Neurosurgery

NEUROSURGERY

By now, it would be clear that brain and nervous system are very important and delicate. Its functioning is also very different. Damage to different parts of this system causes different group of symptoms, which can be diagnosed with the help of medical examination as well as investigations like M.R.I, CT Scan, E.M.G., blood tests, lumbar puncture test etc. One can take the help of a neurophysician (or an experienced physician) for this. These doctors treat these diseases mainly with drug therapy. But in cases where these medicines cannot cure the disease or where there is a tumor in the brain or spinal cord, compression of the spinal cord, obstruction in the blood vessels or an accidental injury to the brain or spinal cord, surgery becomes imperative and the services of a neurosurgeon are required. Thus the surgery of the nervous system includes the surgery of the brain, skull, vertebrae, spinal cord, nerves and the blood vessels supplying blood to the brain.

As mentioned earlier all these organs are very delicate and so they are well protected by nature. Thus their surgery requires expertise, caution and alertness. Once damage occurs to these organs it can not be repaired. In some diseases there is no role of treatment by drugs. Like in some cases of brain tumor, there is no other option except an operation, whereas in some other cases, treatment has to be done by combination of both medicines and surgery.

Some of the diseases that require Surgery are listed below (There are other indications of surgery also) :

1. Injury of the brain or spinal cord (through accident or some other way).

·           lFracture of the skull or vertebrae,

·           Extradural or subdural hematoma (blood clot in the membranes of the brain),

·           Contusion of the brain or spinal cord, and

·           Secretion of CSF from the nostrils (CSF Rhinorrhea).

2. Infection of the brain :

·           Abscess,

·           A large TB tumor (Tuberculoma), and

·           Enlarged ventricles of the brain (Hydrocephalus).

3. Tumors of the brain or spinal cord :

·           Simple tumors like meningioma, neuroma, epidermoid, dermoid, tumor of the pituitary gland, and

·           Cancerous tumors like glioma, metastasis.

4. Abnormality or defects in the blood vessels :

·           Ballooning of the blood vessel (aneurysm)

·           Entanglement of the blood vessels (AN. Malformation)

·           Obstruction of the carotid artery due to Plaque formation (stenosis) and

·           Brain hemorrhage

5. Congenital defects :

·           Abnormal development of the skull (craniostenosis)

·           Hydrocephalus

·           Congenital tumor in the brain

·           Exposure of the spinal cord due to defects in the vertebrae (meningomyelocele), and

·           Craniovertebral anomaly.

6. Degenerative diseases of the nervous system :

·           Damage to the cervical or lumbar vertebrae (disc prolapse).

·           Lumbar canal stenosis (lack. of space between lumbar vertebrae).

7. Compression of the nerve, like carpel tunnel syndrome or nerve repair in case of the nerve trauma or nerve transplant surgery.

8. Functional neurosurgery for Parkinsonism, seizures etc.

Basic information :

It is very correct to say that before going in for any such surgery absolutely accurate diagnosis is a must. It is the duty of the neurosurgeon to inform the patients and his relatives how much the patient is likely to benefit from the surgery. Risk factors involved in the surgery if any, should also be explained. Though in our system the diagnosis and the decision of the need for surgery is mainly in the hands of the neurophysician, still it is necessary that before surgery, the neurophysician and the neurosurgeon discuss the case and if there is any doubt further investigations may be done to confirm the diagnosis, and surgery attempted only after full satisfaction regarding the diagnosis.

There are various methods of operation. Due to innovations in anesthesia, it can be said that there is no riskof life, even in the elaborate and complicated cases where there used to be a danger of life during surgery earlier. However, it is not incorrect to say that the brain surgery is comparatively more dangerous than other surgeries. The brain surgeries last approximately for 2 to 4 hours, but sometimes it may also go on for 16 to 20 hours or more. After obtaining a fitness report for surgery from the physician, usually the anesthetist examines the patient to ascertain whether the patient can withstand anesthesia. However, if there is a fear of impending death and not much time is available, neurosurgeons ignore everything and perform emergency surgery in spite of the risk for the sake of humanity. For example, when there is a brain hemorrhage in a road accident and emergency operation is inevitable.

These operations are also of different kinds. Surgery is done on the organs according to the disease. The planning of surgery depends upon the organ to be approached.

1.        If the aim is to reach only the outer membrane of the brain a hole called Burr-hole is drilled in the skull. This is done in subdural haematoma.

2.        The surgery where a part of the skull is cut open is called craniotomy and craniectomy. The brain can be approached through this opening directly.

3.        Opening the vertebra partially is called hemilaminectomy. If the vertebra is opened completely it is called laminectomy, etc...

4.        A minor surgery can be performed, by drilling a hole in the vertebrae.

As mentioned earlier, the brain and the spinal cord are very sensitive and delicate parts of the body are thereforewell protected. In order to reach these parts special instruments need to be developed. From well-equipped operation theatres to appropriate operation tables and proper lighting arrangements are essential requirements. Many operations can be done better with the help of microscopes. In order to drill holes swift drills, quality retractors and cautery (to stop bleeding) are vital.

Rapid acting ultrasonic systems are used to dissolve various tumors. During surgery also, monitoring by ultra sound can pinpoint the exact location of the defect deep inside the brain.

The stereotaxis instruments help in the biopsy and removal of tumors deep inside the brain and spinal cord.

The stereotaxis method has worked wonders in disease like Parkinsonism, Epilepsy etc. Without opening the skull, through a Burr-hole in the brain, using a needle and an electrode that penetrates deep into the brain, various very complicated diseases can be treated easily.

