DEPARTMENT OF NEUROSUGERY

SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

Craniotomy
A craniotomy is an operation performed by neurosurgeons in order to treat various conditions
affecting the brain.In simple terms, craniotomy means a hole in the head (Crani- = head; -otomy
= hole).
A craniotomy involves making an incision in the scalp and removing a window of bone from the
skull (this bone is secured back in position at the end of the operation). This allows access to the
inside of the skull and brain, and the tumour is either biopsied , or excised.
Brain surgery has undergone major developments over the past 15 years or so. The result is that
neurosurgeons can operate on parts of the brain previously thought to be unreachable.
Furthermore, brain surgery has become much safer and is more likely to be successful than it was
previously.
stereotactic craniotomy
Almost all tumour craniotomies are performed with the assistance of computerized navigation
techniques, also known as stereotaxy. This is done order to improve the accuracy of the surgery,
reduce the size of the incision, and increase the safety of surgery by avoiding important structures
in the brain.
Stereotaxy works like a satellite navigation or GPS system in your car. It allows the surgeon to use
a wand or a pointer to see exactly where he or she is in the brain or on the skull, as depicted on a
CT or MRI scan within the operating theatre. This real-time navigation facilitates location and
removal of the tumour.
There are two types of stereotaxy. The original type is frame-based, where a special frame (for
example the CRW frame) is fixed to the skull, relevant brain scans are performed, and surgery is
carried out with the frame remaining on. This is a very accurate system, but has the disadvantages
of inconvenience, additional time requirements to fit the frame and perform the scans, restricted
surgical access to some regions of the head, and patient discomfort (if the patient is awake when
the frame is put on). Despite these disadvantages, frame-based systems continue to be used in
some situations, and are slightly more accurate than frame less systems. For some tumour
biopsies, a frame-based system remains the safest and most appropriate method of stereotaxy.
The second (and more popular) type of stereotaxy is frame less stereotaxy. These systems, such as
the Stealth and Brain Lab, rely on the application of small markers (fiducials) which are stuck to
the patients head before the brain scan is performed. Anatomical landmarks such as the nose, eyes
and ears may be used instead of fiducials. More recently, surface tracing techniques have done
away with the need for fiducials and anatomical landmarks in some situations.
Frame less stereotaxy is slightly less accurate than the frame-based systems, however its numerous
advantages have meant that it is used by the vast majority of contemporary neurosurgeons
performing brain surgery.
Whilst stereotaxy represents a tremendous advance in the field of neurosurgery, it is not infallible.
All stereotactic techniques suffer from the limitations imposed by brain shift, the phenomenon
whereby the brain moves after part of a tumour or some brain (cerebrospinal) fluid (CSF) is
drained. Its utility therefore declines as the operation progresses. A potential solution to brain shift
is intraoperative MRI, which allows the surgeon to see exactly where he or she is once some of the
tumour has been removed.
DR.KANAK SONI
1
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE

DEPARTMENT OF NEUROSUGERY
SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

goals of surgery for brain tumours

There are several potential goals of a tumour craniotomy. These may include one or more of the
following:
To establish a diagnosis. This is called a biopsy. This is usually done through a small hole (burr
hole), rather than a craniotomy, but in some situations a craniotomy is the best option. Biopsies are
often done at the same time as removal of the tumour.
To reduce pressure on the brain (intracranial pressure).
There are several types of surgery to achieve this:
Tumour debulking. The goal here is to remove enough of the tumour to reduce the amount of
pressure on the brain (partial resection).
o Tumour removal (excision)./ Drainage of a cyst (fluid filled structure) associated with the
tumour.
The primary goal of brain tumour surgery usually is to remove as much of the tumour as possible
without injury to the surrounding brain. This may be particularly complicated if the boundaries of
the tumour cannot easily be identified at surgery, or if the tumour is invading critical structures
such as blood vessels or cranial nerves ,
Preventing future problems or deterioration from tumour growth or hemorrhage./ Alleviating
seizures (epilepsy) or determining precisely which area of the brain is causing seizures./ Curing
the condition (benign tumours)./ Increasing the length and quality of survival time (malignant
tumours).
alternatives to craniotomy
The alternatives to surgery depend upon the type, size, location, and number of tumours being
treated, as well as the patients overall condition:
Stereotactic biopsy through a small hole (burr hole) in the skull. This can be used to obtain a
diagnosis and may enable the drainage of some fluid from a tumour cyst to relieve raised
intracranial pressure.
Radiotherapy: This may be delivered to the entire brain (whole brain radiotherapy) or to the area
of and surrounding the tumour. Not all tumours are amenable to radiotherapy.
Stereotactic radiosurgery: This involves blasting the tumour with a single treatment session of
concentrated radiotherapy. It may be useful for small tumours, as well as deep tumours which may
not be amenable to surgery. The Gamma Knife is the best-known system.
Chemotherapy: These may be given in oral (tablet) form, or into the bloodstream (intravenous).
Not all tumours are amenable to chemotherapy.
tests required before surgery
The following investigations may then be ordered:
1. MRI Brain : This gives much more detail than a CT scan, and is important for surgical planning.
It may also detect smaller tumours and vascular malformations which may be missed with CT.
2. Magnetic resonance spectroscopy (MRS): MRS gives information about the likely chemical
composition of the tumour, and therefore its probable diagnosis. It can be done at the same time as
the MRI in some institutions.
3. Positron Emission Tomography (PET) and Single Photon Emission CT (SPECT) scans : These
give information about the blood flow and metabolic activity of a mass within the brain. They are
DR.KANAK SONI
2
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE

DEPARTMENT OF NEUROSUGERY
SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

frequently useful in differentiating between a recurrent tumour and the effects of radiotherapy,
both of which may look identical on MRI.
4. Cerebral angiography/CT angiogram (CTA)/Magnetic resonance angiogram (MRA):These tests
provide detailed information about the appearance of blood vessels in the brain. Angiography may
be helpful where a tumour appears very vascular, or where a diagnosis of a vascular malformation
or aneurysm is being considered.
5. CT Chest, Abdomen and Pelvis/Nuclear Medicine Bone Scans/Breast Ultrasound or
Mammogram:These scans help to pick up tumours elsewhere in the body. This process of
"staging" is frequently important in deciding the best way to manage brain metastases.
6. Plain X-rays of the skull are rarely needed nowadays.
specific risks
Whilst the majority of patients will not have any complications, there is a small risk of problems.
In general the risks of craniotomy include, but are not limited to:
Stroke or hemorrhage / Infection / Seizures /Impaired speech (dysphasia), with problems either
understanding speech or actually speaking / Blindness /Deafness / Memory loss/ Cognitive
impairment /Swallowing impairment /Balance problems/Hydrocephalus /Numbness of the skin
around the scalp incision/Headaches /Cosmetic issues, with a small dimple in the skull where the
holes were drilled.
risks of anaesthesia
Significant scarring (keloid) /Wound breakdown /Drug allergies / DVT
Pulmonary embolism / Chest and urinary tract infections /Pressure injuries to nerves in arms and
legs /Eye or teeth injuries /Myocardial infarction /Stroke /Loss of life

STEPS OF OPERATION
Anesthesia Procedure
A general anesthetic is given and endotracheal tube is inserted. Intravenous antibiotics, and
frequently dexamethasone and anticonvulsants are administered. A catheter is often placed in the
bladder (this will be removed the next day). A dehydrating agent, such as Mannitol, is often given
in an attempt to control brain swelling.The patient is then positioned according to the area of the
brain that must be operated upon. The hair over the incision area is then clipped and shaved, and
the frame less stereotactic navigation system is set up. Local anesthetic and adrenaline are then
injected into the proposed incision site.
Incision
A curved or straight incision is made in the scalp over the appropriate location. The scalp flap is
then pulled back to expose the skull.
Craniotomy (bone removal)
DR.KANAK SONI
3
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE

DEPARTMENT OF NEUROSUGERY
SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

One or more small holes (burr holes) are drilled in the skull with a high speed drill. This sounds
dangerous but is actually quite safe in skilled hands. A surgical saw (craniotome) is then used to
connect the burr holes and create a "window" in the skull through which brain surgery will take
place. The removed piece of bone (bone flap) is kept sterile, and is usually secured back in
position at the end of the operation.
Removal of the Tumour
When the dura is exposed, an assessment of the likely location of the underlying tumour is
performed. The dura is then incised with a scalpel and scissors, and the underlying brain is
exposed.A small incision is made in the surface of the brain and the neurosurgeon proceeds along
the appropriate path until the tumour is reached. After the tumour is identified, it is carefully
dissected from the normal surrounding brain.
biopsy
It is sent to the pathologist for analysis. A frozen section analysis usually takes around 20-30
minutes and should tell the surgeon whether the tissue taken is likely to be a tumour, and roughly
what type of tumour it is. The frozen section is not, however, 100% accurate, and the tissue is then
prepared and stained for a more thorough and accurate pathological evaluation, a process which
usually takes 2-3 days.Special microsurgical and other instruments are used by the neurosurgeon
to locate, incise, and remove the tumour. These may include a microscope or special magnification
glasses (loupes), lasers, and an ultrasonic tissue aspirator (abbreviated to CUSA) that breaks up
and then aspirates the abnormal tissue.
With meningiomas and metastatic tumours, it usually easy to distinguish the tumour from the
normal brain tissue around them, and a fairly complete excision is usually possible (gross
macroscopic excision). This is in contrast to surgery for gliomas, where the tumour boundaries
are usually unclear and difficult to identify. Furthermore, the tumour cells in glioma usually spread
well beyond the visible edges of the tumour, deep into the brain and sometimes into the other side
of the brain.
Once the tumour has been removed, the surgeon ensures that there is no significant bleeding
(obtaining hemostasis). In situations where there is a large cystic component to the tumour, a drain
and reservoir may be inserted into the cystic cavity. This allows easy drainage of fluid if it
accumulates in the cyst after surgery, by simply passing a small needle through the scalp and into
the reservoir. An intracranial pressure monitoring device is occasionally implanted, and a drain is
sometimes placed within the fluid channels in the middle of the brain (the ventricles).
Bone Replacement
After the dura has been stitched back together, the piece of bone that was removed is replaced and
secured using small plates and screws, or several small clamps which hold the bone flap fairly
firmly.
If there are significant defects in the skull from the drilled holes (which may cause cosmetic issues
or feel may uncomfortable when combing your hair) these will be filled and the skull recontoured
using acrylic or titanium. This is known as a reconstructive cranioplasty.
Incision closure
DR.KANAK SONI
4
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE

DEPARTMENT OF NEUROSUGERY
SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

The operation is completed when the incision is closed, usually in two or three layers. Unless
dissolving suture material is used, the skin staples will have to be removed after the incision has
partially healed (usually around 7 days after surgery).
Neurological Observation
Patients will be transferred to the recovery room immediately after surgery, where he will wake
up. The recovery room nurses will monitor him closely, particularly in relation to your level of
consciousness, arm and leg strength, as well as breathing, blood pressure and heart rate.
Once he is more awake and relatively stable, he will be moved to the neurosurgical high
dependency unit or a closely monitored bed on the neurosurgery ward, where his condition can be
closely monitored for around 24-48hrs. These highly specialized areas provide ongoing close
observation with highly-trained nursing care.
The first 24 hours after surgery represents the period of highest risk for post-operative bleeding.
Patients blood pressure will be kept under control and your level of consciousness will be watched
closely. In some cases a monitor may be used to measure the pressure inside your skull. A CT or
MRI scan is often performed the day after surgery to make sure things are satisfactory. When fully
conscious and completely stable, patient will be returned to his regular room.

Postoperative Pain and Nausea

A dull headache is common, but is usually all the post-operative pain that is expected. Pain
medication will be ordered for this. Nausea and vomiting may also occur, and these will be treated
with medications.
Incision care
The incision will be covered with a dressing, and sometimes a crepe bandage. The wound is
usually checked, cleaned and redressed 3 or 4 days after surgery. The staples are usually removed
7 or 8 days after surgery. The wound must be kept dry for the first 2 weeks following g your
operation.
Fluid Replacement and Nutrition :Intravenous fluids will be ordered during the early recovery
period and continued until you are fully awake and tolerating a reasonable amount of liquid by
mouth. For the first few days, all fluids intake and output will be carefully monitored, due to the
danger of brain swelling lessens.
Emotional changes
Brain surgery is generally fairly stressful, both physically and psychologically. It is common to
feel discouraged and tired for several days after surgery. This emotional let-down must not be
permitted to obstruct the positive attitude essential to recovery and a return to fairly normal
activity.

