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Perioperative Considerations and

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Perioperative
Considerations and
Positioning for
Neurosurgical Procedures

A Clinical Guide

Adam Arthur
Kevin Foley
C. Wayne Hamm
Editors

123
Perioperative Considerations and
Positioning for Neurosurgical Procedures
Adam Arthur · Kevin Foley
C. Wayne Hamm
Editors

Perioperative
Considerations
and Positioning
for Neurosurgical
Procedures
A Clinical Guide
Editors
Adam Arthur Kevin Foley
Semmes-Murphey Neurologic Semmes-Murphey Neurologic
and Spine Clinic and Spine Clinic
Memphis, TN, USA Memphis, TN, USA

C. Wayne Hamm
Medical Anesthesia Group
Germantown, TN, USA

ISBN 978-3-319-72678-6    ISBN 978-3-319-72679-3 (eBook)


https://doi.org/10.1007/978-3-319-72679-3

Library of Congress Control Number: 2018931172

© Springer International Publishing AG 2018


This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
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Printed on acid-free paper

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AG part of Springer Nature
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword

“It wasn’t raining when Noah built the arc.”


Howard Joseph Ruff (December 27, 1930–November 12, 2016),
financial adviser and author of the investing newsletter The Ruff Times

The importance of preparation and attention to detail in the field of neurosur-


gery cannot be overemphasized. Perhaps in no other endeavor of surgery is
there so little tolerance for error.
In the history of medicine, the chapter on neurosurgery is among the most
interesting. Archaeological evidence proves that humans were performing
trephinations since prehistoric times. Despite the early genesis of surgery on
the human skull and brain, the specialty of neurosurgery is a relatively recent
evolutionary product of the broader field of general surgery. The field made
little progress until Harvey Cushing established neurosurgery as a unique disci-
pline in the twentieth century. Our specialty was limited by a poor understand-
ing of pathology, archaic imaging of that pathology, primitive anesthesiology,
limited intraoperative visualization, and marginal postoperative care.
The past few decades have witnessed dramatic improvements in all of
these important facets of neurosurgical care: introduction of the operating
microscope, mind boggling advances in neuroimaging, development of the
subspecialty of neuroanesthesiology, introduction of neurocritical care, neu-
roendovascular therapy, neuromodulation and molecular biology, to name a
few. Despite these remarkable advances, the practicing neurosurgeon must
never lose sight of the basic surgical principles and details that often deter-
mine the outcome for our patients.
The attention to detail required for success in neurosurgery begins with
patient selection and continues throughout the patient’s hospital course and
postoperative care. Once the decision for surgery has been agreed upon, every
detail matters and proper preparation will influence the outcome. The natural
tendency to focus on high-tech issues may create complacency and neglect of
the basics.
The editors have provided the first monograph dedicated to the important,
but often trivialized, issue of surgical positioning in neurosurgical proce-
dures. This seemingly routine issue may have a profound influence on the
outcome of an otherwise well-planned procedure.
Although certain standard positions are typically used for most com-
mon neurosurgical procedures, the positioning must be tailored to the indi-
vidual patient body habitus and comorbidities. Selection of the appropriate

v
vi Foreword

position must balance patient comfort, surgeon comfort, and a vast array of
physiological issues and therefore must be tailored to the unique patient
and their procedure.
The contributing authors have created an authoritative reference book that
includes a balanced presentation of the positions commonly utilized in neu-
rosurgery, alternative positions for unique situations, and a comprehensive
discussion of the potential complications associated with all positioning
options. This treatise should be read and studied by neurosurgeons of all lev-
els of training and experience as well as those anesthesiologists who are so
vitally important in determining the outcomes of our procedures.

Department of Neurosurgery Daniel L. Barrow


Emory University School of Medicine Pamela R. Rollins
Atlanta, GA, USA
Preface

“I would like to see the day when somebody would be appointed surgeon somewhere who
had no hands, for the operative part is the least part of the work.”
—Harvey Cushing

If a neurosurgical patient isn’t positioned well, it can make operating with


both hands unfeasible for the surgeon. Neurosurgical positioning errors can
make surgery difficult or impossible in a myriad of ways. Aside from making
the pathology inaccessible, improper positioning can result in increased
blood loss, cardiopulmonary complications, and herniation.
Patients undergoing a procedure at the hands of any type of surgeon must
be positioned properly to allow access to the surgical pathology and to keep
the patient safe during the procedure. Most surgical specialties involve one or
two “standard” and well-described positions that allow surgical access. In
some surgical specialties, positioning requires consideration as a means of
minimizing blood loss. Some surgical specialties must even give consider-
ation to positioning with regard to using gravity as a means of minimizing
retraction on eloquent tissues. Neurosurgery requires that we consider all of
these factors and how they are impacted in a number of different positions.
The neurosurgeon is confronted with variations in pathology that are con-
stantly requiring adjustments to “standard” positions. Thus, a full working
knowledge of how to position patients to achieve the above desired goals, the
expected results of the applied position, the complications of the applied
position, and means of minimizing and/or avoiding those complications is
necessary. This working knowledge must incorporate existing recommenda-
tions and guidelines and be applied with a reciprocal knowledge of the oper-
ating room nurses and anesthesia personnel for maximum surgical benefit
with minimum surgical complications. As certain positions are infrequently
used and operating room personnel and anesthesia providers are often chang-
ing, the neurosurgeon can sometimes find themselves the party most
acquainted with the position and its attendant risks and benefits.
Our intent is that this work helps to advance the understanding of neurosur-
gical positioning and improve the safety of surgery for neurosurgical patients.
This book owes a great debt to Dr. John Martin and Dr. Mark Warner for their
pioneering work in the three editions of Positioning in Anesthesia and Surgery.

Memphis, TN Adam Arthur


Memphis, TN  Kevin Foley
Germantown, TN  C. Wayne Hamm

vii
Contents

1 Positioning Patients for Neurosurgical Procedures:


A Historical Perspective����������������������������������������������������������������    1
Mallory Roberts and Jon H. Robertson
History of Anesthesia in Neurological Surgery ������������������������������    1
Harvey Cushing����������������������������������������������������������������������������    2
Hunterian Laboratory at Johns Hopkins��������������������������������������    5
Local Anesthesia��������������������������������������������������������������������������    6
Positioning in Neurological Surgery������������������������������������������������    6
Use of the Operating Microscope������������������������������������������������    7
Endovascular Suite����������������������������������������������������������������������    9
Cranial Procedures ����������������������������������������������������������������������   10
Spine Procedures��������������������������������������������������������������������������   11
Partnership Between Neuroanesthetist and Neurosurgeon��������������   15
A Brief History of Semmes-Murphey Neurosurgery in Memphis,
Tennessee ����������������������������������������������������������������������������������������   15
Conclusion ��������������������������������������������������������������������������������������   17
References����������������������������������������������������������������������������������������   18
2 Biomechanics and the Mathematics of Positioning��������������������   19
George F. Young
References����������������������������������������������������������������������������������������   25
3 Anesthesia and Patient Positioning����������������������������������������������   27
C. Wayne Hamm
Introduction��������������������������������������������������������������������������������������   27
Supine Position��������������������������������������������������������������������������������   27
Spinal Procedures������������������������������������������������������������������������   27
Complications Associated with the Supine Position��������������������   29
Cranial Procedures ����������������������������������������������������������������������   29
Sitting Position��������������������������������������������������������������������������������   31
Spinal Procedures������������������������������������������������������������������������   31
Cranial Procedures ����������������������������������������������������������������������   32
Complications Associated with the Sitting Position��������������������   34
Lateral Position��������������������������������������������������������������������������������   34
Spinal Procedures������������������������������������������������������������������������   35
Cranial Procedures ����������������������������������������������������������������������   36
Complications Associated with the Lateral Position ������������������   38
Prone Position����������������������������������������������������������������������������������   38

ix
x Contents

Spinal Procedures������������������������������������������������������������������������   39


Cranial Procedures ����������������������������������������������������������������������   41
Complications of the Prone Position�������������������������������������������   42
References����������������������������������������������������������������������������������������   45
4 Preoperative Assessment of the Patient
for the Planned Position����������������������������������������������������������������   51
C. Wayne Hamm and Jaafar Basma
Introduction��������������������������������������������������������������������������������������   51
Describing the Process of Surgery and Anesthesia
and Developing Rapport with the Patient����������������������������������������   51
Content of the Preanesthetic Evaluation Includes
but is not Limited to Readily Accessible Medical Records ������������   53
Patient Interview��������������������������������������������������������������������������   55
Preoperative Tests When Indicated����������������������������������������������   56
Other Consultations When Appropriate��������������������������������������   56
Basic Elements of a Directed Preanesthetic
Physical Examination������������������������������������������������������������������   57
Cervical Stability ����������������������������������������������������������������������������   57
Evaluation of Cervical Instability and Neural Compression ����������   60
Incidence of Cervical Stenosis Accompanying Lumbar Stenosis ���   61
Evaluation for Intrinsic Cervical Spinal Cord Pathologies��������������   61
References����������������������������������������������������������������������������������������   62
5 Organization of the Operating Room for Neurosurgical
Procedures��������������������������������������������������������������������������������������   65
Jaafar Basma and Daniel Hoit
Introduction and General Principles������������������������������������������������   65
History of Operating Room Organization����������������������������������������   66
Basic Scheme ����������������������������������������������������������������������������������   67
Operating Table and Head Holder�����������������������������������������������   68
Operating Microscope������������������������������������������������������������������   69
Surgeon’s Positioning������������������������������������������������������������������   70
Anesthesia Space ������������������������������������������������������������������������   71
Lighting����������������������������������������������������������������������������������������   71
Instrument Tables������������������������������������������������������������������������   72
Basic Surgical Devices: Bovie, Bipolar, Suction
Cannulas, Drill, and Pedals����������������������������������������������������������   73
Airflow Regulation and Prevention of Surgical Infections����������   74
Neuro-Imaging and Neuro-­Navigation Devices��������������������������   75
Neuro-Monitoring������������������������������������������������������������������������   75
Intraoperative Angiography, Endovascular Suite,
and “hybrid OR”��������������������������������������������������������������������������   76
Doppler Probes����������������������������������������������������������������������������   77
Storage, Supplies, and Trash Management����������������������������������   77
Communication and Teamwork ��������������������������������������������������   77
Patient Safety and Checklists������������������������������������������������������   78
Conclusion ��������������������������������������������������������������������������������������   78
References����������������������������������������������������������������������������������������   78
Contents xi

