Neurosurgery

Neurosurgery (or neurological surgery) is the medical specialty concerned with the prevention, diagnosis, treatment, and
rehabilitation of disorders which affect any portion of the nervous system including the brain, spinal cord, peripheral nerves,
and extra-cranial cerebrovascular system.[1]

Main divisions of neurosurgery[edit]

General neurosurgery involves most neurosurgical conditions including neuro-trauma and other neuro-emergencies such as
intracranial hemorrhage. Most level 1 hospitals have this kind of practice.
Specialized branches have developed to cater to special and difficult conditions. These specialized branches co-exist with
general neurosurgery in more sophisticated hospitals. To practice advanced specialization within neurosurgery, additional
higher fellowship training of one to two years is expected from the neurosurgeon. Some of these divisions of neurosurgery
are:

1. vascular neurosurgery and endovascular neurosurgery

The term endovascular means inside a blood vessel. Endovascular neurosurgery uses tools that pass through the
blood vessels to diagnose and treat diseases and conditions rather than using open surgery. The surgeon often uses
radiology images to help him or her to see the part of the body involved in the procedure.
Endovascular neurosurgical procedures include:

Thrombolytic therapy. This procedure uses clot-busting medication to dissolve a clot in a blood vessel in the
brain or elsewhere in the body.

Endovascular coiling. A surgeon inserts a very thin metal wire that forms a coil inside a brain aneurysm to block
blood flow. A brain aneurysm is a bulging, weakened area in the wall of an artery in the brain, resulting in an abnormal
widening or ballooning. Because the artery wall has a weakened spot, the aneurysm is at risk for bursting if blood flow
isnt blocked. Aneurysm can be treated by coiling or clipping it closed.

Minimally invasive spine surgery. This procedure is used to treat spinal disorders, such as fractures, tumors,
compressed nerves, and other conditions that put pressure on the spinal cord.

Cerebral angiography. This is a radiology procedure that looks at how blood is flowing in the brain.
Carotid artery angioplasty/stenting. This procedure uses a small balloon and/or a tiny metal scaffold called
a stent to open a narrowed carotid artery. The carotid arteries supply blood to the brain.

2. stereotactic neurosurgery, functional neurosurgery, and epilepsy surgery

Stereotactic surgery or stereotaxy (not to be confused with the virtuality concept of stereotaxy) is a minimally
invasive form of surgicalintervention which makes use of a three-dimensional coordinate system to locate small
targets inside the body and to perform on them some action such as ablation, biopsy, lesion, injection, stimulation,
implantation, radiosurgery (SRS), etc.
In theory, any organ system inside the body can be subjected to stereotactic surgery. However, difficulties in
setting up a reliable frame of reference (such as bone landmarks which bear a constant spatial relation to soft
tissues) mean that its applications have been, traditionally and until recently, limited to brain surgery. Besides
the brain, biopsy and surgery of the breast are done routinely to locate, sample (biopsy) and remove tissue. Plain
X-ray images (radiographic mammography), computed tomography, and magnetic resonance imaging can be used
to guide the procedure.

Another accepted form of "stereotactic" is "stereotaxic". The word roots are stereo-, a prefix derived from
the Greek word (stereos, "solid"), and -taxis (a suffix of New Latin and ISV, derived from Greek taxis,
"arrangement", "order", from tassein, "to arrange").

The Functional and Stereotactic Neurosurgery Center provides comprehensive evaluation and care for patients with
movement disorders, epilepsy, obsessive-compulsive disorder, and certain chronic pain syndromes. The center works
closely with the Partners Parkinson and Movement Disorders Treatment Center, and the MGH Epilepsy Unit.

