Neurosurgery is one surgical specialty that is highly
reliant on advanced technology as well as dedicated
facilities staffed by specially trained and qualified
technicians. What follows in this section is a review of some
of the types of dedicated facilities that one would expect in a hospital
with a significant interest in Neurological Surgery.
Part of the challenge for the Neurosurgeon to achieve the best
outcome possible for the patient is to identify, as accurately as
possible, the precise nature and anatomical configuration of the
pathological condition and its relationship to vital adjacent
structures(such as blood vessels, nerves, etc.) The advances
in the last several years in diagnostic and therapeutic technology
have resulted in far greater accuracy and improved outcomes for
Neuroimaging is the term
applied to techniques that allow us to inspect the Brain/Skull,
Spinal Cord & Nerve Roots/Spinal Column without making any
incisions. (NOTE: ALL OF THIS IMPORTANT INFORMATION IS REVIEWED ON
Figure 1A (Left): 3-D MRA (Angiogram). MRI technology combined
with sophisticated computer software permits a 3 dimensional
reconstruction of the Skull and blood supply to Brain.|
Figure 2B (Right): 3-D reconstruction image of a child with
premature closure of cranial sutures. This imagery is created
using CT technology and is useful in pre-operative surgical
planning for Skull Base Tumors as well as for Craniofacial
These advanced technologies incorporate Non-invasive as
well as Invasive methods. Among the Non-invasive
techniques Magnetic Resonance Imaging (MRI) and Computed Axial
Tomography (CAT or CT) are two of the most advanced neuroimaging
systems. MRI has the capacity to evaluate "soft" tissues (Brain
and Spinal Cord) in a superior manner while CT is superb for evaluating
Bone Anatomy. Each technique has overlapping capabilities. Both
of these technologies incorporate computer-driven capabilities that
permit the investigation of the blood supply (angiography) to the
Central Nervous System (CNS= Brain & Spinal Cord) as well as
some ability to examine the actual FUNCTIONING of the Brain.
The amalgamation of CT Scanning with Radioisotope methods (a technology
called Positron Emission Tomography/CT or "PET/CT").
Occasionally your surgeon will need information from all of these
technologies in order to completely evaluate the problem.
Figure 2: PET/CT Scan. This technology incorporates radioisotope
imagery combined with CT Scan to render images that are useful
in the evaluation of Cancer patients.|
There are several INVASIVE technologies that are used as well in
selected patients where the Non-invasive methods fail to give the level
of information deemed necessary. Neuroradiologists use Invasive
Arteriography to provide additional vital information about the
Blood Supply to the Brain & Spinal Cord and/or the Tumors
that affect them.
use this same avenue to treat Vascular CNS problems as
well as some Tumors. Myelography with Post-myelographic CT Scan
is another Invasive technique that can provide invaluable
information regarding certain Spine problems.
Figure 3A (Left): Cerebral Angiogram of a Right Posterior
Frontal Lobe Arteriovenous Malformation (AVM). The precise
anatomical configuration of the Blood Supply to and Venous
"Aneurysm" (Arrow) draining the AVM is provided by "Invasive"
Figure 4B (Right): Post-operative Angiogram of a successful
treated AVM. Microvascular surgical techniques were used to
remove this AVM. Two Aneurysm Clips were used to control large
arterial branches feeding the AVM. Two metallic "Hemoclips" were
used to control the large Venous "Aneurysm" (Arrow).
Figure 4A (Left): Cervical Spine MRI Scan of a patient with
advanced Degenerative Arthritis (Spondylosis) at multiple
levels. The MRI indicates a small area of Spinal Cord injury
(the faint white image in the substance of the Spinal Cord at
the C4, 5 level indicated by the Arrow). The MRI Scan is able
to give greater details of Spinal Cord and Brain anatomy than
Figure 4B (Right): Post-myelographic CT Scan (Same patient). The
anatomical detail of bone, bone spurs and calcified Posterior
Longitudinal Ligament is far greater on this study than on the
comparable view of the MRI Scan.
The Operating Room environment is no less dependent on advanced
technology. Whether it is the very latest in Image Guidance
(a type of Global Positioning System-GPS [see Figure 11B]
similar in concept to that used in modern day automobiles for
determining precise geographical location), intra-operative
real-time imaging (MRI/CT/Ultrasound/Fluoroscopy), high
level optical magnification systems (Operating
Microscopes/Neuroendoscopes) or powerful ultramodern
Ultrasonic Tumor Resection instruments, all these
advances make for improved technical results and improved quality of
Figures 5A (Left) & 5B (Right): Dr. Lazar is performing a
Minimally Invasive Microendoscopic Transsphenoidal removal of
a Pituitary Tumor. The image of the Surgeon's maneuvers is
transmitted to a Video Monitor from the Endoscope's camera
allowing Dr. Lazar & Neurosurgical Nurse Chris Thomson to
conduct the procedure through a tiny opening in the Skull Base.
