Neurosurgical Treatments Guide

A craniotomy involves temporary removal of a bone flap to access the brain. The flap is replaced at the end of the procedure. It is the fundamental cranial surgical technique adapted for almost every intracranial pathology.

• Patient positioning — Supine (frontal, parietal, temporal), prone (posterior fossa, occipital), lateral (temporal, subtemporal approaches). Head fixed in Mayfield clamp
• Scalp incision — Planned to maximise surgical exposure while preserving scalp vascularity and avoiding motor/sensory cortex. Temporalis muscle preserved where possible
• Bone flap — Multiple burr holes connected with craniotome (power drill). At BVH: manual Hudson brace + Gigli saw during craniotome restoration period. Target: <60 min total craniotomy time
• Dural opening — Cruciate or curvilinear incision; tack-up sutures prevent epidural haematoma. Microsurgical work through dural window under Zeiss microscope
• Intraoperative CT (BodyTom) — Portable full-body CT scanner wheeled into OT; confirms extent of resection or position of instruments mid-procedure. Unique capability at BVH
• Haemostasis — Bipolar cautery, haemostatic agents (Surgicel, Gelfoam), bone wax for diploic bleeding
• Closure — Watertight dural closure (primary or pericranial patch). Bone flap reattached with titanium plates. Scalp wound closure in layers

Common Craniotomy Approaches

Awake craniotomy allows real-time monitoring of neurological function during tumour resection near eloquent cortex — maximising safe tumour removal while preventing permanent neurological deficits.

• AAA protocol (Asleep-Awake-Asleep) — General anaesthesia for opening, patient awakened during resection, re-anaesthetised for closure. Propofol/dexmedetomidine target-controlled infusion
• Scalp block — Regional anaesthesia with bupivacaine; renders the skull opening pain-free while awake
• Cortical mapping — Direct electrical stimulation of cortical surface identifies motor, speech, and sensory areas; surgeon avoids positive-response areas during resection
• Patient tasks — Speaking (counting, naming objects), moving hand, following commands. Any change = surgeon stops at that margin
• BVH Practice — Awake craniotomy performed without formal IONM; clinical monitoring by dedicated anaesthesiologist + neurologist + surgeon team. Patients selected for cooperative temperament, good reserve, and accessible tumour location
• Outcomes — Increases extent of resection by ~20%; reduces permanent neurological deficits from 10% → 3% for eloquent area tumours

Stereotactic biopsy uses a 3D coordinate system to precisely target deep, small, or eloquent-area brain lesions for tissue diagnosis without open craniotomy.

• Frame-based (ARC + BodyTom at BVH) — Inomed ARC stereotactic frame fixed to skull; BodyTom CT acquired with fiducial markers; 3D coordinates calculated; 14G biopsy needle directed to target. Diagnostic yield: 90–95%
• Indications — Deep glioma (thalamus, basal ganglia); brainstem lesion; lymphoma (avoid resection, needs tissue); small enhancing lesion of unknown type; lesion in eloquent cortex
• Haemorrhage risk — 1–2% symptomatic; higher for vascular lesions. Pre-op MRA to exclude vascular target. Stop aspirin 7 days prior
• Rapid intraoperative pathology — Frozen section during biopsy confirms adequate tissue before frame removal

Removal of a large bone flap (NOT replaced) to allow brain expansion and relieve refractory raised ICP. Life-saving in malignant cerebral oedema.

• Malignant MCA infarction — ≥10cm frontoparieto-temporal craniectomy within 48h; DESTINY/HAMLET trials: mortality reduced 78% → 29%
• TBI — DECRA trial: bifrontal craniectomy for refractory ICP; RESCUEicp trial showed reduced mortality but increased severe disability; patient selection critical
• Duraplasty mandatory — Expansion dura with pericranial graft to fully accommodate swelling
• Cranioplasty — Bone flap stored (frozen or autoclaved) or titanium/PMMA custom implant placed at 8–12 weeks post-op once swelling resolved

• Posterior midline approach; tubular retractor or microscope-assisted 2cm incision
• Ipsilateral hemilaminotomy; dural retraction; herniated fragment removal
• Day 1–2 post-op mobilisation; 85–90% excellent/good outcomes at 1 year
• Hospital stay 1–2 days; driving restriction 2–4 weeks; heavy work 6–8 weeks
• At BVH: performed under Zeiss microscope with Moon Ray C-arm level confirmation

• Posterior approach; pedicle screw placement (4 screws minimum for single level); intervertebral PEEK cage + bone graft
• Fluoroscopy-guided pedicle screw insertion (Moon Ray C-arm at BVH); BodyTom CT post-instrumentation for verification
• Fusion rate: 90–95% at 12 months with autograft iliac crest bone or OP-1
• Hospital stay 4–7 days; lumbar brace 6–12 weeks; return to light work 6–8 weeks; heavy work 3–6 months

• Right-sided neck incision (left side for >C5 to avoid non-recurrent laryngeal nerve risk)
• Discectomy + PEEK cage or bone graft + anterior plate fixation (Synthes, DePuy systems)
• Intraoperative somatosensory EP monitoring recommended for myelopathy (where available)
• Patient discharged day 2–3; soft collar 4 weeks; bone fusion assessed at 3 months (CT scan)
• Adjacent segment disease (ASD) risk: ~3%/year; total disc replacement (TDR) reduces ASD risk

• Bilateral laminae removed exposing dura and nerve roots; ligamentum flavum excised
• Lumbar laminectomy: 85% satisfaction for neurogenic claudication at 5 years (SPORT 2008)
• Cervical laminoplasty (preferred over cervical laminectomy): opens canal while preserving posterior tension band; reduces post-laminectomy kyphosis
• Combined with lateral mass screws/rods if instability present (laminectomy + fusion)