Neurosurgery is complex. Sometimes, brain surgery is compared to rocket science to emphasize the complexity involved. Small errors in decision making, planning, or execution would have devastating consequences. Innovations in Neurosurgery – which is one of the youngest surgical specialties – have significantly reduced the incidence of complications. These innovations have happened in the last few decades and have made operating on the brain much safer. There was a time when neurosurgery meant accepting a high risk of complications. But with advances in technology and understanding of brain functions, the goal of neurosurgery has shifted its focus not just to save the life, but to reverse the deficits and integrate the person functionally back in the society.
Here is a glimpse into four critical innovations in Neurosurgery and how these techniques are helping Neurosurgeons in aiding patients with brain tumors to live a better life.
- Operating microscope
An operating microscope is an important tool in Neurosurgery. A newer generation of operating microscopes is large optical instruments with optical apparatus hanging above the operative field, which is supported by a large stand. Brain tumor surgery generally involves stabilizing the head using a clamp, under anaesthesia. The neurosurgeon then opens the skin flap and does a craniotomy. Craniotomy means the opening of the skull bone using high-speed drills, to access the brain. After craniotomy, the covering of the brain – dura – is opened to expose the brain. An operating microscope is brought into the field at this stage.
An operating microscope has two important functions.
- It illuminates the small field with bright light entering the deepest crevices of the operative area.
- 2. It gives a zoomed image of the operative area for better delineation of critical structures which are less than a few millimetres in size.
The surgeon generally sits on a special motorized chair and operates viewing through the eyepiece of the microscope.
The operating microscope has become indispensable for almost all neurosurgical operations.
The endoscope allows visualization of internal structures of the brain with a pencil-sized instrument that is inserted into cavities of the brain through a small hole in the skull.
Some forms of hydrocephalus which earlier required shunts from ventricles to the abdominal cavity are easily treated without placement of shunts by using an endoscope. A small hole will be created in the ventricular floor to bypass the obstruction to flow of cerebrospinal fluid in this operation called – ‘endoscopic third ventriculostomy’.
It is also used to remove some tumors like colloid cysts of the third ventricle and to take biopsies. An endoscope is also used to remove some forms of brain tumors through nose – trans-nasal endoscopic surgery. Here surgeons access the tumor through the nose and carefully remove it under endoscope guidance. The treatment avoids opening the skull with big incisions and offers complete removal of pituitary tumors, thanks to better illumination in the deepest areas of the tumor cavity.
Another major milestone in Neurosurgery is the advent of Neuronavigation. Here, the GPS technology is used to assist the surgeon in navigating through the deeper parts of the brain. It allows safer complete removal of complex tumors that are invading into adjacent sensitive structures. It also helps neurosurgeons in safer placements of screws in the vertebral pedicles to stabilize the spine.
This sophisticated machine relies on the registration of patient data and superimposing it on the brain images (CT/ MRI). The display then shows the tip of the surgeon’s instrument in real-time, updating the surgeon about the exact location of the operative site and extent of tumor removal. It also helps to identify the right approach and mark the extent of opening required, before the operation. Surgeons are constantly guided about the position of their tools throughout the procedure. Neuronavigation also helps in keeping the skull openings of craniotomy small and in minimizing the damage to healthy structures.
- Awake craniotomy
This is a sophisticated technique in neurosurgery with support from anaesthesia. Here the patient will be kept awake during the procedure of brain tumor resection. The idea is to identify the important areas of the brain like speech area, area for hand movements, and leg movements, during the operation by asking the patient to speak or perform simple hand or leg actions. By doing so, the surgeon will be able to avoid those important areas during the resection of tumors and prevent major complications like speech disturbances or weakness in limbs.
It is extremely useful in resections of tumors close to important functional areas of the brain like speech and limb areas.
This procedure, of course, requires a generous understanding and co-operation of the patient. After taking his or her consent the patient will be thoroughly explained about the procedure and is made to visit the operating room environment on the day before surgery to get acquainted. Local anaesthesia and mild sedation will be given to avoid any pain or discomfort. The procedure is surprisingly well accepted by the patients and they are extremely happy as the major complications are avoided.
With these recent innovations, surgery for brain tumors has become much safer. Most of the patients can walk back home three to five days after surgery.
And yes, we have stopped shaving scalp hair before brain surgery! An incision is placed in between hair to give good cosmesis and help patients in amalgamating early with society.