Currently available treatments for movement disorders include microelectrode-guided deep brain stimulation of the
subthalamic nucleus, the globus pallidus or the thalamus as appropriate. The Epilepsy Surgery Unit at MGH offers a full
range of treatments for medically refractory seizure disorders in children and adults. Procedures to treat chronic pain
disorders such as trigeminal neuralgia include microvascular decompression, radio-frequency lesions, and deep-brain or
motor-cortex stimulation.
Surgery for Intractable Tremors

Surgery for Parkinson's Disease

Epilepsy Surgery for Tumors, Vascular Malformations, Trauma and Cerebrovascular Disease

Psychosurgery

Occult Vascular Malformations and Seizures

Functional MRI: A Neurosurgeons Perspective - ppt version - or html version

3. oncological neurosurgery (also called neurosurgical oncology; includes pediatric oncological

neurosurgery)
The Neurosurgical Oncology Center of Excellence features two primary divisions: Adult Neurosurgical Oncology and
Pediatric Neurosurgical Oncology.
Our program includes leading neurosurgeons, neuro-oncologists, radiation oncologists, neuropathologists, researchers,
rehabilitation experts, nurses and support staff. This multidisciplinary team delivers compassionate and sophisticated care
and uses the latest technologies to treat patients with tumors of the brain, spine and skull base.
Adult Neurosurgical Oncology Program
UPMCs Adult Neurosurgical Oncology division is internationally recognized as a leader in the treatment of patients - with
both cancerous and benign tumors of the brain and spine. Our experts are skilled in the full array of treatments and
technologies, and have been at the forefront in developing and advancing minimally invasive surgical techniques,
stereotactic radiosurgery (SRS), and traditional surgical approaches.
Patients with both primary and metastatic brain and spine tumors are seen at Hillman Cancer Center in our Brain Cancer
Specialty Care Center.

The center brings together specialists from neuro-oncology, neurosurgery, and radiation oncology to streamline patient care.
The group holds a weekly tumor board to review patient cases and formulate care management recommendations.
Similarly, there is a weekly skull base tumor board with involvement from adult and pediatric neurosurgery,
otolaryngology/head and neck cancer specialists, neuro-ophthalmology, and radiology.
Minimally Invasive and Traditional Techniques
UPMC experts have experience with a comprehensive array of both traditional and minimally invasive neurosurgical
procedures. Some of our highly specialized techniques include:
Neuroendoport Surgery
Neuroendoport surgery is a minimally invasive technique for removing brain tumors using an endoscope through a small
clear tube, called the Neuroendoport. This tube, or port, allows doctors to access deep-seated tumors through a smaller
opening in the lining of the brain than would be used in traditional brain surgery.
Program Highlights:

Suitable for tumors within the substance of the brain (the parenchyma), tumors within the fluid-filled spaces
of the brain (the ventricles), metastases from cancer, and gliomas.

Neuroendoport surgery offers patients a number of benefits that may improve their quality of life, including
minimal scarring, fewer side effects and complications, and faster recovery times than with traditional
surgery.

Awake Craniotomy
During an awake craniotomy, our neurosurgeons use sophisticated brain mapping technology to locate motor and speech
regions prior to tumor removal, so they can avoid these sensitive areas during surgery. The patient is kept awake throughout
the procedure so the neurosurgical team can map motor and speech areas prior to the tumor removal. This approach allows
neurosurgeons to remove a greater portion of the tumor, since they are able to monitor critical functions during the operation,
while minimizing damage to healthy tissue.
Endoscopic Endonasal Approach (EEA)
EEA is an innovative surgical technique used to remove benign and cancerous brain tumors that are located at the skull base.
EEA uses the nose and sinuses as natural corridors to access tumors and lesions in critical areas at the base of the skull or top
of the spine and allows surgeons to treat many hard-to-reach tumors, even those once considered "inoperable," without
disturbing the face or skull.
Advanced Imaging Modalities
Our neurosurgeons use sophisticated high-definition fiber tracking (HDFT) and magnetoencephalography (MEG) to view
the detailed wiring and function of the patients brain to plan the most effective and least damaging pathways to remove
brain tumors. '
Stereotactic Radiosurgery
For more than two decades, UPMC has been providing state-of-the-art stereotactic radiosurgery (SRS) treatment for tumors
of the brain and spine. Our neurosurgeons and radiation oncologists are recognized worldwide for our experience with the
Gamma Knife and CyberKnife radiation delivery platforms for brain lesions. We also offer treatment using the
TrueBeam STx and Trilogy platforms for spine lesions.