6 Overall Positioning Considerations for Intracranial


Procedures��������������������������������������������������������������������������������������   81
Adam Arthur
7 Intracranial Procedures in the Supine, Semi-Sitting,
and Sitting Positions����������������������������������������������������������������������   83
Jaafar Basma, Vincent Nguyen, and Jeffrey Sorenson
Introduction��������������������������������������������������������������������������������������   83
General Setup����������������������������������������������������������������������������������   84
Supine Position����������������������������������������������������������������������������   84
Sitting Position����������������������������������������������������������������������������   85
Complications����������������������������������������������������������������������������������   85
Supine Position����������������������������������������������������������������������������   85
Sitting Position����������������������������������������������������������������������������   86
Rationale for Approach-Guided Positioning:
Basic Mechanics and Nuances��������������������������������������������������������   87
Head, Neck, and Body Mechanics����������������������������������������������   88
Surgical Perspectives to Anatomical Corridors����������������������������   88
Gravity-Dependent Retraction ����������������������������������������������������   90
Ergonomic Working Angles ��������������������������������������������������������   91
The Pterional Approach (Yasargil)��������������������������������������������������   91
Fronto-Temporal Orbito-Zygomatic Approach (FTOZ)
and Supraorbital Modification ��������������������������������������������������������   92
Lateral Supraorbital and “Eye-Brow Incision” Approaches������������   92
Pretemporal Approach ��������������������������������������������������������������������   93
Temporal and Subtemporal Approaches������������������������������������������   93
Parieto-Occipital Approaches����������������������������������������������������������   94
Midline Approaches ������������������������������������������������������������������������   94
Bifrontal Craniotomy and Subfrontal Approach��������������������������   94
Anterior Interhemispheric Transcallosal Approach ��������������������   94
Cranio-Facial Approaches����������������������������������������������������������������   95
Transnasal and Trans-Sphenoidal Approaches����������������������������   95
Transoral Approaches������������������������������������������������������������������   95
Infratentorial Approaches����������������������������������������������������������������   96
Asleep-Awake Craniotomies������������������������������������������������������������   97
Conclusion ��������������������������������������������������������������������������������������   98
References����������������������������������������������������������������������������������������   98
8 Intracranial Procedures in the Lateral Position ������������������������ 101
L. Madison Michael II and Douglas R. Taylor
Part I: Introduction�������������������������������������������������������������������������� 101
Part II: The Lateral Position for Intracranial Neurosurgery������������ 102
Part III: Complications Specific to the Lateral Position������������������ 105
Part IV: Conclusion�������������������������������������������������������������������������� 109
References���������������������������������������������������������������������������������������� 109
9 Intracranial Procedures in the Prone Position���������������������������� 111
Mirza Pojskic and Kenan I. Arnautovic
Introduction�������������������������������������������������������������������������������������� 111
Physiology of the Prone Position���������������������������������������������������� 111
xii Contents

Influence of the Prone Position on Intracranial Pressure ���������������� 112


The Full Prone Position: Technique and General Considerations���� 113
The Concorde Position: Technique and General Considerations���� 118
Indications���������������������������������������������������������������������������������������� 120
Supratentorial Lesions �������������������������������������������������������������������� 121
Infratentorial Lesions ���������������������������������������������������������������������� 121
Lesions of the Cerebellum and Brainstem �������������������������������������� 122
Lesions of the Pineal Region ���������������������������������������������������������� 123
Complications���������������������������������������������������������������������������������� 124
Neuronavigation in the Prone Position�������������������������������������������� 129
Neuromonitoring in the Prone Position ������������������������������������������ 129
References���������������������������������������������������������������������������������������� 130
10 Spinal Surgery Positioning Overview������������������������������������������ 133
Kevin Foley
Introduction�������������������������������������������������������������������������������������� 133
Optimal Surgical Exposure�������������������������������������������������������������� 133
Patient Safety ���������������������������������������������������������������������������������� 134
Operative Ergonomics���������������������������������������������������������������������� 134
Conclusion �������������������������������������������������������������������������������������� 135
11 The Supine, Sitting, and Lithotomy Positions ���������������������������� 137
Shaheryar F. Ansari and Jean-Pierre Mobasser
Introduction�������������������������������������������������������������������������������������� 137
The Sitting Position������������������������������������������������������������������������� 137
Positioning the Patient ���������������������������������������������������������������� 137
Procedures Performed������������������������������������������������������������������ 138
Anesthesia and Monitoring���������������������������������������������������������� 138
Advantages���������������������������������������������������������������������������������� 138
Complications and Disadvantages ���������������������������������������������� 139
The Supine Position ������������������������������������������������������������������������ 140
How to Position the Patient���������������������������������������������������������� 140
Procedures Performed in the Supine Position������������������������������ 141
Anesthesia and Monitoring���������������������������������������������������������� 141
Advantages���������������������������������������������������������������������������������� 141
Disadvantages and Complications ���������������������������������������������� 141
The Lithotomy Position ������������������������������������������������������������������ 142
How to Position the Patient���������������������������������������������������������� 142
Anesthesia and Monitoring���������������������������������������������������������� 144
Procedures Performed in the Lithotomy Position������������������������ 144
Advantages���������������������������������������������������������������������������������� 144
Disadvantages and Complications ���������������������������������������������� 144
Conclusion �������������������������������������������������������������������������������������� 145
References���������������������������������������������������������������������������������������� 145
12 Spinal Procedures in the Lateral Position ���������������������������������� 149
Matthew T. Brown, Raul Cardenas, and Julius Fernandez
Introduction�������������������������������������������������������������������������������������� 149
Positioning for the Elective Spine���������������������������������������������������� 149
Contents xiii

Positioning for the Traumatic Spine������������������������������������������������ 153


Physiologic Considerations�������������������������������������������������������������� 155
Complication Avoidance������������������������������������������������������������������ 155
Conclusion �������������������������������������������������������������������������������������� 157
References���������������������������������������������������������������������������������������� 157
13 Spinal Procedures in the Prone Position�������������������������������������� 159
Prayash Patel and Christopher Nickele
Introduction�������������������������������������������������������������������������������������� 159
Preoperative Assessment������������������������������������������������������������������ 159
The Full Prone Position ������������������������������������������������������������������ 160
Preparations���������������������������������������������������������������������������������� 160
Types of Tables���������������������������������������������������������������������������� 161
Turning the Patient Prone������������������������������������������������������������ 163
Full Prone Position�������������������������������������������������������������������������� 164
Cervical Spine Procedures in Prone Position���������������������������������� 165
Unstable Cervical Pathology������������������������������������������������������������ 168
Thoracic and Lumbar Procedures in Prone Position������������������������ 168
Unstable Thoracic or Lumbar Pathology ���������������������������������������� 169
Special Considerations for Navigated Instrumentation ������������������ 170
Complications���������������������������������������������������������������������������������� 171
Visual Complications ������������������������������������������������������������������ 171
Peripheral Nerve and Brachial Plexus Injuries���������������������������� 171
Myocutaneous Complications������������������������������������������������������ 172
References���������������������������������������������������������������������������������������� 173
14 Special Considerations in Positioning for Neurosurgical
Tumors: Spinal ������������������������������������������������������������������������������ 175
Jason A. Weaver
Oncologic Terms Applied to the Spine�������������������������������������������� 176
The Importance of Pathology on Positioning���������������������������������� 176
Primary Spinal Column Tumors������������������������������������������������������ 176
Extradural, Intradural, and Intramedullary Primary Tumors ���������� 183
Metastatic Spinal Tumors���������������������������������������������������������������� 185
Conclusion �������������������������������������������������������������������������������������� 187
References���������������������������������������������������������������������������������������� 190
15 Special Considerations for Intracranial Tumors������������������������ 191
Pascal O. Zinn and Ganesh Rao
Introduction�������������������������������������������������������������������������������������� 191
Perioperative Considerations ���������������������������������������������������������� 191
Intracranial Tumor Pathology���������������������������������������������������������� 192
Intra-Axial Tumors���������������������������������������������������������������������� 192
Extra-Axial Tumors �������������������������������������������������������������������� 193
Skull Base Tumors ���������������������������������������������������������������������� 194
Comorbidities���������������������������������������������������������������������������������� 194
Positioning for Common Approaches: Tricks
of the Trade and Pitfalls ������������������������������������������������������������������ 195
Supine Position�������������������������������������������������������������������������������� 195
xiv Contents

Trans-Sphenoidal ������������������������������������������������������������������������ 196


Frontal/Trans-Frontal Sinus Approach���������������������������������������� 197
Orbito-Zygomatic and Pterional Approaches������������������������������ 197
Temporal�������������������������������������������������������������������������������������� 198
Lateral Position���������������������������������������������������������������������������� 198
Retrosigmoid�������������������������������������������������������������������������������� 199
Far Lateral������������������������������������������������������������������������������������ 199
Parieto-Occipital�������������������������������������������������������������������������� 199
Prone and Sitting Position���������������������������������������������������������������� 200
Suboccipital���������������������������������������������������������������������������������� 200
Awake Craniotomies������������������������������������������������������������������������ 201
Summary������������������������������������������������������������������������������������������ 202
References���������������������������������������������������������������������������������������� 202
16 Special Considerations for Pediatric Positioning
for Neurosurgical Procedures ������������������������������������������������������ 205
Michael DeCuypere
Introduction�������������������������������������������������������������������������������������� 205
Age Terminology ���������������������������������������������������������������������������� 205
General Principles of Pediatric Positioning ������������������������������������ 206
Thermal Homeostasis���������������������������������������������������������������������� 206
Head Immobilization Devices and Pediatric Patients���������������������� 207
Prone Positioning in Children���������������������������������������������������������� 207
Special Circumstances in Pediatrics������������������������������������������������ 208
Neonatal Surgery������������������������������������������������������������������������� 208
Hydrocephalus and Shunt Procedures ���������������������������������������� 209
Pediatric Brain Tumors���������������������������������������������������������������� 210
Surgery for Craniofacial Abnormalities�������������������������������������� 210
Epilepsy Surgery�������������������������������������������������������������������������� 210
Trauma ���������������������������������������������������������������������������������������� 211
Spine Surgery������������������������������������������������������������������������������ 211
Conclusion �������������������������������������������������������������������������������������� 211
References���������������������������������������������������������������������������������������� 211
17 Comorbidities and Positioning: Morbid Obesity
and Multiple Trauma�������������������������������������������������������������������� 213
Emily P. Sieg and Shelly D. Timmons
The Polytrauma Patient�������������������������������������������������������������������� 213
Case 1 Illustration������������������������������������������������������������������������ 213
Positioning for Simultaneous Surgeries�������������������������������������� 213
Complications������������������������������������������������������������������������������ 218
The Morbidly Obese Patient������������������������������������������������������������ 218
Case 2 Presentation���������������������������������������������������������������������� 218
Positioning of the Morbidly Obese Patient���������������������������������� 218
Complications������������������������������������������������������������������������������ 220
References���������������������������������������������������������������������������������������� 221
Contents xv

