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CIS Lesson Plans

CIS Lesson Plans provide members with ongoing education in the complex and ever-changing area of surgical instrument care and handling. These lessons are designed for CIS technicians, but can be of value to any CRCST technician who works with surgical instrumentation.

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Lesson Plan CIS 207
Neurosurgical Instruments
[Reprinted from Communiqué: May/June 2008]

Neurosurgery focuses on treating diseases of the central nervous system (CNS: the brain and spinal cord which carries impulses to and from the brain), the spinal column (which protects the spinal cord), and the peripheral nervous system (nerves and nerve tissues outside of the CNS). By contrast, neurological surgery uses medicine and specialty surgery to manage disorders of the CNS, the peripheral nervous system, and the autonomic nervous system (which controls smooth and cardiac muscles and glands including their supporting structures and vascular supply). As with any surgical procedure, there are many risks to neurosurgery. Since these procedures involve the brain or spinal cord, they may cause paralysis, brain damage, infections, and even death.

Hundreds of conditions are treated by neurosurgeons. The following are examples:

Brain tumors – any intracranial tumor created by abnormal and uncontrolled cell division.

Spinal stenosis – narrowing of the spinal cord causing pinched nerves that lead to persistent pain.

Head trauma – injury ranging from a minor bump on the skull to serious brain damage which affects the scalp, skull, or brain.

Cerebral aneurysm – a cerebrovascular disorder in which weakness in a cerebral artery or vein wall causes a localized dilation or ballooning of the blood vessel.

Carotid artery stenosis – Narrowing of the carotid arteries (the main arteries in the neck that supply blood to the brain). This condition, also called carotid artery disease, is a major risk factor for ischemic stroke, the most common form of stroke.

Carpal tunnel syndrome (CTS; also called Median Neuropathy at the Wrist) – This occurs when the median nerve is compressed at the wrist, leading to pain, paresthesias (a skin sensation such as burning or numbness which can occur without external stimulus), and muscle weakness in the forearm and hand. A form of compressive neuropathy, CTS is more common in women, and the lifetime risk for CTS approximates 10% of the adult population.

Spinal tumors – a malignant or benign growth that begins in or around the spinal cord or in the bones of the spine. Malignant tumors of the breast, prostate, lung, and kidney can spread into the spine where they are especially dangerous if they cause spinal canal compression, which may lead to neurologic dysfunction including paralysis.

The above and other specialty procedures require the most delicate and complicated surgical instrumentation. Examples include electro-surgical bipolar forceps, Frazier suction tubes, aneurysm clip appliers, curettes, Shadow Line® and McCulloch® retractors, and cranial clamps and screws. Certified Instrument Specialists (CIS) must be familiar with the different types of instruments and sets used for neurosurgical procedures. In addition, many procedures require loaner trays such as Synthes® or Depuy® which contain implants. The manufacturer’s recommendations which accompany them provide the required sterilization methods and parameters to assure implantable devices are appropriately processed.

Trays and their contents processed for common neurosurgical procedures include those for laminectomies, disectomies and craniotomies. Basic knowledge and advanced training is critical for these instruments and sets to be made ready for use.

After every procedure, all surgical instruments should be wiped with a damp cloth at the point of use. Never use saline, Betadine®, or any other liquid not approved by the manufacturer as they can stain or damage the instruments. Sterile, distilled or tap water may be used to keep instruments moist, and they should be returned to the Central Service decontamination area immediately after each procedure. Normal facility routines may include soaking, rinsing, manual cleaning, flushing, and inspection before being placed in a washer decontaminator/washer sterilizer. After the final washing and de-ionized water rinse, the CIS must visually inspect the instruments a final time. Are the tips of the bipolar forceps aligned? Is the irrigating bipolar forceps channel clear of all gross contamination and soils? Is the count sheet accurate? Are we following the correct procedures for sterilization and packaging? Does the tray contain implants and, if so, has the correct biological indicator been included? Many facilities use a checklist or tray report to help in the final preparation of the trays. Then processing employees are reminded and can confirm, for example, that they have included count sheets, filters, and integrators, and that they have documented any missing items.