CyberKnife M6
Utilizing the latest technology, the CyberKnife M6 is an image-guided stereotactic radiosurgery delivery system that does
not require the use of a head frame for cranial radiosurgery. It has the ability to deliver fractionated radiosurgical treatments
for larger lesions, and also provide radiosurgery for spinal lesions.
Program Highlights:

Consistently ranked as a top treatment center in the United States and internationally

Performed more than 7,933 procedures

Gamma Knife
Gamma Knife radiosurgery is a stereotactic procedure that uses hundreds of highly focused radiation beams to target tumors
and lesions within the brain.
With no surgical incision required, Gamma Knife radiosurgery is especially useful when conventional surgical procedures
pose a high risk for patients.
Program Highlights:

Nations leading provider of Gamma Knife procedures

Installed the first North American Gamma Knife in 1987

Performed more than 12,500 procedures

Trilogy
Trilogy is an advanced linear accelerator and radiosurgery treatment system that allows clinicians to target tumors in difficult
or hard to reach areas. Using image-guided technology, clinicians are able to monitor the movement of the tumor throughout
the treatment cycle, delivering high doses of highly accurate targeted radiation beams directly the tumor, helping to spare
healthy surrounding tissue.
TrueBeam STx with Novalis
TrueBeam is one of the most advanced linear accelerators and radiosurgery treatment systems that allow clinicians to target
tumors in difficult or hard to reach areas. Utilizing sophisticated imaging technology called ExacTrac to capture images of
the tumor, the TrueBeam platform accounts for natural tumor movement using the captured images to confirm that the
radiation beams are always targeting the tumor.
Research and Clinical Trials
UPMC Adult Neurosurgical Oncology, in partnership with the University of Pittsburgh Cancer Institute, is renowned for
adult brain and spinal tumor research and clinical trials.
Our program is actively investigating:

Glioma and glioblastoma immunotherapy

Pharmacological and gene-therapeutic strategies

Use of oncolytic viruses

New radiation and imaging modalities

Our team is also actively studying other neurological complications of systemic cancer and its treatment, including stroke,
neurobehavioral disorders, neurological complications of chemotherapy and/or radiation therapy, and paraneoplastic
neurological syndromes, in collaboration with medical neuro-oncologists Frank Lieberman, MD, and Jan Drappatz, MD.
Pediatric Neurosurgical Oncology
UPMC Pediatric Neurosurgical Oncology is a leading research program funded in part by the National Institutes of Health,
including the National Institute for Neurological Disorders and Stroke and the National Cancer Institute.
Our program has a collaborative relationship with the University of Pittsburgh Cancer Institute, the regions only National
Cancer Institute-designated Comprehensive Cancer Center.
Current clinical trials are investigating:

Glioma vaccines

Ependymoma vaccines

Interferon-based treatments

Chemotherapy-based treatments

4. skull base surgery

kull base surgery may be done to remove both benign and cancerous growths, and abnormalities on the underside of the
brain, the skull base, or the top few vertebrae of the spinal column. Because this is such a difficult area to see and reach,
skull base surgery may be done by a minimally invasive endoscopic procedure in which instruments are inserted through the
natural openings in the skullthe nose or mouthor by making a small hole just above the eyebrow. This type of surgery
requires a team of specialists that may include ENT (ear, nose, and throat) surgeons, neurosurgeons, and radiologists.
Before endoscopic skull base surgery was developed, the only way to remove growths in this area of the body was by
making an opening in the skull. Under some circumstances, this type of surgery may be necessary.
Facts about skull base surgery
These are some of the growths and conditions that may be treated by skull base surgery:

Cysts that develop from birth.