18 Comorbidities and Positioning: Pregnancy �������������������������������� 223


Thomas Scott Guyton
Maternal Weight Gain���������������������������������������������������������������������� 223
Physiological Changes During Pregnancy�������������������������������������� 223
Aortocaval Compression������������������������������������������������������������������ 224
Importance of Aortocaval Compression������������������������������������������ 225
How to Reduce Aortocaval Compression in the Supine Position ���� 226
Fetal Evaluation ������������������������������������������������������������������������������ 226
Estimate of Fetal Gestational Age���������������������������������������������������� 226
Evaluation of the Fetus In Utero������������������������������������������������������ 227
Timing of Surgery���������������������������������������������������������������������������� 228
Diagnostic Imaging�������������������������������������������������������������������������� 229
Prone Position���������������������������������������������������������������������������������� 229
Lateral Position�������������������������������������������������������������������������������� 231
Supine���������������������������������������������������������������������������������������������� 232
The Sitting Position������������������������������������������������������������������������� 232
Antibiotic Prophylaxis �������������������������������������������������������������������� 233
Seizure Prophylaxis ������������������������������������������������������������������������ 233
Treatment of Intracranial Pressure�������������������������������������������������� 233
Tocolysis������������������������������������������������������������������������������������������ 234
Neurosurgery with Fetus In Utero �������������������������������������������������� 234
Neurosurgery with Cesarean Section���������������������������������������������� 235
Conclusions�������������������������������������������������������������������������������������� 235
References���������������������������������������������������������������������������������������� 235
19 Postoperative Positioning in the Neurointensive Care Unit ������ 241
Abhi Pandhi and Lucas Elijovich
Introduction�������������������������������������������������������������������������������������� 241
Review of Basic Positions and General Principles�������������������������� 241
Transfer of Critically Ill Neurosurgical Patients������������������������������ 243
Neurosurgical Procedures and Intensive Care Unit Positioning������ 243
Neuroendovascular Surgery �������������������������������������������������������� 244
Mechanical Thrombectomy (MT): Autoregulation
and Cerebral Blood Flow ������������������������������������������������������������ 244
Endovascular Aneurysm Coiling and Microsurgical Clipping
in Subarachnoid Hemorrhage, Positioning for Optimizing
Cerebral Blood Flow and Intracranial Pressure �������������������������� 244
Craniectomy for Ischemic Stroke, Intracranial Hemorrhage,
and Traumatic Brain Injury: Positioning Considerations
for Intracranial Pressure Management ���������������������������������������� 245
Complex Spine Surgery: Positioning Considerations
for Postoperative Airway Management and Cerebrospinal
Fluid Leakage������������������������������������������������������������������������������ 245
Cranial and Skull Base Surgery Tumor Surgery: Positioning
Considerations for Optimizing Intracranial Pressure
and Management of Brain Edema������������������������������������������������ 246
Conclusions�������������������������������������������������������������������������������������� 247
References���������������������������������������������������������������������������������������� 247
xvi Contents

20 Differential Diagnosis, Treatment, and Prognosis


of Peripheral Nerve Injuries Associated
with Neurosurgical Procedures���������������������������������������������������� 251
Nickalus R. Khan and Michael S. Muhlbauer
Background�������������������������������������������������������������������������������������� 251
Pathophysiology������������������������������������������������������������������������������ 251
Preoperative History and Physical Assessment������������������������������� 253
Classification of PPNI���������������������������������������������������������������������� 253
Specific Nerve Considerations �������������������������������������������������������� 253
Upper Extremity�������������������������������������������������������������������������� 253
Lower Extremity�������������������������������������������������������������������������� 259
Diagnosis of PPNI���������������������������������������������������������������������������� 260
Management of PPNI���������������������������������������������������������������������� 260
References���������������������������������������������������������������������������������������� 261
21 Legal Issues in Patient Positioning ���������������������������������������������� 265
Emily Hamm Huseth
Background�������������������������������������������������������������������������������������� 265
Medical Malpractice������������������������������������������������������������������������ 266
Standard of Care�������������������������������������������������������������������������� 268
Breach of Standard of Care, Causation,
and Res Ipsa Loquitur������������������������������������������������������������������ 271
Damages�������������������������������������������������������������������������������������� 272
Limitations on Medical Malpractice Actions������������������������������ 274
Informed Consent���������������������������������������������������������������������������� 275
Recent Federal Legislative Efforts at Medical Malpractice
and Health Care Liability Reform���������������������������������������������������� 277

Index�������������������������������������������������������������������������������������������������������� 279
Contributors

Shaheryar F. Ansari Goodman Campbell Brain and Spine, Indianapolis,


IN, USA
Department of Neurological Surgery, Indiana University School of Medicine,
Indianapolis, IN, USA
Kenan I. Arnautović Department of Neurosurgery, Semmes-Murphey
Clinic, University of Tennessee, Memphis, TN, USA
Adam Arthur Semmes-Murphey Neurological and Spine Clinic,
University of Tennessee Health Sciences Center, Memphis, TN, USA
Jaafar Basma University of Tennessee Health Sciences Center, Memphis,
TN, USA
Matthew T. Brown Department of Neurosurgery, University of Tennessee,
Memphis, TN, USA
Raul Cardenas Department of Neurosurgery, University of Tennessee,
Memphis, TN, USA
Department of Neurosurgery, Semmes-Murphey Clinic, University of
Tennessee, Memphis, TN, USA
Michael DeCuypere Department of Neurosurgery, University of Tennessee
Health Science Center, Memphis, TN, USA
LeBonheur Children’s Hospital, Memphis, TN, USA
Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee,
USA
Lucas Elijovich Department of Neurology, University of Tennessee Health
Sciences Center, Memphis, TN, USA
Semmes-Murphey Neurologic Institute, University of Tennessee Health
Sciences Center, Memphis, TN, USA
Julius Fernandez (deceased) Department of Neurosurgery, University of
Tennessee, Memphis, TN, USA
Department of Neurosurgery, Semmes-Murphey Clinic, University of
Tennessee, Memphis, TN, USA

xvii
xviii Contributors

Kevin Foley Semmes-Murphey Clinic, University of Tennessee Health


Science Center, Memphis, TN, USA
Thomas Scott Guyton Methodist Le Bonheur Healthcare, Memphis,
TN, USA
C. Wayne Hamm Medical Anesthesia Group, Germantown, TN, USA
Daniel Hoit Department of Neurosurgery, Semmes-Murphey Brain and
Spine Institute, University of Tennessee Health Sciences Center, Memphis,
TN, USA
Emily Hamm Huseth Harris Shelton Hanover Walsh, PLLC, Memphis,
TN, USA
Nickalus R. Khan Department of Neurosurgery, University of Tennessee
Health Science Center, Memphis, TN, USA
L. Madison Michael II Semmes-Murphey Clinic, Memphis, TN, USA
Department of Neurosurgery, University of Tennessee Health Science Center,
Memphis, TN, USA
Jean-Pierre Mobasser Goodman Campbell Brain and Spine, Indianapolis,
IN, USA
Department of Neurological Surgery, Indiana University School of Medicine,
Indianapolis, IN, USA
Michael S. Muhlbauer Department of Neurosurgery, University of
Tennessee, Memphis, TN, USA
Vincent Nguyen University of Tennessee Health Sciences Center, Memphis,
TN, USA
Christopher Nickele Department of Neurosurgery, Semmes-Murphey
Clinic, University of the Tennessee Health Sciences, Memphis, TN, USA
Abhi Pandhi Department of Neurology, University of Tennessee Health
Sciences Center, Memphis, TN, USA
Semmes-Murphey Neurologic Institute, University of Tennessee Health
Sciences Center, Memphis, TN, USA
Prayash Patel Department of Neurosurgery, Semmes-Murphey Clinic,
University of the Tennessee Health Sciences, Memphis, TN, USA
Mirza Pojskic Department of Neurosurgery, Philipps University Marburg,
Marburg, Germany
Department of Neurosurgery, Semmes-Murphey Clinic, University of
Tennessee, Memphis, TN, USA
Ganesh Rao Department of Neurosurgery, The University of Texas MD
Anderson Cancer Center, Houston, TX, USA
Mallory Roberts Department of Neurosurgery, University of Tennessee,
Memphis, TN, USA
Contributors xix

Jon H. Robertson Department of Neurosurgery, University of Tennessee,


Memphis, TN, USA
Emily P. Sieg Department of Neurosurgery, Milton S. Hershey Medical
Center, Penn State University College of Medicine, Hershey, PA, USA
Jeffrey Sorenson University of Tennessee Health Sciences Center,
Memphis, TN, USA
Semmes-Murphey Clinic, Memphis, TN, USA
Douglas R. Taylor Department of Neurosurgery, University of Tennessee
Health Science Center, Memphis, TN, USA
Shelly D. Timmons Department of Neurosurgery, Milton S. Hershey Medical
Center, Penn State University College of Medicine, Hershey, PA, USA
Jason A. Weaver Department of Neurosurgery, Semmes Murphey Clinic,
University of Tennessee Health Sciences Center, Memphis, TN, USA
George F. Young Germantown, TN, USA
Pascal O. Zinn Baylor College of Medicine, and The University of Texas MD
Anderson Cancer Center, Houston, TX, USA
Positioning Patients
for Neurosurgical Procedures: 1
A Historical Perspective

Mallory Roberts and Jon H. Robertson

In the first century AD, Dioscorides of Greece


 istory of Anesthesia
H recorded the use of botanical substances for pain
in Neurological Surgery relief including mandrake, alcohol, and opium
and he perhaps coined the term “anesthesia” [1].
Archaeological evidence exists of intracranial Use of these substances during cranial proce-
neurosurgical procedures being performed as dures was not widespread at the time or for years
early as during the Paleolithic period, but there is to come, as some thought that the pain would
little known about what, if any, efforts were taken “render [the patient] strong in endurance” and
to anesthetize these subjects before extracting was considered “noble” even as late as the Middle
sections of their skulls (Fig. 1.1) [1]. There is Ages (Fig. 1.6).
speculation that coca leaves were chewed before Modern anesthesia was born in the mid-1800s
procedures in areas where the plant grows natu- with the advent of antiseptic technique and general
rally, but early neurosurgical patients likely anesthesia using ether. Dr. Morton in 1846 demon-
found themselves having their heads drilled upon strated the use of vaporized ether for surgical
after a skull fracture or in order to release the anesthetic (Fig. 1.7). Ether’s widespread use was
supernatural elements thought to be causing con- implemented within a year of its introduction and
vulsions or headaches (Figs. 1.2 and 1.3) [1]. chloroform was used as an anesthetic agent just
Though the Egyptians recorded descriptions one year later; however, it took several decades for
of spine pathology as early as 2900 BC, some of the use of these two agents to become prevalent in
the first known spinal procedures were performed neurosurgical procedures [1, 3]. Once general anes-
in the late fifth and early fourth centuries BC by thesia was broadly available, surgeons were able to
Hippocrates, the father of spine surgery [2]. perform longer and more complicated surgeries.
Hippocrates made note of the positions used to With the utilization of this new technology came
manipulate the spine and hips for his procedures new hurdles concerning preoperative patient posi-
(Figs. 1.4 and 1.5). tioning by the surgeon and the anesthetist. Frequent
patient complications and deaths were associated
with the use of ether, and the rate of implementation
of vital sign monitoring did not increase with the
M. Roberts · J. H. Robertson (*) rapidity to parallel the drug’s use. Once vital sign
Department of Neurosurgery, University
of Tennessee, Memphis, TN, USA
monitoring devices were widely used, accessing the
e-mail: Mrober41@uthsc.edu; patient’s limbs or anterior chest again influenced
jrobertson@semmes-­murphey.com preoperative positioning.