Let’s review several neurosurgical procedures commonly performed in some facilities:

Laminectomy. This is a surgical procedure for treating spinal stenosis by relieving pressure on the spinal cord. The lamina of the vertebra is removed or trimmed to widen the spinal canal which creates more space for the spinal nerves. Instruments used for this procedure commonly include assorted elevators, nerve retractors, and currettes as well as rongeurs of various bite sizes, bite direction, and tip angles used to grasp soft tissue for dissection, decompression or biopsy. Retractors used to expose the surgical site are unique to spinal procedures. Less invasive versions of this procedure developed to improve patient outcomes including smaller incisions and reduced healing times require even more complex instrumentation.

Craniotomy. Craniotomies involve removal of part of the skull (the bone flap) to access the brain. They are often performed on patients suffering from brain lesions or Traumatic Brain Injury (TBI), or to implant deep brain stimulators to treat Parkinson’s Disease, epilepsy, and cerebellar tremors. They are also widely used in neuroscience for extracellular recording, brain imaging, and neurological manipulations including electrical stimulation and chemical titration. The most common instruments used for craniotomies are assorted penfield dissectors, gelpi retractors, and kerrison rongeurs which are available in various sizes and angles, and are used to remove bone in small bites. The small screw along the rongeur’s handle must be checked before and during surgery to ensure it does not become loose or even lost during a procedure.

Anterior Cervical Decompression (Discectomy). Cervical disc herniations can be removed through an anterior (frontal) approach to relieve spinal cord or nerve root pressure and to alleviate associated pain, weakness, numbness, and tingling. The most common instruments used for this procedure include rongeurs and graspers. A bone graft procedure used with metal plates and screws may be required to hold the bones in place while the vertebrae heals, and the bones fuse with
the graft.

While the instruments and trays used for neurosurgical procedures may vary in different facilities, the basic steps to process them do not. For example, all instruments must be inspected prior to the assembly and sterilization cycles, and any deficiencies must be immediately addressed. All instruments in these specialized trays must be sharp, functional, complete, and sterile because any deficiency can cause a major relapse, surgical delay, or patient infection. The instruments must be carefully handled, and the CIS must be trained in proper decontamination, assembly, sterilization, and transport procedures. Specialized training to process all loaner trays is imperative, and documentation should be retained in personnel files.

Cleaning delicate and complicated neurosurgical instruments can be a significant challenge. For example, many rongeurs such as kerrisons are difficult to clean, and careful examination is needed to assure that all tissues are removed. Many facilities use ejector kerrison rongeurs, which are easier to clean. However, all assembly screws must be individually inspected prior to packaging for sterilization. One additional challenge involves processing the plating and screw system used to close cranial bone defects or flaps. The systems are contained in trays which demand gentle and exacting care. Different components and styles are arranged in levels which can topple and require hours to properly reassemble. In particular, the screws must be sorted and sized correctly because busy surgeons cannot search for a screw that may be misplaced in the screw caddy. Since these screws are measured in millimeters, a magnifying glass will be needed for accurate sizing.

Patients rely upon surgeons to alleviate their health problems. In turn, surgeons and nurses require a knowledgeable, productive, and supportive Central Service team. Vendors of loaner equipment and Central Service Managers must ensure that these complicated trays and instruments are properly processed because the instruments they contain may differ depending upon their source. When frequent use justifies purchase of loaner instruments, personnel must receive in-service training, and inventory records should be updated. The result: it is an on-going challenge for the CIS to learn and consistently use required processing procedures.

References

ANSI/AAMI ST79. Comprehensive Guide to Steam Sterilization and Sterility Assurance in Healthcare Facilities. 2006.

International Association of Healthcare Central Service Material Management. Central Service Technical Manual 7th Edition. Chicago, IL. 2007.

Natalie Lind. Instrumentation Resource Course: Identification, Handling and Processing of Surgical Instruments. Chicago, IL. International Association of Healthcare Central Service Materiel Management. 2005.

Rick Schultz. Inspecting Surgical Instruments: An Illustrated Guide. 2005.

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