Growths caused by infections.

Pituitary tumors. The pituitary gland sits behind the nose and eyes.

Meningiomas. These tumors are often benign and grow from the meninges, the tissue that covers the brain and lies
between the brain and skull.

Chordomas. This is a slow-growing bone tumor most often found at the base of the skull.

Trigeminal neuralgia, an intense pain on one side of the face.

Craniopharyngiomas, growths that occur near the pituitary gland.

Craniosynostosis, a condition in which the bones of the skull of an infant close too early, causing problems with
brain growth and the shape of the skull.

Cerebrospinal fluid fistulas.

Cerebral aneurysm, a weak, often bulging area in a blood vessel in the brain.

Arteriovenous malformations. These are arteries and veins that are abnormally connected to one another.

Types of skull base surgery

Skull base surgery can be done in two main ways. Although the preferred method is endoscopic, open surgery is also an
option, depending on the type of growth that needs to be removed and its location:

Endoscopic or minimally-invasive skull base surgery. This type of surgery usually does not require a large
incision. An ENT surgeon may make a small opening inside the nose to allow a neurosurgeon to remove a growth
through a thin lighted tube called an endoscope. An MRI is a type of picture taken of the skull base using magnets and a
computer and may be done by a radiology specialist while the surgical specialists are operating to help them make sure
all of the growth has been removed.

Traditional or open skull base surgery. This type of surgery may require incisions in the facial area and in the
skull. Parts of bone may need to be removed so that the growth can be reached and removed. An operating room
microscope is often used for this type of surgery.

5. spinal neurosurgery
Diskectomy -- surgery to remove all or part of your disk
Foraminotomy -- surgery to widen the opening in your back where nerve roots leave your spinal column
Laminectomy -- surgery to remove the lamina, two small bones that make up a vertebra, or bone spurs in your
back, to take pressure off your spinal nerves or spinal column
Spinal fusion -- the fusing of two bones together in your back to correct problems in your spine

6. peripheral nerve surgery

Advanced Treatment of Peripheral Nerve Issues
As one of the only centers in the northeastern United States specializing in surgical treatment of peripheral nervous system
disorders, the Peripheral Nerve Surgery Service at Massachusetts General Hospital offers advanced treatment options to
restore sensation, movement and motor skills.
Our service treats all peripheral nerve issues, including:

Traumatic peripheral nerve injuries including brachial plexus injury, major peripheral nerve injury and
iatrogenic injury

Tumors of the peripheral nerve including schwannomas, neurofibroma and sarcoma

Carpal tunnel syndrome and other compressive neuropathies

Restoring Injured Nerves
Although peripheral nerves are able to heal themselves after minor injuries, serious injuries may require surgery.
Our surgeons specialize in treating nerve injuries throughout the body. We have extensive experience treating injuries to the
brachial plexus, a network of nerves near the neck and shoulder that control the shoulder, arm and hand. We also offer
specialized treatments to help restore nerves damaged during previous surgeries or other medical procedures (iatrogenic
injuries).

Our surgeons are at the forefront of developing new techniques for reconstructing peripheral nerves severed or damaged by
injury or tumor. One highly sophisticated procedure transfers healthy nerves from elsewhere in the body to a damaged area
to "reanimate" body parts and restore normal functionality and feeling.
Removing Nerve Tumors
Nerve tumors sit directly on the nerve so surgery to remove them can be especially delicate. It is very important to avoid
damage the nerve itself. The Peripheral Nerve Surgery Service's multidisciplinary team has extensive experience removing
all types of peripheral nerve tumors:

Neurofibromas caused by neurofibromatosis, a genetic disorder

Schwanommas, also known as nerve sheath tumors

Malignant peripheral nerve sheath tumors (sarcomas) that develop in the cells surrounding peripheral nerves

Treating Carpal Tunnel Syndrome

Our surgeons treat carpal tunnel syndrome using either open surgery, making an incision in the palm of your hand, to relieve
the pressure that is causing pain, tingling or numbness.

