs.
4Medication will be given to control these symptoms and it is important that you take them, as it will make getting out of bed the next day much easier.
4You will be permitted to get out of bed a few hours after the operation, but only with the assistance of your nurse. You may stand or walk but no sitting allowed.
4You may be wearing a pair of surgical stockings, which are to help prevent clots forming in the legs. You will also be taught how to do simple leg exercises.
4You may have a small drainage tube in the wound.
4When awake fully you will be allowed to start drinking and then progress to eating in a few hours if tolerated. Due to a combination of anesthesia and pain medication you may however feel nauseated-medication can be given to relieve this
4Some pain is to be expected on moving – the nurses will help change your position in bed every 2 hours to help prevent stiffness developing and to maintain correct body alignment.
4When awake, you will be asked to do breathing exercises.
4Initially, you may have difficulty urinating – again this can be due to the anesthesia and pain medication. If necessary, a catheter (tube into your bladder) may need to be inserted, the urine drained and the catheter will then be removed.
4A small injection may be given under your skin (Heparin), also to help prevent blood clots forming in the legs.
Day one post-OP.
4Pain and stiffness are reduced by early mobility. Initially, you will be helped out of bed and taught some simple techniques to minimize possible injury or pain.
4The physiotherapist will teach you to “logroll”, using the muscles of the hip instead of the back, to turn from side to side in bed to prevent stiffness and promote good circulation. You will also be shown how to get in and out of bed.
4Keep your hips and shoulders in line while lying in bed and turning. When lying on bed, keep your shoulders on the bed.
4Do not come up onto your elbow when eating as this twists the spine.
4Walking is a very important part of your recovery- we encourage you to be up walking as much as tolerated. Start with short trips and increase gradually. Leg aching is not uncommon- it will go away as the nerve recovers.
4Avoid prolonged sitting. If you are comfortable you may sit in an upright chair, but only for mails.
4It is common to feel unexpectedly tired- this can last for several days. It will help to take several short rests throughout the day. You are likely to wake up with a stiff back, which may be relieved by taking a short walk.
4The nurse will assist you with hygiene needs.
4If you have an infusion of painkiller this may be discontinued and the needle removed. You will be prescribed pain medication in tablet form.
4The nurse will check your blood pressure, pulse, temperature and limbs every 4 hours.
4The dressing on the wound will be checked and, if necessary, changed. If a drain is present- this will be removed.
4Constipation can be a side effect of the medications- the physician will prescribe a laxative to relieve this if necessary. We also recommend drinking plenty of fluids, especially fruit juice, and eating fruit to help with this.
Day two – Until Discharge
4Time spent walking should increase every day.
4Continue to sit for meals only.
4Usually you are allowed to take a shower. This will make you feel better and should be done with a dressing in place to protect the incision. Your nurse will change the dressing afterwards.
4If you have not had a bowel movement since the operation, it may be necessary to give you a suppository.
4Before you leave the hospital, the physiotherapist will teach you appropriate exercises for you – these can vary from patient to patient.
4The physiotherapist will teach you the correct way to climb stairs.
4Your pain will be controlled with tablets. Once your bladder and bowel functioning well, you will be discharged on the third day following the operation.
4After the wound is dry, the dressing will be removed before going home.
Discharge Instructions
4This is the time for healing and recovery – you must concentrate on protecting your back.
4Arrange transport home that will allow you to ride in a leaning back, or lying down, position. Ideally, when leaving hospital, the driver should flatten the front passenger seat.
Activity
4Active walking as much as tolerated. Walking is a very important part of your recovery – try to increase your distance a little each day, setting a pace that avoids fatigue or severe pain.
4On discharge, you should continue to sit for meals only. Then you must stand, walk or lie down for awhile. Increase the sitting period slowly – listen to your body and let pain or discomfort guide you. Remember to sit in an upright chair with back straight.
4May climb stairs when necessary – one at a time. If your legs are weakened, you must have some one with you.
4Important to keep your back straight while lying, standing, sitting or walking.
4You must concentrate on protecting your back. Use the large muscles of your legs for lifting and bending. When picking up objects – do not bend your back. With your feet apart, bend your hips and knees. Bring the object as close to your body as possible, stand up by straightening hips and knees and keeping your back straight.
4No housework or picking up heavy objects.
4It is recommended that you sit in an upright chair to pray for the first 2 weeks after surgery. Do not knee!
4It is not recommended to use an Arabic toilet, a western style toilet or commode is preferable for 2-4 weeks after surgery, avoid positions that strain the back or cause pain. Side positions or lying on your back are generally acceptable.
Medication
4You will be prescribed pain medication to take home with you – you will gradually be able to reduce the amount. A certain amount of discomfort and pain can be expected until the inflammation and nerve sensitivity have subsided. Exercise and short rest periods will also help relieve pain.
Hygiene
4Unless instructed otherwise, you may take a daily shower; this can help you to feel better. Let the water run over the incision, but do not scrub or rub over it.
Wound
4Have a family member check the incision daily for any redness, swelling or drainage.
4Some wounds may have sutures that will dissolve and therefore do not require removal. Otherwise, the sutures will be removed 7-10 days after your surgery – an appointment will be made for you in nurse clinic. If you live outside of Jeddah, you can arrange for this to be done at a local hospital.
Traveling
4From 2 weeks after surgery, you may sit for short periods in the car.
4Initially, drive for short distances only. The driving distance should gradually progress over the next few weeks, but you should not drive longer than 2 hours continuously without stopping, getting out and walking about a few minutes.
Nutrition
4A well balanced diet is necessary for proper healing.
4Include plenty of high fiber foods, especially if constipation is a problem.
4If overweight, weight reduction is one of the most important aspects to reduce strain on the back.
Follow-up
4Before leaving hospital, you will be given an appointment to be seen by the physician in the out patient clinic.
Working
4Your physician will determine when you can return to work and with what limitations.
General
4“Listen” to your body and use common sense. Discomfort is normal while you gradually return to normal activity, but severe pain is a signal to stop what you are doing and proceed more slowly.
Complications
Complications occur rarely, however, if any of the symptoms stated overleaf occur you should contact the physician.
After surgery warning signs
Infection
4Redness, swelling or tenderness at the wound site
4Drainage from the wound
4Fever
4Shaking/shivering chills
Blood Clots
4Pain, swelling or redness in the calf
4Tenderness which may extend above or below the knee
Nerve Pressure
4Increasing pain or numbness in your legs, back or buttocks.
4Inability to pass urine.
4Loss of control of bladder or bowels.
|