© Springer International Publishing AG 2018 1


A. Arthur et al. (eds.), Perioperative Considerations and Positioning for Neurosurgical Procedures,
https://doi.org/10.1007/978-3-319-72679-3_1
2 M. Roberts and J. H. Robertson

Many early developments in operative moni-


toring techniques, improving the safety of deliv-
ering anesthetic agents, and in defining
neurological surgery as a specialized practice can
be attributed to Harvey Cushing.

Harvey Cushing

Dr. Harvey Cushing is considered the father of


neurosurgery in the United States. Cushing, who
avidly journaled, described experiences while a
student at Harvard Medical School where he was
called to anesthetize patients who routinely suf-
fered from the crude mechanisms used in the late
1800s [5].
Dr. Codman and I having entered the hospital
together… we gave the anesthesia. I hesitate to
recall what an awful business it was and how many
fatalities there were. I was called down from the
seats (of the surgical amphitheater) and told to put
the patient to sleep. I proceeded as best I could
under the orderly’s directions. The operation was
started… there was a sudden great gush of fluid
Fig. 1.1 Patients often received no anesthetics prior to from the patient’s mouth, most of which he inhaled
“trephination,” the drilling of holes in the skull [1] and he died… Codman and I resolved that we
would improve our technique of giving ether.
Endotracheal tube placement for ventilation
assistance in neurosurgical operations was first After witnessing many patients die due to
used with chloroform anesthesia soon after in the ether administration during surgical procedures,
late 1870s by Sir William Macewen; oral intuba- Cushing and his classmate Earnest Codman
tion, too, took many years to be widely accepted began regularly recording pulse rate [5].
[3]. The first general anesthesia department was We made a wager of a dinner as to who could give
not formed until the 1920s at the University of the best anesthesia. We both became very much
Wisconsin, headed by Ralph Waters, and anes- more skillful in our jobs than we otherwise would
thesia up until this point was performed by the have become but it was particularly due to the
detailed attention which we had to put upon the
surgical team [4]. patient by the careful recording of the pulse rate
In the early twentieth century neurosurgical throughout the operation [5].
operations, especially intracranial procedures,
involved high morbidity rates. The importance of Co-residents E. A. Codman and Harvey
delivering intraoperative intravenous fluids, per- Cushing are credited as the first to regularly record
forming blood transfusions, maintaining ade- patient vital signs and interventions performed by
quate blood pressure, and understanding those administering anesthesia. Codman was the
cerebrospinal fluid circulation were paramount to first to record an anesthesia record in 1894 and
improving patient outcomes. This was especially Cushing improved upon it, with his earliest chart
important in the developing field of neurosur- recorded in 1895 [5]. Pulse rate, respirations,
gery, as manipulation of the brainstem and spinal pupillary size, mucus production, and drugs used
cord could cause rapid hemodynamic deteriora- were recorded. Though he often made notes of
tion in addition to the risks of intraoperative pulse quality in his anesthesia notes, Cushing did
blood loss and hypothermia that exist with all not begin recording blood pressure until 1901
surgeries. upon his return from Europe [5].
1 Positioning Patients for Neurosurgical Procedures: A Historical Perspective 3

Fig. 1.2 Skull fragment carbon dated to the late Neolithic fracture or perhaps for a separate anterior injury.
to early Bronze Age with evidence of frontal trephination (Reproduced from Piek J, Lidke G, Terberger T. The neo-
found near Berlin. Posterior healed fractures extending lithic skull from Bölkendorf—evidence for Stone Age
over the lambdoid suture are also present. The trephination neurosurgery? Cent Eur Neurosurg. 2011;72(1). With
could have been employed as a treatment for the posterior permission from Thieme)

Figs. 1.4 and 1.5 Hippocrates used a platform or upright


ladder and bound patients to physically reduce spinal cur-
vature with external force. He has been called “the father
Fig. 1.3 Instrument used for trephination found in Peru of spine surgery” due to these techniques [3, 4].
as depicted by the handle’s engraving. This was used (Reproduced from Marketos SG, Skiadas P. Hippocrates:
around 1300–1500 BC. Coca leaves were perhaps chewed the father of spine surgery. Spine. 1999;24(13). With per-
as a pain relief measure prior to cranial procedures [1] mission from Wolters Kluwer Health, Inc.)
4 M. Roberts and J. H. Robertson

Figs. 1.4 and 1.5 (continued)

Fig. 1.6 Though anesthetic agents were available at the


time (alcohol, opium, mandrake), pain was thought to be
useful and its endurance noble—as such, their use was
uncommon in the Middle Ages [1]

Fig. 1.7 “Ether Day 1846,” a painting by Warren and SP, Desai MS. A tale of two paintings: depictions of the
Lucia Prosperi. A public demonstration of anesthesia first public demonstration of ether anesthesia,
using ether as administered by Dr. Morton (pictured hold- Anesthesiology. 2007;106(5). With permission from
ing anesthesia delivery device) in the amphitheater of Wolters Kluwer Health, Inc.)
Massachusetts General Hospital. (Reproduced from Desai
1 Positioning Patients for Neurosurgical Procedures: A Historical Perspective 5

On going abroad and getting interested in blood Cushing not only recognized the importance of
pressure I discovered in Padua a simple recording
Riva-Rocci’s sphygmomanometer, but also rec-
instrument in Riva-Rocci’s clinic. On returning
home I came to utilize this always during the course ognized the importance of integrating laboratory
of my neurological operations… A much more elab- research alongside his surgical practice after
orate ether chart was thereupon prepared, on which studying under Dr. Theodore Kocher [9, 10].
not only pulse rate and respiration but the systolic
Cushing as a young faculty member of the surgi-
blood pressure was recorded [5].
cal department at Johns Hopkins was appointed
Cushing’s excitement for having found an Director of the Hunterian Laboratory by Dr.
objective measure of blood pressure is evident in William Halstead in 1904.
his writings though he was met with considerable
skepticism upon return to Boston [5–8]. Harvard
Medical School went so far as suggesting “The Hunterian Laboratory at Johns
adoption of blood-pressure observations in surgi- Hopkins
cal patients does not at present appear to be neces-
sary as a routine measure,” after setting up a study The Hunterian Laboratory was established at
to evaluate its merits [5]. Some institutions were Johns Hopkins during the early 1900s by Drs.
more enthusiastic and implemented regular William Welch and William Halstead. In 1904
recordings of this data during surgeries as early as after being appointed director of the lab, Cushing
1903, as inspired by Cushing’s charts. The routine raised monies and approached the Board of
use of measuring physiological signs or charting Trustees of Johns Hopkins to build a special
these measurements was not consistently recom- building to enlarge and enhance the Hunterian
mended or described in surgical or anesthesia Laboratory. With completion of the new facility,
literature until the 1920s and was not advocated Cushing studied surgical technique on anesthe-
as the standard of care until years later [5]. tized dogs and emphasized teaching for medical
Though Cushing recognized and promoted the students. Medical students performing operations
crucial role of intraoperative monitoring, he was on live dogs were taught not only the method of
no longer able as a young practicing neurosur- tissue dissection, but also learned the importance
geon to record and monitor anesthetic adminis- of aseptic technique, meticulous recordings of
tration as he did while a medical student and laboratory data, surgical and postoperative notes,
intern. His clear recognition of the importance of and the benefits of postmortem exams [10].
the role of the anesthetist during neurosurgical Harvey Cushing modeled the life of a physi-
operations and his development of a reliable cian, surgeon, and scientist. His work in the
measure of the patient’s status while anesthetized Hunterian Laboratory has been described as “one
served a dual purpose of easing the burden on the of Cushing’s most significant contributions to
anesthetist and decreasing operative risk for the American surgery” [5]. As Cushing’s personal
patient [5]: workshop for experimental surgery, the Hunterian
Were it possible, therefore, under such circum- Laboratory yielded numerous fundamental dis-
stances for [the anesthetist] to be told with the coveries in the field of neuroscience during
definiteness which figures alone can give, or for Cushing's tenure at Johns Hopkins [9]. One such
him to read by a glance at a plotted chart that the development was a “precordial stethoscope,” a
strength of the cardiac impulse, irrespective of its
rapidity, was keeping at a normal level or was tool for monitoring heart sounds without the need
affected in one way or another by certain manipula- for maintaining a hand on the patient’s chest in
tions, not only would this feeling of responsibility order to palpate the heart rhythm and quality.
be much lightened, but the operative procedure This was achieved by strapping a transmitter to
might oftentimes be modified with a consequent
lessening of its risks [6]. the anterior chest of dogs and passing a long rub-
ber tube to an aural receiver that the anesthetist
While studying and operating abroad in could listen through while freeing their hands [5].
England and Switzerland in 1901, Dr. Harvey The skills practiced in the Hunterian Laboratory
6 M. Roberts and J. H. Robertson

were translated into the operating room and transfusion in 1906, and his experimentation with
paved the way for a safer anesthetic environment volume repletion and blood pressure monitoring
for Cushing’s and his colleagues’ patients. These in patients with shock are especially noteworthy
developments also allowed for more freedom in [8, 11].
patient positioning, as vital sign monitoring no
longer required continual physical contact with
the patient. Local Anesthesia
Dr. George Washington Crile (Fig. 1.8), a co-­
founder of the Cleveland Clinic and its first presi- Also stemming from his aversion to improperly
dent, carried out extensive blood pressure administered general anesthetic were Cushing’s
experiments in a dog lab as well, outlining the experimentations with the uses of local anes-
effects of adrenaline, saline, and pneumatic pres- thetic, in particular cocaine [5]. Though his
sure in increasing blood pressure (Fig. 1.9). He teacher Halstead had used cocaine for nerve
also recognized and described acidosis as effect- blocking in 1884, Cushing was not largely
ing from shock and suggested bicarbonate as an exposed to its use during his training under Dr.
antidote [8]. Crile too, like Cushing, was inspired Halsted. Cushing “resurrected” the local nerve
to improve upon the existing meager knowledge block using cocaine and coined the term
of blood pressure monitoring and shock after he “regional anesthesia” in 1902 preferentially
encountered the tragic death of a patient—a over “local anesthesia” [5, 8]. Although widely
young man whose legs had been crushed by a used because of its safety, regional anesthesia
train and who subsequently died of hemorrhagic had its limitations as noted by Dr. Charles
shock [8]. He is credited with being the first to H. Frazier: “No doubt the operation can be per-
administer a successful human-to-human blood formed under local or regional anaesthesia but
in our experience the patient welcomes loss of
consciousness” [12].

