Neurosurgery and Emergency

What do neurosurgeons do?

If one is unlucky enough to develop a condition affecting the brain or spinal cord, there are only a small number of medical practitioners capable of operating. Neurosurgeons, as the name suggests, undertake operations on the nervous system: a challenging and sometimes dangerous procedure requiring great precision. Neurosurgery is the diagnosis, assessment and surgical management of disorders of the nervous system. Within it, there are many sub-specialties, such as:

  • Functional neurosurgery – the management of a wide range of problems such as epilepsy, spasticity and movement disorders
  • Paediatric neurosurgery – the diagnosis, evaluation and treatment of disorders of the nervous system in children
  • Neuro-oncology – the management of brain and spinal tumours
  • Neurovascular surgery – dealing with complex aneurysms and abnormal or narrowed blood vessels
The risks of neurosurgery

Neurosurgeons must be cautious not to affect ‘eloquent cortex’ — sensitive areas of the brain that directly control function such as language and vision. The brain also has a network of blood vessels, any of which, if accidentally ruptured, could potentially cause catastrophic haemorrhage. The spinal cord, likewise, is made of delicate nervous fibres and tissue that, if damaged, can leave a patient temporarily or permanently paralysed (although Evoked Potential monitoring can be used to warn the surgeon if they are about to cause paralysis). It is no surprise, therefore, that neurosurgery is an elite sector of the medical profession consisting of less than one percent of all physicians and requiring seven years of surgical training.

Decision-making

Neurosurgery, however, extends further than just operating. Neurosurgeons must decide, with each patient they see, whether it is the best decision to operate or not, weighing up both the risks of the operation and the risk of the patient's disorder to their health by not operating. An elderly man, for example, may have an aneurysm with an eight per cent chance of bursting each year and a twenty per cent chance of bursting during operation. These decisions, some neurosurgeons say, are more difficult than the operations themselves. In some cases, such as with brain tumours, it can be difficult to predict how risky the operation is until it is underway. Tumours can be hard, soft, dry, or pour with blood. Some are easy to remove, while others are stuck to the brain, unknown to the surgeon until operating.

Types of brain surgery

If the surgeon decides to operate, there are a few routes that the operation can take, depending on the nature of the disorder.

Craniotomy

The first procedure, craniotomy, involves making an incision into the scalp near the affected area of the brain and creating a hole (known as a bone flap) in the skull. This method of brain surgery is done to remove tumours, clip aneurysms, drain blood or fluid from an infection and remove abnormal brain tissue. A scalpel is used to dig into the brain, and a sucker to clear away blood. Computer navigation shows the position of the surgeon’s instruments within the patient’s brain. Most tumours are removed by gradual debulking, collapsing the tumour in on itself. In the case of an aneurysm, a device called an applicator is used to place a metal clip across the aneurysm, sealing it off from the artery to prevent blood flowing into it.

Neuroendoscopy

Similarly, a minimally invasive process known as neuroendoscopy can be performed in order to remove tumours. This involves making an incision the size of a small coin in the skull and using an endoscope to view the surgeon’s instruments within the brain.

Endonasal endoscopic surgery

For tumours of the pituitary gland, the base of the skull or the bottom part of the brain, endonasal endoscopic surgery can be performed. This is a minimally invasive process, allowing the surgeon to access parts of the brain through the nose without making an incision. A telescopic device known as an endoscope, fitted with lights and a camera, is used so that the surgeon can see where they are operating.

Advances in neurosurgery

Neurosurgery is always changing. Advances are primarily in minimally invasive surgery such as minimally invasive spine surgery and minimally invasive cranial surgery, allowing neurosurgeons to do complex surgery through very small openings.

By Benjamin Jeyasingham


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