(Endoscope provided by Aesculap, Inc.)|
Figure 6A (Left): Operative Photo of Neurosurgeons performing a
Minimally Invasive Microsurgical Lumbar (Spine) Laminotomy. They
are using a LEICA Neurosurgical Operating Microscope.|
Figure 6B (Right): Operative Photo, "close-up view" of the
Minimally Invasive (Medtronic-Sofamor-Danek, Inc.) tube
retractor and special slender drill.
Figure 8A (Left): MRI Scan (Coronal View) Right Anterior Skull
Base Meningioma (Arrows)|
Figure 8B (Right): Operative Photo of an Endoscopic (Assisted)
Image Guided (Arrow) Resection of this tumor through a "Keyhole"
Craniotomy fashioned through a small EYEBROW incision.
Neurosurgeons are now able to monitor critical neurological
functions during the performance of neurosurgical operations even with
the patient under anesthesia. Intraoperative Evoked Response
Monitoring employs electronic techniques to measure
special functions such as hearing, facial muscle control, vision, eye
muscle control, facial sensation, motor and sensory function in
extremities, etc. These techniques are critically important
for certain types of operations such as the removal of
Skull Base Tumors,
and Microvascular Decompression(MVD) procedures. These adjunct techniques help the Neurosurgeon to prevent
injury to critical functions controlled by vital nerves that are either
directly involved by a pathological process or are in contiguity with
the anatomical problem and are therefore at some risk to injury. An
example is the very delicate technique critical to the management of
removal when attempting to PRESERVE HEARING function as well as
FACIAL MUSCLE control.
Figure 9A (Left): MRI Scan (Gadolinium Enhanced) of a Left
Acoustic Schwannoma (Neuroma). The tumor occupies the Internal
Auditory Canal (IAC) where it arises from one of the Vestibular
Nerves and compresses and distorts the Cochlear Nerve (Hearing)
and Facial Nerve (Facial Movement).|
Figure 9B (Right): Operative Photo of the Acoustic Schwannoma
(Upper Arrow) arising from A Vestibular Nerve (Lower Arrow)
after the posterior bone wall of the IAC has been removed.
Figure 10A (Left): MRI Scan Post-operative resection of the
Acoustic Schwannoma seen in Figure 9A. The tumor has been
removed and the Cochlear and Facial Nerves have been preserved.
The nerves can be seen entering the IAC on the patient's Right
& Left sides.|
Figure 10B (Right): Operative Photo (same patient as 9B)
immediately after the Acoustic Schwannoma was removed in this
HEARING CONSERVATION operation. A small surgical dissector
(Arrow) is reaching over the lower lip of the IAC.
By way of example, we have a 30 year history of innovative
utilization of Intraoperative Evoked Response Monitoring, which
are electronic techniques that measure important neurological
functions during Neurosurgical Operations. We work with
specialists who have unique expertise with these techniques.
Among these monitoring professionals are those from BIOTRONIC
NEURAL MONITORING SPECIALISTS.
Critically ill Neurosurgical Pre and Post-operative patients are
best managed by specially trained and certified Neurosurgical Nurses
in a dedicated Neurosurgical Intensive care Unit. These units are
uniquely adapted to the needs of the Neurosurgical patient and are
usually supervised by a specialist in Critical Care Medicine.
Figure 11A (Left): Neuro ICU Photo. A Neurosurgical patient is
being evaluated by a specially qualified Neurosurgical ICU RN.|
Figure 11B (Right): Neuro ICU Photo. Neurosurgical ICU RN'S
work in teams in a state-of-the art dedicated Neurosurgical
Intensive care Unit. Their work is assisted by different types
of high level monitoring technology.
The length of stay for any particular patient depends
on several factors including the Medical and Neurological
condition of the patient, the type of surgery performed, the need for
"invasive" monitoring (such as arterial lines/intraventricular or lumbar
subarachnoid drains) and the requirement for "isolation" to protect the
patient and/or others.
Neurosurgical Nursing requires a very special skill level.
The American Association of Neuroscience Nurses
is an organization that certifies Neurosurgical Nurses
who possess special expertise to care for neurosurgical patients.
A hospital that encourages and employs these highly motivated and
exceptional nurses with this skill level demonstrates its commitment to
the neurosurgical program in that facility.
Once again by way of example, our Neurosurgical Nursing Staff
employs nurses skilled in the management of Neurosurgical
problems and certified by the American Association of
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This page last edited on 2/19