Positioning in Neurological Surgery

Positioning a patient prior to an operation on


either the spine, brain, or peripheral nervous
system is of utmost importance in neurological
surgery. Ideal positioning results in maximum
access to the patient for the surgeon and anesthe-
tist and reduces the risk of patient injury.
Historical developments in the techniques used
to position patients have occurred in congruence
with technological and scientific progress in sur-
gery. Many of these advancements occurred
through trial and error in the operating room.
Hurdles encountered during neurological surger-
Fig. 1.8 Photography of Dr. George Washington Crile in
1905. Dr. Crile, a general surgeon in Ohio and friend of
ies have spurred numerous inventions, tech-
Cushing’s, made great contributions to medicine through niques, surgical approaches, and equipment
his studies of blood pressure and treatments for shock. adjustments. This trend of problem identification
These advancements allowed for volume repletion during and resulting progress has benefits that reach
prolonged neurosurgeries or those that caused significant
blood loss. He carried out many of these experiments in a
beyond the scope of neurosurgery and has influ-
dog lab in Cleveland, much like Cushing at the Hunterian enced the standards of care in neurosurgical posi-
Lab [10] tioning over time.
1 Positioning Patients for Neurosurgical Procedures: A Historical Perspective 7

Fig. 1.9 A pneumatic rubber suit invented by Dr. George Crile, he worked in conjunction with Goodyear Tire and
Washington Crile. This suit was designed to combat Rubber Company to adapt this design for antigravity suits
shock and was laced on the patient then inflated with a used by pilots during World War I [10–12]
bike tire pump. Although this suit was abandoned by

Before the patient can be appropriately posi- supine, lateral, or prone intracranial approaches
tioned, they must be transferred to the operat- may involve rotating or flexing the neck to posi-
ing table. Patient transfer assistant devices such tion the head and adjusting the limbs and torso to
as slider boards and roll aids have become achieve the desired physiological position for the
implemented since the 1990s and can ease the patient during the surgical procedure. Fixation of
physical burden of safely transferring patients the head is critical for positions such as the park-­
to the operating table. Prior to this, physical bench, three-quarter (lateral oblique) prone,
lifting or pushing/pulling the patient horizon- Concorde, and others. Skeletal fixation of the
tally if the patient could not move over to the head may be accomplished with a three- or four-­
table themselves was standard. The majority of pin fixation. The most commonly used cranial
improvements regarding safety for both the fixation device is the Mayfield frame, which was
patient and those assisting in the transfer have introduced in the 1970s (Fig. 1.12).
come in the form of education and courses in As general anesthetics have become safer and
proper technique. intraoperative monitoring improved over time,
Once on the table and anesthetized, special patients have tolerated longer and more complex
care must be taken to ensure that the patient is procedures. As the length of surgeries has
sufficiently secured to the table and to prevent increased, so have injuries related to positioning.
development of pressure ulcers or peripheral Peripheral nerve injuries such as ulnar or brachial
nerve injury. Points of pressure or traction on the nerve palsies have long been potential adverse
patient’s body must be recognized and protected outcomes that increase in frequency with the
after anesthetizing and prior to sterile draping. length of each operation. Positioning the arms
From early use of sheets, blankets, and pillows to out laterally during supine operations has allowed
the use of foam and invention of viscoelastic gel the anesthetist easier access to the patient’s arms
cushioning today, the developments in table for blood pressure monitoring and administration
padding have significantly reduced the frequency of drugs and fluids.
of pressure ulcers caused during surgeries.
Much of the development and changes regard-
ing the supine or prone positions for intracranial Use of the Operating Microscope
surgery have required changes with the operating
table, including developments in padding, move- Operating microscopes were first utilized in neu-
able parts of the table, and increased safety mea- rosurgery by Dr. Theodore Kurze at UCLA in
sures (Figs. 1.10 and 1.11). Variations of the 1957 for the removal of a CNVII schwannoma
8 M. Roberts and J. H. Robertson

from a child [13]. Improvement to the micro- ability to more thoroughly and precisely access
scope including illumination, stabilization, multiple and visualize intracranial pathology. Through
viewing ports for surgical assistance, increased augmentation of surgical access, more complex
magnification, mouth piece driving, and imaging cases are now being operated on, which can
integration with MR or CT viewing through the increase the length of operative time. During
eyepiece has drastically changed the surgeon’s these cases, it is imperative to pay the utmost

Figs. 1.10 and 1.11 Patents submitted for operating tables in 1888 and 1968. As the complexity and length of
neurological surgeries has increased over time, so have the requisite mobility and safety of operating tables [13, 14]
1 Positioning Patients for Neurosurgical Procedures: A Historical Perspective 9

Figs. 1.10 and 1.11 (continued)

attention to preoperative positioning. Once the Endovascular Suite


patient is positioned in anticipation of using the
microscope, extensive padding of all the patient’s With the advent of newer imaging technologies,
pressure points without inhibiting proper access neurosurgery has grown to include endovascular
for anesthesia staff are important for reducing interventions that are performed in an endovas-
risk of injury. cular suite which has brought about new posi-
The operating room layout itself has changed tioning considerations. The supine position is
over the last half century to accommodate large preferred for procedures using the angiography
operating microscopes and to allow for the sur- machine for easy access to the groin or arms.
geon and assistants to sit if desired. Before ster- These tables are fixed and disallow any more
ilely prepping and draping the patient, equipment than subtle position changes during a procedure,
must be gathered and positioned in the best pos- so as to permit free movement of the fluoroscopic
sible formation to prevent unnecessary intraop- C-arms around the patient’s head. This limitation
erative manipulation that could prolong operative is of particular importance when an acute increase
and anesthetic time. in intracranial pressure occurs during a proce-
Though microscopes were first used for intra- dure, as the anesthetist cannot simply raise the
cranial surgeries within neurosurgery, they are of head of the bed to assist in lowering the pressure,
course widely implemented for spinal procedures a feature that is easily achievable in modern oper-
as well. In spinal procedures, the operating room ating rooms with a standard operating table.
layout must adapt not only for the operating Hybrid operating suites with fully mobile operat-
microscope, but also the use of imaging with ing tables and angiography machines are a mod-
C arm and tables that allow intraoperative ern solution to this problem and are becoming
maneuvering. increasingly more common in large care centers.
10 M. Roberts and J. H. Robertson

Fig. 1.12 Patent


submitted for Surgical
Head clamp in 1978.
The implementation of
the three point headrest
has allowed for fixation
of the head to the table
so as to prevent
intraoperative
movement [15]

Cranial Procedures securing the operative position are recommended


for all intracranial procedures.
Supine Position The majority of intracranial procedures are
Patient positioning for intracranial surgical pro- currently and have traditionally been performed
cedures is determined by the location of the with the patient in the supine position. The supine
pathology and surgical approach selected. For all position is chosen for procedures in the frontal,
operative positions, care should be taken to temporal, and anterior parietal areas and for
decrease the risk of intracranial venous engorge- many skull base approaches. The various surgical
ment which could lead to an increase in intracra- approaches in the supine position may require
nial pressure. Simply avoiding extreme turning turning the patient’s head and neck or elevating
of the head and neck during positioning of the one shoulder to rotate the upper trunk. Changes
patient and elevating the patient’s head after in the supine position over time correspond with
1 Positioning Patients for Neurosurgical Procedures: A Historical Perspective 11