Laminectomy
Spinal stenosis results in a symmetric compression on the spinal nerves due to degeneration and
overgrowth of the joints, ligaments, and bone spurs. Surgery to treat spinal stenosis often requires
DR.KANAK SONI
5
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE

DEPARTMENT OF NEUROSUGERY
SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

more extensive decompression than a simple micro discectomy and is known as a Laminectomy.
This procedure involves unroofing the spinal canal by removing the bone, known as the lamina,
and enlarged ligaments along the back of the spine. The arthritic facet joints are also shaved down
to provide more room for the exiting spinal nerves.
Compared to a Microdiscectomy, patients typically experience an increased degree of postoperative discomfort due to the greater extent of muscle dissection and the larger skin incision.
This is required to expose both sides of the spine, as opposed to a microdiscectomy that typically
requires exposure of only one side. On average, patients are discharged from the hospital one to
two days following surgery. Activities are limited to walking for the first several weeks following
the operation. Physical therapy is often useful, initially involving stretching and range of motion
exercises followed by endurance and strength training.

Cervical Laminectomy and Foraminotomy

Degenerative changes of the cervical spine can produce compression of a spinal nerve, causing a
radiculopathy pain, sensory changes, and weakness in a single extremity. Compression of the
spinal cord can lead to more profound dysfunction known as a myelopathy that produces
sensory changes and weakness in both arms and/or legs, loss of coordination, or incontinence of
bowel/bladder function. Nonoperative management may be attempted but is less likely to produce
significant relief, particularly if the spinal cord is affected.
When conservative maneuvers fail or the spinal cord is at risk of permanent injury, surgical
intervention is often the treatment of choice. The procedure is intended to release the spinal cord
and nerves by removal of the degenerative bones and ligaments. If the majority of compression is
located along the back of the spine and a normal spinal alignment is maintained, the procedure of
choice is known as a cervical laminectomy and foraminotomy. Other options include Anterior
Cervical Discectomy and Fusion / Fixation.
Surgical Procedure
Cervical laminectomy and foraminotomy is performed under general anesthesia.
An incision is made down the middle of the neck overlying the areas of pathology. The muscles
are dissected to expose the back of the cervical spine. The cervical lamina are removed (the
laminectomy) to release the spinal cord. Nerves are released by shaving a portion of the facet joint
(the foraminotomy) that is compressing the nerve. Once the decompression is complete, the
muscles are re-approximated and the incision is closed in multiple layers with absorbable sutures.
Course of Treatment
Patients are usually admitted for two or three days following surgery. Post-operative pain is
usually controlled with oral medications. Patients are encouraged to ambulate as soon as possible,
often on the day of surgery. Consultation with a physical therapist and rehabilitation specialists
during hospitalization is usually reserved for patients demonstrating significant neurologic
dysfunction. Following discharge, patients are encouraged to increase their activities as they are
able to tolerate. Physical therapy focused on the neck is not instituted until the initial follow-up
visit, usually four to six weeks after surgery
DR.KANAK SONI
6
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE

DEPARTMENT OF NEUROSUGERY
SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

Lumbar Laminectomy
Instability of the spine as a result of degenerative changes can lead to a reactionary growth of
associated ligaments and joints, natures attempt to restore stability. Unfortunately, these
compensatory mechanisms compromise the normal space occupied by the spinal nerves.
Compression of the nerves as a result of these compensatory changes can lead to the syndrome
known as neurogenic claudication activity-related pain in the lower back and legs that is
relieved with rest. Nonoperative maneuvers typically produce temporary relief. Definitive
correction often requires removal of the compressing elements through a procedure known as a
laminectomy.
Surgical Procedure
The procedure is performed under general anesthesia. A midline incision in the lower back is
centered over the affected area. Dissection through the back muscles provides access to the spine.
The portion of the vertebra known as the lamina is removed along with any thickened ligaments to
release the nerves traveling down the center of the spinal canal. Individual nerves are released as
they exit the spinal canal by shaving a portion of the degenerative facet joint. The soft tissues are
then closed in multiple layers with absorbable sutures.Patients are usually admitted for one to
three days following surgery. Ambulation is encouraged on the day following surgery, and patients
are allowed to increase their activity level as tolerated. If necessary, physical therapy for lower
back strengthening and range of motion is usually started following the first follow-up visit, four
to six weeks after surgery.

DR.KANAK SONI
7
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE