What is the assessment and plan for neurosurgery clearance in a patient with a history of C1 (cervical spine) fracture 8 months ago and a 4 cm Pulmonary Embolism (PE) exactly 3 months ago, whose 83-year-old mother has frailty, limited mobility, and foot drop?

From the Guidelines

The patient requires thorough evaluation and clearance for neurosurgery due to a history of C1 fracture 8 months ago and a 4 cm pulmonary embolism (PE) exactly 3 months ago, with additional concerns for the patient's mother who is 83 years old, frail, and has limited mobility with foot drop. Given these complexities, it is recommended to proceed with caution.

Preoperative Evaluation

The patient should undergo thorough preoperative evaluation including:

• Coagulation studies
• Complete blood count
• Imaging studies such as CT or MRI of the spine to assess the stability of the C1 fracture 1. Risks include bleeding, thromboembolism, and neurological deterioration.

Prophylaxis and Anticoagulation

Prophylaxis should include low molecular weight heparin (LMWH) such as enoxaparin 40mg subcutaneously daily for venous thromboembolism (VTE) prevention, and consideration of bridging anticoagulation with unfractionated heparin if the patient is on oral anticoagulants 1. The patient's anticoagulation regimen should be carefully managed perioperatively, with potential cessation of anticoagulants 5-7 days prior to surgery and resumption as soon as safely possible postoperatively.

Airway Management

The anesthesiology team should be involved early to discuss potential anesthesia risks and plans, including consideration of awake fiberoptic intubation if necessary, to minimize cervical spine movement 1.

Preoperative Preparation

Preoperative preparation should also include optimization of the patient's mobility and medical conditions, with consideration of physical therapy and pain management. The patient's overall condition and the presence of a recent PE should be taken into account when planning the surgical approach, with consideration of the risks and benefits of different techniques, as outlined in guidelines for the management of trauma in elderly and frail patients 1.

From the Research

Assessment and Plan for Neurosurgery Clearance

The patient has a history of C1 (cervical spine) fracture 8 months ago and a 4 cm Pulmonary Embolism (PE) exactly 3 months ago. Additionally, the patient's 83-year-old mother has frailty, limited mobility, and foot drop.

• The patient's history of C1 fracture and PE requires careful consideration in the assessment and plan for neurosurgery clearance 2, 3.
• The study by 2 highlights the importance of interdisciplinary cooperation in determining optimal therapeutic algorithms for patients with complex C1/C2 fractures and concomitant severe coronary artery disease.
• The patient's PE is a significant concern, and the study by 3 emphasizes the importance of perioperative optimization and thorough preoperative risk stratification to minimize major postoperative medical complications, especially cardiopulmonary complications.
• The patient's mother's condition, although not directly relevant to the patient's neurosurgery clearance, may be a consideration in the patient's overall care and support plan.

Considerations for Neurosurgery Clearance

• A thorough evaluation of the patient's cervical spine and PE is necessary to determine the stability of the fracture and the risk of complications during neurosurgery 4.
• The patient's overall health and medical history, including the PE, must be carefully considered in the assessment and plan for neurosurgery clearance 3.
• The study by 5 highlights the importance of patient safety, patient well-being, surgical field exposure, and patient positioning during neurosurgery.
• The patient's education and understanding of the risks and benefits of neurosurgery are crucial, and the study by 6 suggests that electronic materials and interventions using multiple modalities can be effective in improving patient knowledge and decreasing anxiety.