advancements in operating table, anesthesia, before allowing the patient to position themselves
headrest, microscope, and padding technologies. comfortably on the operating table [15]. This
technique, of course, would require a mobile,
Lateral Position cooperative patient who is able to communicate
A lateral approach with the head maintained in a nonverbally and is not widely used for neurosur-
neutral position may be selected for middle cra- gical procedures. There is also a risk of slipping
nial fossa skull base approaches. For surgical and falling in an open table; therefore, only regu-
approaches to the lateral posterior fossa or cra- lar operating tables should be considered for this
niocervical junction, implementation of the park-­ maneuver.
bench and three-quarter (lateral oblique)
variations of the lateral position provided
improved operative exposure. Use of the lateral Spine Procedures
position lessens blood pooling in the surgical
field both through relief of pressure from the Prone Position
abdomen which allows for decreased compres- The majority of spinal surgeries are routinely
sion of the vena cava as well as gravitational approached with the patient in a prone position
drainage. Variations of the lateral approach (Fig. 1.13). Herniated discs were not described as
involve rotating or flexing the neck to position a distinct pathology until 1911 and were thought to
the head and adjusting the limbs and torso to represent benign tumors. Operative management
achieve the desired physiological position for the of herniated discs by laminotomy with an intradu-
patient during the surgical procedure. ral approach for discectomy was described in
1934. The laminotomy for extradural removal of
Prone Position herniated lumbar and cervical discs has since
The prone position is most commonly chosen for remained the standard surgical procedure for disc
unilateral or bilateral suboccipital craniotomies herniations. Once used intracranially, microscopes
to address cerebellar or fourth ventricular pathol- were quickly adopted for spinal procedures. The
ogy of the posterior fossa. The three-quarter first microsurgeries of the spine were described by
prone position (lateral oblique or park bench) Yasargil and Caspar in 1977 though lumbar dis-
with the table tilted to elevate the head is used for cectomies were being performed under the micro-
exposure of the posterior parietal, occipital, lateral scope as early as 1968 [2]. In 1953, the posterior
suboccipital, and craniocervical junction. lumbar interbody fusion was first described [2],
Patients are most often intubated and anesthe- and over the past three decades there have been
tized in the supine position on a stretcher and
then transferred over to the operating table by
rotating them prone. Endotracheal tube position-
ing is of particular importance in neurosurgery as
compared to other areas of anesthesia, as manip-
ulation of the head and neck during positioning
puts the tube at greater risk of being kinked or
moved [14]. This is particularly important when
operating on patients in the prone position, as
close monitoring of the endotracheal tube is
required when rolling them over after
intubation.
One possible alternative to intubating a patient
prior to rotating for prone positioning would be Fig. 1.13 The prone position for a cervical spine opera-
tion, described by Dr. Elsber in this 1916 book, Diagnosis
to first perform an awake intubation using light and treatment of surgical diseases of the spinal cord and
sedation and topical anesthetics for the oropharynx its membranes [16]
Another random document with
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the great bible in the church. Mr Darnley was not at all displeased to
see the eyes of his humble parishioners, when they made their
appearance in that apartment, wandering curiously and modestly
round the room, and leering at the great glass bookcases and the
eighteen-inch globes with as much wonderment as the gulls of two
centuries back used to look at the dried alligators in a conjuror’s
garret. How delicious is the sensation of superiority.
When the name of Primrose was mentioned, Mr Darnley thought
for a moment only of Penelope, and he screwed up his lips and
looked wondrously wise. Mr Primrose entered the room with a light
and lively step, and with a bright and cheerful countenance, taking it
for granted that everybody in England must be as glad to see him as
he was to see his native land again. Mr Darnley rose with great
stateliness, and advanced a step or two towards the door.
“Ah! Mr Darnley, your most humble servant; my name is Primrose,
I received a letter from you about six weeks ago, which you did me
the honor to write to me concerning the death of my poor brother
Greendale.”
At the end of the sentence Mr Primrose spoke in a more subdued
tone, as became him when speaking of the death of a dear friend.
But as he spoke he offered his hand to the rector of Neverden, who
in return offered his, but it was by no means an equivalent; for the
reverend divine gave his hand so formally and indifferently, that it
was to Mr Primrose as cold and flabby as a duck’s foot. And he said,
“Mr Primrose, I am happy to see you. You are welcome to England.”
But though he said he was happy, he did not look so, unless it be
true, as some philosophers have averred, that happiness is the most
serious thing in the world. The rector of Neverden also said, “I beg
you will be seated, sir.” He had learned that from the Right
Honorable the Earl of Smatterton; for no man is so great a simpleton
that nothing can be learned from him.
There was nothing uncivil or rude in this reception, what could be
more proper or polite than to welcome Mr Primrose to England, and
ask him to be seated? But Mr Primrose felt a chill at this reception.
However, he sat down; and then the polite rector, when his visitor
was seated, sat down also. Then he snuffed the candles, and
carefully closed the book that he had been reading, and pushed it
some distance from him, even so far as his arm could reach, and
then he turned himself in his chair from the table, and towards Mr
Primrose, and looked at him as much as to say, “What do you want
with me?”
Mr Primrose interpreted the look, and said “I have never had the
pleasure of seeing you before Mr Darnley, except for a very few
minutes, and at some distance of time; but as you wrote to me an
account of my dear brother’s death, and as I have now returned to
England, and am expecting presently the happiness of a meeting
with my dear child, I thought it might be advisable to call first on you,
that some message may be sent to Penelope, that the surprise may
not be too much for her.”
“Miss Primrose,” said the imperturbable rector of Neverden, “is not
at present in this part of the country.”
The effect of the composing draught was completely gone off, and
Mr Primrose started up from the chair to which he had been so
politely invited, and exclaimed with great impetuosity, “Good God! Mr
Darnley, you don’t say so.”
Mr Darnley was not so much agitated as Mr Primrose, and
therefore he compressed his lips and knitted his brows, and then
opened his mouth and said very composedly: “Mr Primrose, I beg
that you would recollect that I am a clergyman, and therefore that it
is not becoming and correct, that in my presence, you should take
the name of the Lord in vain.”
“I beg your pardon,” said Mr Primrose, with tears in his eyes, “but
consider, sir, I am a father, and—”
“I also am a father,” interrupted the rector, “and have more children
than you have.”
“Oh, but tell me, tell me, sir, is my child living?”
“To the best of my knowledge Miss Primrose is living.”
“But where is she? Why has she left Smatterton?”
“I believe, sir, that Miss Primrose is in London, that is all that I
know of her, except—” Here the rector hesitated, as if reluctant and
fearful to say all that he knew. If composure of manner be at all
contagious, Mr Primrose was the last person in the world to catch
the contagion; for at this dry hesitation he became more violent, and
exclaimed with great earnestness:
“Mr Darnley, you are a man, and must have the feelings of
humanity. I implore and conjure you by all that is sacred to put me
out of this dreadful state of suspense, and tell me at once all you
know of my poor child; something you must know and you ought to
know.”
There was an energy of utterance and a heart-reaching tone in
this last sentence, which staggered Mr Darnley’s cold formality and
discomposed his stateliness. The almost awful emphasis which Mr
Primrose gave to the expression, “you ought to know,” reminded Mr
Darnley that he had but imperfectly performed his duty to the niece
of his old friend Dr Greendale; and the strong feeling thus expressed
compelled the pompous man to something of more kindly thought
and language. He rose from his seat, and took Mr Primrose by the
hand, and said to him:
“My good sir, pray compose yourself, be seated, and I will give you
all the information in my power. Your daughter is living, and is, I
believe, in health. You know, I presume, that there formerly was
something of an acquaintance between Miss Primrose and my son,
and you also know, as I learn by a letter from my son, who had the
honor of meeting you at St Helena, that this acquaintance has
ceased.”
“I know it, Mr Darnley, and I am sorry for it, very sorry for it indeed,
especially from what I have since heard of that young gentleman
who is said to be paying attention to her.”
Mr Darnley here shook his head, and then proceeded.
“After the decease of my good friend and neighbour Dr Greendale,
before I knew that the correspondence had ceased between the
young folks, I offered Miss Primrose an asylum in my house.”
Here Mr Darnley paused for a compliment; he had learned that of
the Right Honorable the Earl of Smatterton. Mr Primrose paid him
the proper compliment on his liberality, and the worthy rector
continued his narrative.
“Miss Primrose was pleased to decline the offer on the ground that
the Countess of Smatterton had taken upon herself to provide for
her. And it is not many days since Miss Primrose left Smatterton for
London, where she now is, in the house of Lord Smatterton, and she
honored us with a call before her departure, and I took the liberty of
giving her the best advice in my power, to guard her against the
snares and dangers to which she might be exposed in that
profession which she is about to adopt.”
“Profession she is about to adopt! Mr Darnley. And may I ask what
that profession is?”
“The musical profession, Mr Primrose.”
The father of Penelope was indignant, and he replied
contemptuously: “Impossible! Can the patronage of the Countess do
nothing better for my child than make her a teacher of music. But
there will be no necessity now—”
Before Mr Primrose could finish the sentence, Mr Darnley
corrected the misapprehension and said: “Not a teacher of music, sir,
but a public singer.”
This made the matter worse, and the poor man was just ready to
burst out into violent exclamations again, but recollecting that it was
in his power now to place his child in a situation of independence,
and considering that the time of her departure from Smatterton had
been too recent to render it likely that she had yet appeared in
public, he contented himself with saying, “I am astonished that the
Countess should think of such a profession for a young woman
brought up as my child has been. If my poor brother-in-law had lived
he would never have suffered it.”
“I was also astonished,” said Mr Darnley, “that Miss Primrose
should give her consent to such a proposal; for my friend Dr
Greendale used to express himself very strongly on that subject, and
endeavour to dissuade Miss Primrose from adopting such a
profession. It has long been the wish of the Countess of Smatterton,
but her ladyship did not succeed in the proposal during the lifetime of
Dr Greendale.”
Much more to the same purpose did Mr Darnley say on the
subject, not much to the satisfaction of Mr Primrose. It is not
pleasant for a father to hear anything to the discredit of a child, but
fortunately parents do not always believe such stories, or they find
excuses which nobody else can. So Mr Primrose did not, could not,
and would not believe the insinuation that Mr Darnley threw out
against Penelope, as if she had waited only for Dr Greendale’s
decease to adopt a profession against which he had serious
objections; and Mr Primrose thought it most probable that the
Countess of Smatterton had used great importunity, or that Penelope
had complied, to relieve Mrs Greendale of a burden. There was
indeed some difficulty in his mind to reconcile this story of Mr
Darnley with the insinuation thrown out in his letter, and corroborated
by the poor woman at the turnpike-gate, concerning the son of the
Earl of Smatterton having withdrawn the affections of Penelope from
Robert Darnley to himself. But Mr Primrose had been out of England
many years; and fashions had changed since he left his native land.
It was perhaps now quite elegant and fashionable to appear on the
stage. He recollected that when he was at school, he had read of
Nero, the Roman emperor, appearing on the stage as a public
performer, and for aught that could be known to Mr Primrose, the
progress of refinement in England might have pointed out dramatic
or musical exhibition as a fit introduction to the honor of an alliance
with nobility.
At all events, whatever were his notions or apprehensions he was
by this time considerably more calm and composed. He had the
satisfaction of knowing that his daughter was alive and well, and he
had the pleasing prospect of speedily seeing her again. Of her moral
and mental qualities, and of her intellectual improvement, he had
been in the constant habit of receiving flattering and agreeable
accounts, and he was not unwilling to believe them. There was some
little mortification, that he had travelled so far and all to no purpose.
But he had no other means of ascertaining where his daughter was.
It was a conceit of his own, (though partly aided by his late
brother-in-law,) not to keep any direct correspondence with his
daughter. His motive was, that as there was a possibility that he
might never return to England, and that he might not ever have it in
his power to provide for her according to his former means, therefore
he thought it best not to excite any expectations which might be
frustrated, or to excite in her mind any interest concerning himself,
which might ultimately be productive of only pain and uneasiness.
He wished his poor child to consider herself an orphan, thinking it
better to surprise her with a living parent than to inflict grief on her
mind at the thoughts of one deceased.
This scheme did not entirely succeed. The worthy and benevolent
rector of Smatterton could not help now and then saying a
favourable word or two concerning his poor brother Primrose; and as
Dr Greendale’s was the charity that hopeth all things and believeth
all things, he was not distrustful of his brother’s promises, but was
nearly, if not altogether, as sanguine as Mr Primrose himself. By
degrees Penelope came to have an interest in her absent parent;
and well it was for her that Dr Greendale had thus accustomed her to
think of her father: for when the good rector departed this life he did
not leave his niece quite so orphaned as if she had had no
knowledge or thought of her absent father. But to proceed with our
story.
We have said that it was late in the evening when Mr Primrose
arrived at Neverden. It was no great distance indeed to Smatterton;
but why should he go there in any hurry, seeing that his daughter
was not there? This consideration induced Mr Darnley to offer to the
traveller the accommodation of a bed: for Mr Darnley was not a
churlish man; he was only very cold, and very formal, and very
pompous. The offer was readily accepted, and the rector of
Neverden then conducted Mr Primrose from the study to the
apartment in which the family was sitting. Great curiosity was excited
as soon as Mr Darnley announced the name of his late arrived
guest. The young ladies felt particularly interested in looking at the
father of Penelope; but they did not make themselves, as they
thought, quite so agreeable as they should have done had matters
been proceeding in proper order with respect to their brother and
Penelope. The absence of that species of agreeableness to which
we allude, was no great inconvenience to Mr Primrose; for he was
weary with travelling, and exhausted by manifold agitations, and it
would not have been very agreeable to him with all this exhaustion to
undergo a cheerful volley of everlasting interrogations; and Miss
Mary Darnley would to a certainty have extorted from him a civil,
ecclesiastical, statistical, botanical, and zoological, history of British
India, to say nothing of Persia, China, Japan, and the million isles of
the Eastern ocean.
But though the young ladies were not disposed to apply the
question to Mr Primrose, their mother, who was as ready to forgive
as she was apt to forget, talked to him as cordially and cheerfully as
if the day had been fixed for the marriage of Robert Darnley and
Penelope Primrose. Her talk, however, was not wearying, because
there was no affectation in it, and because there was much good
feeling in it. Her talk was concerning her dear boy; and Mr Primrose,
who had a parent’s heart, enjoyed such talk.
“And so, Mr Primrose, you have seen my dear Robert? And how
did he look? He is dying to return to Neverden. We expect him next
week, for the ship is now in the Downs. Did you think, sir, he seemed
in good health?”
“In perfect health, madam: in fact I never saw a young man who
had been so long in India look so well as your son.”
“There was no yellowness in his look?” asked Mrs Darnley.
“Not the slightest, I can assure Mrs Darnley.”
“And was he not much sun-burnt?”
Mr Primrose smiled, and said, “Not any more, madam, than a
young man ought to be; and though I never had the pleasure of
seeing the young gentleman before, I do really believe that whatever
darkness may have been added to his complexion is rather an
improvement to his appearance than otherwise.”
“I am ashamed, Mr Primrose, to be so troublesome; but did you go
aboard his ship when you were at St Helena? Do you know what sort
of accommodations he had?”
“I certainly did not, madam, but I have every reason to suppose
that he had every comfort that could be expected.”
“Why, yes, no doubt. But still it must be a great confinement. It is a
very long voyage. Had you any storms, sir, as you came home?”
“Upon my word, Mrs Darnley, I really forget what kind of weather
we had; but we had nothing very serious, or I should have
remembered it.”
With many such-like questions and answers was the evening
beguiled, and it was late before Mr Primrose retired to rest.
The young ladies took some part in the conversation, though but
little; and Mr Darnley himself also now and then joined in the
discourse, especially when Mrs Darnley, in the simplicity of her heart,
asked questions which indicated a sinful ignorance of geography or
history. In such cases Mr Darnley took especial care to manifest how
much wiser he was than his wife. Positively it is a great shame, and
altogether unreasonable to expect that people who have been from
school thirty years or more should be as wise and learned as those
who have just finished their education, or as those who have a study
where they can sit and read and grow learned every hour in the day.
When the young ladies were alone they made amends for their
previous silence. They all talked together to one another concerning
Mr Primrose, and all three gave their opinions of him. By the way, it
is great nonsense to talk about giving an opinion. It is almost as bad
as giving advice; for neither one nor the other is ever taken, and how
can any one give that which nobody takes? There was, however, this
unanimity among the Miss Darnleys; they all concurred in saying and
thinking that he was a very agreeable and interesting man, and a
very lively man. They would indeed have thought him lively had they
witnessed the energy of his manner in the study with Mr Darnley. But
before the discussion closed, Miss Mary Darnley could not help
saying: “What strange questions mamma did ask! I wonder what Mr
Primrose thought of her?”
CHAPTER XVII.
Without the assistance of a composing draught Mr Primrose slept
soundly and woke calmly. But, being naturally impetuous and hasty,
he could not help uttering a few monosyllables of impatience at the
thought that he had travelled two hundred miles from his daughter,
and had incurred the risk of breaking his neck in making a journey to
the place where his daughter was not.
As, however, he was so near Smatterton, he would not of course
return to London without seeing Mrs Greendale, and thanking her for
the kind attention which she had paid to Penelope. He was not
aware that the good lady had plagued and worried the poor girl
almost out of her life. Dr Greendale had never, in his
communications to Mr Primrose, said anything about the annoying
fidgettiness of Mrs Greendale; and he himself, by virtue of his close
and constant application to study, had not felt much inconvenience
from her temper, excepting so far as an occasional interruption,
which was soon forgotten. But poor Penelope did not study
controversial theology, and therefore she had felt all the
inconvenience of Mrs Greendale’s humours and caprices. Of all this
Mr Primrose knew nothing; he therefore resolved to call and pay his
respects to the widow.
Having learned a lesson of forethought from his long fruitless
journey, he did not proceed to Smatterton before he had enquired of
Mr Darnley if Mrs Greendale yet resided there. By this enquiry he
learned that the living had been disposed of, and that as the new
rector was a young and single man, and though he had taken
possession of the rectory-house, he had been kind enough to
accommodate Mrs Greendale with a residence there till it might suit
her to change the place of her abode. “That is very kind of the young
man,” said Mr Primrose; “I like him for it: and pray what is his name
and where does he come from?”
Mr Darnley at these questions put on one of his stately
professional looks, and said: “His name, sir, is Pringle, he comes
from the university of Oxford, he is a son of Lord Smatterton’s
steward. At present I have but little acquaintance with him.”
There seemed, from Mr Darnley’s manner of speaking, to be on
his part no great desire to increase the acquaintance. Of this,
however, Mr Primrose took no notice; in fact, he hardly understood it,
for his own manner was straitforward and downright, he did not
accustom himself to innuendos and insinuations. Thanking the rector
of Neverden for his attention and hospitality, Mr Primrose proceeded
immediately after breakfast to the village of Smatterton. Mrs
Greendale was within, and she received Mr Primrose with the utmost
cordiality and cheerfulness: but when she began to allude to her
poor dear husband then the tears came into her eyes. Mr Primrose
sympathized with her, and they both talked of old times; and as the
subject was changed the tears were dried up. It was very right that
Mrs Greendale should most cordially receive Mr Primrose, for all
persons who come home from the East Indies in good spirits are
supposed to come home rich, and there is to some minds something
very agreeable in the sight of a rich man. Let sentimentality-people
prose as much as they please about the homage that is paid to
wealth; it would be much worse if that homage were paid to poverty.
The conversation then turned to Penelope, and many and sincere
were the thanks that Mr Primrose returned to Mrs Greendale for her
very kind attentions to the poor girl; and then Mrs Greendale, in spite
of all the severe and sneering rebukes, which in former days she had
lavished upon her niece, began to launch out into commendations of
the young lady’s beauty, wit, and accomplishments.
“But what a pity it is, Mr Primrose, that you did not know that
Penelope was in London. Well, you will have such a treat in seeing
her again, she is so grown and so improved. She is a favorite with
everybody. A day or two before my poor dear husband died, we had
a party, and Lord Spoonbill, and Colonel Crop, and Miss Spoonbill
were all here; and Lord Spoonbill was so attentive, you can’t think.
Then my Lady Smatterton has taken such a fancy to her, that she
insists upon having her in London.”
“Ay, but Mrs Greendale, I don’t understand the condition on which
my child is thus taken up to London; and to tell you the truth, I do not
altogether approve the plan which Mr Darnley informed me was in
contemplation. It is not very agreeable to my feelings that my
daughter should be made a public performer.”
“Oh dear no, certainly; but I dare say the Countess of Smatterton
would not recommend anything improper.”
“I don’t know what may be Lady Smatterton’s notions of propriety,
but I shall take care that my daughter does not adopt that or any
other profession.”
While they were talking, the arrival of Nick Muggins with the letter-
bag reminded Mr Primrose that it might be desirable to apprize
Penelope of his being in England and of his intention of immediately
seeing her. He therefore dispatched a note to his daughter, under
cover to the Right Honorable the Earl of Smatterton, and thus he
made wise provision against further accidents preventing their
meeting.
As Mr Primrose had experienced the inconvenience of one
overturn by the stage-coach, he determined not to trust himself again
so soon to the same mode of conveyance; and as he intended to
travel post, and as he was not about to set out immediately, he
amused himself with strolling about the village to admire its beauties;
for everybody said that Smatterton was a very pretty village. In the
month of December English scenery seldom appears to great
advantage; and while Mr Primrose was looking for, rather than at, the
beauties of Smatterton, who should he meet but the very identical Mr
Kipperson with whom he had travelled in the stage-coach? The
parties recognized each other immediately, and they presently
entered into chat. Mr Kipperson expressed great concern for the
accident, but was exceedingly rejoiced to find that his fellow-traveller
was not seriously hurt. “For indeed, sir,” said he, “I almost thought
that you were killed.”
“So did I,” replied Mr Primrose: “but what can be the use of
travelling at that unreasonably rapid rate? When I was in England,
sixteen years ago, the stage-coaches used to go at a very
reasonable and moderate pace.”
“Yes, yes, I remember it,” said Mr Kipperson; “but we should never
be able to get on with business were it not for this quick travelling. I
will tell you, sir, an instance of its utility: the other day I received a
letter from my friend the Earl of Smatterton, informing me of an
important debate which was just coming on, and it was a matter of
infinite moment that I should be in town in order to attend some
meetings that were to be held, and to give my opinion concerning
some clauses which were likely to be introduced greatly affecting the
agricultural interest. I received the letter just in time to take
advantage of the coach, and, by means of quick travelling, I arrived
in town time enough to give my views of the subject, and to prevent
the passing of some most destructive measures.”
“You are a member of parliament, I presume?” said Mr Primrose.
“No, sir,” said Mr Kipperson, with that sort of air that seemed to
indicate that he did not at all desire that honor, and that he was a
person of greater importance; “but now and then parliament is
pleased to do me the honor of consulting me on some topics
connected with the interests of agriculture.”
Though Mr Primrose was what in ordinary language is called an
independent man, yet he could not but feel reverence for greatness;
and finding that the gentleman with whom he was conversing was a
person of some consequence, he was desirous of knowing who it
was. This desire was but slightly hinted, and immediately the great
agricultural luminary gratified Mr Primrose’s laudable thirst after
knowledge by saying: “My name, sir, is Kipperson. Kipperson, sir, of
Smatterton.”
It was very excusable that Mr Primrose, who had been so many
years out of England, should not be familiar with the name, and
should not be aware that he was addressing the celebrated
agriculturist, Kipperson of Smatterton. Mr Kipperson himself was so
modest a man that he did not choose to say that he was the
celebrated one of that name, but he took especial care to let it be
understood indirectly and circuitously that he was a person of some