Microsurgery gives excellent results in epilepsy, especially in temporal lobe epilepsy. Similarly, the stereotaxis surgery can also be used for epilepsy. Vaga1 stimulation is also a similar minor procedure in which microelectrode and a stimulator can be used to stop the electrical storms taking place in the brain with the help of computerized methods. Apart from this, if necessary major surgeries like lobectomy, hemispherectomy, corpus callosotomyetc can be done. Various other surgeries like the transaction surgery where an impulse can be prevented from passing from one neuron to another can also be done.

Laser :

It seems that the utility of laser will increase day by day. Laser is the option of cauterizing the organs, which cannot be excised. The proton beam is also a similar method, with which AV malformation can be cauterized.

Radio Frequency Lesion generator :

This technique has been proved very effective in Trigeminal Neuralgia and other such painful diseases and also in movement disorders like Parkinson’s disease. As the name suggests, relief is obtained in the disease by using radio frequency current to block the functioning of a nerve or to cauterize it.

Gamma knife and Linear Accelerator :

This method is becoming increasingly popular to treat tumors or other such diseases without resorting to surgery. It is available only in few places in India as it is very expensive. But the risks of surgery can be avoided to a large extent. There is an element of failure in it too. This procedure is very popular for treating benign tumors like Meningioma, Schwannoma. Its expenses range from one to two lakhs.

Endoscopic Neurosurgery :

This is also a kind of minimally invasive surgery, which means that without opening the brain completely, the diseases located deep inside the brain especially tumors or aneurysms are tackled. This reduces the risk of surgery considerably but conducting the surgery from a very small opening with a microscope requires profound experience. This procedure is extensively used in the third or fourth ventricle tumor, aneurysm, etc. The surgery can be compared to the “beating heart surgery” of the heart.

Similarly, the surgery is done through operating microscope, removing only the damaged part intricately with expertise. This prevents the surrounding areas from getting damaged. This surgery is a time consuming procedure and requires patience and expertise, e.g. surgery for temporal lobe epilepsy.

Now-a-days our surgeons have gained expertise in conducting “Awake Craniotomy” in which no anesthesia is used and the patient is operated upon in a fully conscious state.

When the disease has spread beyond limit, surgeons just remove a part of it and feel the satisfaction of having helped the patient. When it is not possible to remove the entire tumor and there is a danger that the patient may die on the operation table or surgery may paralyze a major portion of the body, it makes sense for the doctor to excise some part of the tumor so that the patient can feel better and survive a little longer. This is known as palliative surgery.

Thus, there are three kinds of neurosurgeries :

1.        Resectivesurgery : as far as possible the damagedparts are excised.

2.        Palliative Surgery :In this, as mentioned earlier,partial removal of the tumor is done.

3.        Functional Neurosurgery :In ‘this there is not muchh of : excision involved but the nonfunctional parts are made to function in a different way. If necessary grafting of new cells or putting a stimulator in the brain, injecting chemicals or drugs or making newer paths through small openings can be done.

It is quite gratifying to inform that all these surgeries are now available in India and 90 % of these surgeries are also done in Ahmedabad. In major cities like Mumbai, Delhi all types of surgeries are available and the world-renowned doctors having the best of education and expertise are available to serve the patients, and that is the pride of our nation.

In majority of operations the risk factor is 2% to 4% at good centres, but if the patient is aged and suffers from diabetes or heart disease or blood pressure or the operation has had to be done in an emergency, the risk may go up to 10% to 20%. If the surgeon or the anesthetist feels that the risk is high, it is advisable to avoid surgery and treat the patient with medicines only. If the relatives of the patient insist on taking a chance, the surgeon can perform surgery on consent. Like in brain attack, if there is hemorrhage with a lot of swelling and if the prognosis is very bad, the skull can be opened so that the brain can swell outside or attempts are made to suck out the hemorrhage, so the chances of saving the patient’s life compared to certain death can be calculated as S to 25%. If the operation is successful, eventually the patient is given discharge. Usually, the patient can go home in six to nine days. However, in risky surgeries it may take more time to give a discharge. After being discharged, special attention is given to the fact that the patient becomes ambulatory as soon as possible.

Physiotherapy is started during hospitalization itself and is continued even after the patient goes home till he gets completely cured.

After the surgery, the follow up by neurosurgeon and neurophysician are again required for the rest of the treatment. Many patients can be completely cured while some get relief by Surgery. In some cases, after the surgery also, drugs have to be continued for a short or long period of time. Before surgery, as MRI and CT Scan are done to confirm the diagnosis, after the surgery also in order to ascertain the result, in some cases (specially in the cases of tumor) post-operative CT Scan or MRI is essential. In all these procedures the patient and the relatives find themselves confused. They are also plagued by financial and social problems. Therefore, the best option is to discuss all the aspects of the surgery frankly before and after the surgery and the doctor should also give a clear picture right from the beginning. This difficult mission can be accomplished with mutual trust, love and co-operation.

Thus, the field of neurosurgery is not just limited to the neurosurgeons. It requires the teamwork of the neurophysician, the neurosurgeon, the physiotherapist, the occupational therapist and the physician. This alone can help in comprehensive and definite treatment of the patient.

It should be realized that the expenditure in each case differs according to the case The kind of disease, severity, necessity of an emergency surgery, experience of the surgeon, the place where the surgery is done, how well equipped is the hospital, the risk of anesthesia (like in the aged patients as well in diabetic and heart patients the risk is more) and many other such factors determine the cost. In foreign countries most of the expenses are being borne by the insurance agencies, so the patient or the doctors do not have to waste time and energy on these matters.

We hope that our society also awakens in this matter.