pediatric neurosurgery (for cancer, seizures, bleeding, stroke, cognitive disorders or congenital neurological
disorders)

7. neuropsychiatric surgery (neurosurgery for the treatment of adult or pediatric mental illnesses)
8. geriatric neurosurgery (for the treatment of neurological disorders and dementias and mental impairments due to
age, but not due to a stroke, seizure, tumor, concussion, or neurovascular cause- namely, Parkinsonism,
Alzheimer's, multiple sclerosis, and similar disorders)
Neurosurgery methods[edit]

Neuroradiology plays a key role not only in diagnosis but also in the operative phase of neurosurgery.
Neuroradiology methods are used in modern neurosurgery diagnosis and treatment. They include computer assisted imaging
computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography
(PET), magnetoencephalography (MEG), and stereotactic radiosurgery. Some neurosurgery procedures involve the use of
intra-operative MRI and functional MRI.
In conventional open surgery the neurosurgeon opens the skull, creating a large opening to access the brain. Techniques
involving smaller openings with the aid of microscopes and endoscopes are now being used as well. Methods that utilize

small craniotomies in conjunction with high-clarity microscopic visualization of neural tissue offer excellent results.
However, the open methods are still traditionally used in trauma or emergency situations. [10] Principles of Neurosurgery-Rengachari,
Ellenbogen [11] Neurotrauma and Critical Care of the Brain-Jallo, Loftus
,
.''
Microsurgery is utilized in many aspects of neurological surgery. Microvascular techniques are used in EC-IC bypass
surgery and in restoration carotid endarterectomy. The clipping of an aneurysm is performed under microscopic
vision. minimally-invasive spine surgery utilizes microscopes or endoscopes. Procedures such as microdiscectomy,
laminectomy, and artificial disc replacement rely on microsurgery.[5]
Using stereotaxy neurosurgeons can approach a minute target in the brain through a minimal opening. This is used in
functional neurosurgery where electrodes are implanted or gene therapy is instituted with high level of accuracy as in the
case of Parkinson's disease or Alzheimer's disease. Using the combination method of open and stereotactic surgery,
intraventricular hemorrhages can potentially be evacuated successfully.[6] Conventional surgery using image guidance
technologies is also becoming common and is referred to as surgical navigation, computer assisted surgery, navigated
surgery, stereotactic navigation. Similar to a car or mobile Global Positioning System (GPS), image guided surgery systems,
like Curve Image Guided Surgery and StealthStation, use cameras or electromagnetic fields to capture and relay the patients
anatomy and the surgeons precise movements in relation to the patient, to computer monitors in the operating room. These
sophisticated computerized systems are used before and during surgery to help orient the surgeon with three-dimensional
images of the patients anatomy including the tumor.
Minimally invasive endoscopic surgery is commonly utilized by neurosurgeons when appropriate. Techniques such
as endoscopic endonasal surgery are used in pituitary tumors,craniopharyngiomas, chordomas, and the repair of
cerebrospinal fluid leaks. Ventricular endoscopy is used in the treatment of intraventricular bleeds, hydrocephalus, colloid
cystand neurocysticercosis. Endonasal endoscopy is at times carried out with neurosurgeons and ENT surgeons working
together as a team.
Repair of craniofacial disorders and disturbance of cerebrospinal fluid circulation is done by neurosurgeons who also
occasionally team up with maxillofacial and plastic surgeons. Cranioplasty for craniosynostosis is performed by pediatric
neurosurgeons with or without plastic surgeons.
Neurosurgeons are involved in stereotactic radiosurgery along with radiation oncologists in tumor and AVM treatment.
Radiosurgical methods such as Gamma knife, Cyberknifeand Novalis Radiosurgery are used as well.[7]
Endovascular Neurosurgery utilize endovascular image guided procedures for the treatment of aneurysms, AVMs, carotid
stenosis, strokes, and spinal malformations, and vasospasms. Techniques such as angioplasty, stenting, clot retrieval,
embolization, and diagnostic angiography are endovascular procedures. [8]
A common procedure performed in neurosurgery is the placement of Ventriculo-Peritoneal Shunt (VP Shunt). In pediatric
practice this is often implemented in cases of congenitalhydrocephalus. The most common indication for this procedure in
adults is Normal Pressure Hydrocephalus (NPH).
Neurosurgery of the spine covers the cervical, thoracic and lumbar spine. Some indications for spine surgery include spinal
cord compression resulting from trauma, arthritis of the spinal discs, or spondylosis. In cervical cord compression, patients
may have difficulty with gait, balance issues, and/or numbness and tingling in the hands or feet.Spondylosis is the condition
of spinal disc degeneration and arthritis that may compress the spinal canal. This condition can often result in bone-spurring
and disc herniation. Power drills and special instruments are often used to correct any compression problems of the spinal
canal. Disc herniations of spinal vertebral discs are removed with special rongeurs. This procedure is known as a discectomy.
Generally once a disc is removed it is replaced by an implant which will create a bony fusion between vertebral bodies above
and below. Instead, a mobile disc could be implanted into the disc space to maintain mobility. This is commonly used in
cervical disc surgery. At times instead of disc removal a Laser discectomy could be used to decompress a nerve root. This
method is mainly used for lumbar discs. Laminectomy is the removal of the Lamina portion of the vertebrae of the spine in
order to make room for the compressed nerve tissue. Radiology assisted spine surgery uses minimally-invasive procedures.
They include the techniques ofvertebroplasty and kyphoplasty in which certain types of spinal fractures are managed.
[12] Principles of Neurosurgery- Rengachary, Ellenbogen
Potentially unstable spines will need spine fusions. At present these procedures include
complex instrumentation. Spine fusions could be performed as open surgery or as minimally invasive surgery. Anterior
cervical diskectomy and fusion is a common surgery that is performed for disc disease of cervical spine. [13] Core Techniques in Operative
Neurosurgery - Jandial, McCormick, Black
However, each method described above may not work in all patients. Therefore, careful selection

of patients for each procedure is important. It has to be noted that if there is prior permanent neural tissue damage spinal
surgery may not take away the symptoms.
Surgery for chronic pain is a sub branch of functional neurosurgery. Some of the techniques include implantation of deep
brain stimulators, spinal cord stimulators, peripheral stimulators and pain pumps. [14] Neurosurgical Operative Atlas, Philip A. Starr, Nicholas M. Barbaro,
Paul S. Larson

Surgery of the peripheral nervous system is also possible, and includes the very common procedures of carpal tunnel
decompression and peripheral nerve transposition. Numerous other types of nerve entrapment conditions and other problems
with the peripheral nervous system are treated as well.
Conditions[edit]
Other conditions treated by neurosurgeons include:

Meningitis and other central nervous system infections including abscesses

Spinal disc herniation

Cervical spinal stenosis and Lumbar spinal stenosis

Hydrocephalus

Head trauma (brain hemorrhages, skull fractures, etc.)

Spinal cord trauma

Traumatic injuries of peripheral nerves

Tumors of the spine, spinal cord and peripheral nerves

Intracerebral hemorrhage, such as subarachnoid hemorrhage, interdepartmental, and intracellular hemorrhages

Some forms of drug-resistant epilepsy

Some forms of movement disorders (advanced Parkinson's disease, chorea) this involves the use of specially
developed minimally invasive stereotactic techniques (functional, stereotactic neurosurgery) such as ablative
surgery and deep brain stimulation surgery

Intractable pain of cancer or trauma patients and cranial/peripheral nerve pain

Some forms of intractable psychiatric disorders

Vascular malformations (i.e., arteriovenous malformations, venous angiomas, cavernous angiomas, capillary
telangectasias) of the brain and spinal cord
Moyamoya disease