importance in the world.
And now it was very natural that the great agriculturist should be
desirous of knowing the name and designation of his fellow traveller,
and to ascertain that was also no great difficulty. As soon as he
found that he was conversing with the father of Penelope Primrose,
he broke out into the most eloquent panegyrics on the character,
moral, intellectual, and professional, of the late rector of the parish,
and congratulated Mr Primrose in having had the good fortune to
confide his daughter to the care of so superlatively excellent a man.
“But, sir,” as suddenly recollecting himself, “perhaps you will do me
the honor to walk in and sit down under my humble roof; for I can
give you the latest information concerning Miss Primrose. It is very
singular that I should have travelled up to London with the daughter
and down from London with the father.”
At that singularity, or at his own penetration in discovering the
curious coincidence, Mr Kipperson smiled. Mr Primrose accepted the
invitation and walked into Mr Kipperson’s house, which was near the
place where they had met. It was a piece of affectation in Mr
Kipperson to call his place of abode a humble roof. True, it was not
so magnificent as Smatterton castle, but its owner had been at great
pains and expense to make it look quite the reverse of humble. That
which had been a productive little garden was converted into a lawn.
Those barns, piggeries, and outhouses, in which was deposited no
small part of the owner’s wealth, had been gracefully, but
ungratefully, planted out. French windows supplied the place of old-
fashioned casements, and green verandahs gave Peter Kipperson’s
farm-house as much as possible the air of an Oriental palace.
Mr Primrose was surprised, as Peter hoped and designed, at the
very learned air of the library, to say nothing of the numerous busts
and casts which in the narrow entrance occupied that room which
would have been much more usefully devoted to cloak-pegs. When
they were seated in the library Mr Kipperson commenced his
narrative, telling Mr Primrose what the reader is already acquainted
with. But still the father of Penelope was not reconciled even to the
attempt or proposal to make his daughter a public singer. Mr
Kipperson however assured him, that nothing could be more
respectable than the manner in which the Countess of Smatterton
designed to bring out Miss Primrose.
“I was present at an evening party,” said the agriculturist, “given by
my friend the Countess of Smatterton, for the express purpose of
introducing Miss Primrose to some of the best society in town. There
were several persons of rank there, and among the rest the
celebrated Duchess of Steeple Bumstead; and her Grace was quite
enraptured with Miss Primrose.”
“Well,” said the father of Penelope with some shortness and
dryness of manner, “I don’t understand these matters. I have been
so long out of England that I almost forget the customs of my native
land; but I do not approve of this kind of association with persons of
so much higher rank and fortune. The Countess of Smatterton
cannot consider my daughter as an equal, and therefore she is
tolerated for the amusement she can afford. I don’t like it, sir, I don’t
like it. But, Mr Kipperson, can you tell me what kind of a man is Lord
Spoonbill?”
Mr Kipperson promptly replied: “A man of no intellect whatever.”
“A fig for intellect,” replied Mr Primrose; “but is he a man of good
character?”
“Indeed sir,” responded the great agriculturist of Smatterton, “I am
sorry to say he is not. The Earl himself is a very respectable man, so
far as moral conduct is concerned, though he is a man of no mind;
and he is a proud man, very distant and pompous, and quite an
exclusive.”
“An exclusive!” echoed Mr Primrose; “what is meant by an
exclusive?”
“By exclusive, sir, I mean that the Earl is not easily led to associate
with those whom he considers of an inferior rank to himself; he is
one of a set, as it were.”
“Oh, is that all!” exclaimed Mr Primrose; “why at that rate all the
world is exclusive. This is no new character though it may be a new
name.”
“Very true, indeed, very true, there has always been too much
pride among persons of high rank.”
“And not too little among persons of low rank, I presume,” replied
Mr Primrose; “and I suppose as you have a set of people in England,
called exclusives, you have most likely another set called intrusives.
For my part I like a little pride, or at least what the world calls pride; I
have so much myself, that I dislike the situation in which I find my
daughter is placed, and I shall make all haste to remove her from it. I
am most happy that I have arrived in England time enough to
prevent her from making a public display of her musical talents.”
The wise and scientific Mr Kipperson was not sorry to hear that the
father of Penelope Primrose could talk thus boldly and definitely
concerning his daughter’s independence. It was also not unpleasant
to him to hear that it was the intention of the young lady’s father to
remove her from the house and patronage of the Earl of Smatterton.
It has been already hinted that Mr Kipperson was an admirer of the
young lady, and it was not likely that his admiration should be less
when he found that her father had returned to England in
possession, most probably, of ample means of securing his
daughter’s independence. This consideration inspired the
agriculturist with an earnest desire of making himself more agreeable
than usual; and as there was a great deal of freedom of manner and
candour of feeling about Mr Primrose, he very readily and sociably
conversed with Mr Kipperson on any and every topic that could be
started. In the fullness of his heart the admirer of Penelope urged the
young lady’s father to partake of a humble dinner, quite in a social
friendly way. This invitation however was of necessity declined, it
being the intention of Mr Primrose to pass the remainder of the day
at the rectory.
The mention of the rectory led Mr Kipperson to speak of the new
rector, the Rev. Charles Pringle. “You will of course meet this
gentleman at dinner. He is a very different man from our late rector;
as yet we know little of him. I have conversed with him occasionally;
he seems to have very just notions on the subject of the interests of
agriculture; but his mind does not appear to be comprehensive and
philosophical; he does not read much, I think; indeed, he has
scarcely any books of his own, and though I have offered him the
use of my library he does not avail himself of it. But you will see him
at the rectory at dinner, and then you may form your own opinion of
him.”
It was very kind and liberal of Mr Kipperson to give Mr Primrose
leave to form his own opinion of the new rector. What opinion Mr
Primrose did form of the new rector we cannot say, for he was not
very free in expressing his opinion of those with whom he had no
common interest or sympathies, nor was he particularly and
curiously observant to ascertain whether those with whom he
conversed occasionally were persons of comprehensive and
philosophical minds or not. He was not quite sure that he knew what
was meant by the term comprehensive, as applied to the mind; and
as to philosophical, if that meant loving wisdom, he himself was
philosophical enough in all conscience, for he liked wise men much
better than fools. In a word, the father of Penelope had quite as good
an understanding as multitudes who make a great deal of prating
about intellect, but he was not a man of much reading, and did not
value pedantry of any kind, whether literary, scientific, fashionable or
philosophical.
CHAPTER XVIII.
Even as Mr Kipperson predicted so it came to pass; Mr Primrose
met at dinner the new rector of Smatterton.
The great difference which there is between an old man and a
young one, is one cause of the general common-place notion of the
deterioration of the human species. It seemed a very great transition
from Dr Greendale to Mr Pringle. The doctor used to be grave,
sedate, yet cheerful, very placid and gentle in his manner, and
towards his parishioners he wore the aspect of a father. His dress
too was so venerable. He used to wear a long single-breasted coat,
and he had such fine broad old-fashioned silver buckles at his knees
and on his shoes; his hat too was just such a hat as a clergyman
ought to wear. And when he walked out into the village he always
carried under his arm an old gold-headed walking cane; for he
seldom leant upon it. He walked slowly and demurely, and when the
little boys and girls who met him planted themselves, according to
their clumsy but sincere politeness, directly before him to make their
bow or curtesy, he patted them on the head, and they felt
themselves as much honoured and pleased as the alderman of
some provincial borough when the king places the sword on his
shoulder. And when the old people met him he talked to them, and,
even more than that, he listened to their talk; he could not always
understand it, but he paid attention to it and it pleased them.
Sometimes he would be in a gayer and livelier mood than usual,
especially if in his morning studies he had been successful in
detecting, or eloquent in pointing, some irrefragable argument
against the sectarians. And then, if he met any young woman of
pretty and smiling looks, for there were many such in Smatterton, he
would ask her when she was going to be married, and then she
would laugh and try to blush, and she would go home and tell her
mother what a funny man Dr Greendale was.
Now whatever might be the virtues, moral or professional, of the
Rev. Charles Pringle, it is very clear that he could not find the way to
the hearts of his parishioners by the same means as his
predecessor. A slightly built youth of five-and-twenty would look
anything but venerable, if dressed in attire of the same form, cut and
complexion as that which Dr Greendale wore. The gold-headed
cane, the looped hat, the slow and stately walk, would not at all
answer with a young man; and had he asked any young woman
when she was going to be married, it would have been thought quite
indecorous. The old women too would not think of telling a young
man round-about stories concerning their sufferings with the
rheumatiz, or other ills that “flesh,” or more properly skin and bone,
may be “heir to.”
It was therefore essential and unavoidable that there should be a
difference between the old and the new rector. It will however be
supposed by our readers, who remember that we have described the
Earl of Smatterton as boasting that he always bestowed his livings
according to merit,—it will be supposed, that the Rev. Charles
Pringle had merit, though not precisely of the same nature as the
merit of Dr Greendale. The merit for which his lordship bestowed the
living of Smatterton on Mr Pringle, was not his own merit but that of
his father. For the young rector was, as already noticed, the son of
Lord Smatterton’s house-steward. This steward had been faithful in
his office, and was a great favorite with his lordship; but though he
was faithful he had saved a little money, and was desirous of setting
his son forward in life. The father was of opinion that the legal
profession would suit the young man very well, seeing he was so
very clever. The son also was perfectly well aware of his own
cleverness; but as the confinement of an attorney’s office did not suit
his inclinations, he excused himself from that pursuit. On the same
or similar ground he declined the medical profession, inasmuch as it
was contrary to his notions of comfort to be called from his bed at
midnight, or to be interrupted at his meals. The church seemed to be
the only comfortable profession, and on that the young gentleman
fixed his choice. Moreover it gratified his vanity to go to college. He
might have had ambition, but he did not like trouble; and being, as
we have said, a clever young man, he shewed his cleverness by
studying only just so much as might save him from being plucked.
He obtained his degree and that was all. With equal dexterity and
cleverness did he manage that reading which was necessary
preparatory to taking orders. The examining chaplain who passed
him, observed that he was a clever man, for he had most ingeniously
hit upon the exact minimum of information which would enable him
to pass. There is a proverb, which says that lazy folks take the most
pains; and in many cases Mr Pringle illustrated this proverb, for
nobody could take more pains than he did to avoid labour.
We cannot see how the Earl of Smatterton was to blame for
appointing this young gentleman to the living of Smatterton. It is not
to be supposed that his lordship should take the trouble to examine
the youth; and as the father was a faithful servant the Earl was
rewarding merit by providing for the son.
More remains to be said concerning the new rector. He was a man
of good temper and very harmless disposition. He was not at all
given to quarrelling, for he did not like the trouble; and he was very
easy to deal with in fixing the composition for his tithes. The farmers
thought him rather proud; for he took very little notice of any of them
except Mr Kipperson, who kept an excellent table. He paid great
attention to Miss Spoonbill, though his only recompense for that
attention was an occasional cup of tea, and that by no means strong:
but it was handed to him on a large silver waiter, and presented by a
servant who wore a very splendid livery. There was much courtesy of
manner in Mr Pringle; he was, according to the best of his ability, a
perfect gentleman, and whenever he observed any article of dress,
or mode of expression or pronunciation, or any species of action
peculiar to persons in high life, he copied it most faithfully as far as
his profession would allow. His courtesy was very great, for he had
the sagacity to know that, if he was too lazy to provide for himself, he
must persuade some one else to provide for him.
One word more, and that concerning the young man’s politics. The
world does not much care about Mr Pringle’s politics, but still the
politics of a clergyman looking for preferment are to himself matters
of great moment. Before Mr Charles Pringle went to Oxford, he was
what is called liberal in his politics; at Oxford he found it more

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