Neurosurgery

[JJR512]

Do neurosurgeons operate on actual brain matter, or does neurosurgery consist only of vascular surgery within the brain?

 

[SanDiegoEmt7]

googlefu

Google:

Conditions treated by neurosurgeons include:

* Chiari Malformations
* Spinal disc herniation
* Spinal stenosis
* Hydrocephalus
* Head trauma (brain hemorrhages, skull fractures, etc.)
* Spinal cord trauma
* Traumatic injuries of peripheral nerves
* Brain tumors
* Infections and infestations
* Tumours of the spine, spinal cord and peripheral nerves
* Cerebral aneurysms
* Stroke, including hemorrhagic stroke and stroke
* Intracerebral hemorrhage, such as subarachnoid hemorrhage, intraparenchymal, and intraventricular 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
* Malformations of the nervous system
* Carotid artery stenosis
* Vascular malformations (i.e., arteriovenous malformations, venous angiomas, cavernous angiomas, capillary telangectasias) of the brain and spinal cord
* Peripheral neuropathies such as carpal tunnel syndrome and ulnar neuropathy
* Moyamoya disease
* Congenital malformations of the nervous system, including spina bifida and craniosynostosis

 

[JJR512]

This is part of why I don't like Google and don't like looking up definitions, and try to get answers from real people. I could have looked that up myself and I would still be as clueless as I am now that someone else has done it for me.

But I suspect that my question might not clearly indicate what it is I wish to know. So I will elaborate.

I don't want to learn about all the things that neurosurgeons can do. I don't care about anything they can do outside of the brain itself, including the spinal cord, the skull, etc. I specifically don't care about what they can do with vascular structures inside the brain. What I want to know is whether or not there is actually any surgery that can be performed on brain tissue.

What prompted me to ponder this is a show on Discovery Health I was watching, one of the trauma shows. Some guy had been shot through the head. Now I know a neurosurgeon can take care of any bleeding going on in there, but how much capability, if any, do they have to repair damage to brain matter itself?

 

[Seaglass]

Do neurosurgeons operate on actual brain matter, or does neurosurgery consist only of vascular surgery within the brain?

Yep, they do cut or remove actual brain matter--look up corpus callosotomy for a well-known example. They can also implant things like electrodes directly into the brain. Vascular procedures are pretty important, too.

Fun fact of the day: neurosurgery is often performed on awake patients.

What prompted me to ponder this is a show on Discovery Health I was watching, one of the trauma shows. Some guy had been shot through the head. Now I know a neurosurgeon can take care of any bleeding going on in there, but how much capability, if any, do they have to repair damage to brain matter itself?

To the best of my knowledge, not much. Researchers still don't know a lot about how the brain heals--in fact, it's only relatively recently that they realized it does have some healing capacity, both through creating new neurons and rerouting capabilities.

 

[JJR512]

Yeah, the brain itself is incapable of feeling pain, so if it's not necessary to put the patient to sleep, it's generally preferred not to, right?

And thanks, I'll look that up, now that I know something to look for.

 

[SanDiegoEmt7]

Sorry bout that

I took the easy route, sorry bout that.

Yup they do all sorts of procedures with actual brain matter, the spine, and also with the vascular system in the brain.

After medical school, a doctor will do a neurosurgery residency where they will learn all procedures and techniques of their trade. They also conduct research in their field.

AFTER ALL THAT (6-7 years residency, 4 years med school) they then have the option to specialize further. This is called a fellowship. Neurosurgeons can specialize in vascular neurosurgery and other specialties involving "the matter".

 

[SanDiegoEmt7]

Yeah, the brain itself is incapable of feeling pain, so if it's not necessary to put the patient to sleep, it's generally preferred not to, right?

And thanks, I'll look that up, now that I know something to look for.

It depends on the procedure. Sometimes they will only provide a local anesthetic, but generally I believe if they need you awake for some part of the procedure they will "wake you up" during the middle of it, even then you will be heavily sedated. Most people would not want to be awake while someone cut through their skull.

 

[JJR512]

So I just looked that up, corpus callosotomy, and that's interesting.

What about repairing, in the sense of having to put things back together again? Let's suppose someone is stabbed in the head, and there's a clean cut (not clean as in antiseptic, but clean as in not jagged) in the brain matter. What would be done in this situation? If it was skin, it would just be stitched up and left to heal, but I'm guessing that brain matter doesn't ever get stitched up. But I don't know, so I'm asking. Does the brain heal itself, as skin would, over time? Or does the brain remain sliced forever? (Assuming the injury was survived.)

 

[Seaglass]

Yeah, the brain itself is incapable of feeling pain, so if it's not necessary to put the patient to sleep, it's generally preferred not to, right?

And thanks, I'll look that up, now that I know something to look for.

More or less. It's also because you want to keep an eye on their mental status as you go, especially if you're working with electrical stimulation. The level of sedation varies really widely by patient and procedure. Even in "fully awake" surgeries, though, patients are anesthetized for the parts where they're cutting through the skull.

If you're curious about the general topic, I recommend starting by reading up on basic neuro--the subject gets very complicated very quickly. I'm not aware of any really good websites, and searching isn't as helpful as it could be. Message me sometime if you want me to find the names and titles of some old textbooks.

 

[Aidey]

They can't reattach pieces of the brain that are removed, and there isn't really anything like stitches for brain tissue, so I guess the answer to your question is no.

If there is some sort of penetrating trauma to the tissue the treatment is probably going to depend a lot on where it is, how deep it is etc.

 

[mikie]

DeWalt, anyone?

Prefrontal Lobotomies? :blink:

 

[Seaglass]

What about repairing, in the sense of having to put things back together again? Let's suppose someone is stabbed in the head, and there's a clean cut (not clean as in antiseptic, but clean as in not jagged) in the brain matter. What would be done in this situation? If it was skin, it would just be stitched up and left to heal, but I'm guessing that brain matter doesn't ever get stitched up. But I don't know, so I'm asking. Does the brain heal itself, as skin would, over time? Or does the brain remain sliced forever? (Assuming the injury was survived.)

Nope, no stitching brain matter back together--you're likely to cause even more damage if you try. The brain will sometimes heal to a certain extent, but you can't count on it, and it's not likely to recover much. How to make that happen is still largely unknown. Rerouting of functions is somewhat more likely, but also still very poorly understood. Read up on neuroplasticity for that.

Massive brain injuries are indeed survivable--in fact, one neurosurgeon at a conference I got to attend quoted a ~60% survival rate for penetrating trauma to the brain, if the patient got to the operating table alive. Of course, 'survival' doesn't mean much in terms of recovery of function, and he never discussed final outcomes. The most famous case here is Phineas Gage.

Neurosurgery has advanced quite a bit from where it started (which was with the Mayans and ancient Egyptians, if I remember right... even with primitive methods, they had some remarkably good outcomes), and made some enormous leaps, like stereotaxy, in recent history. But the knowledge to back it up has lagged a bit--we don't always know exactly why or how a particular procedure works, only that it does. Or what something in the brain is doing, exactly... look up the hippocampal theta rhythm for a good example of that. And we don't always know exactly what went wrong, when something does. So the field is still in the position of getting a lot of its information from animal studies, injuries, and surgical aftereffects. For instance, neuroscientists learned a lot about the role of certain structures in memory from poor HM... and expect to learn much more, now that his brain is being dissected. In short, the field has a very long way to go.

By the way... if you really look into it, you'll start seeing why the idea of neurosurgery really freaks people out. Lobotomies have gotten a bad name because they've often been misused--look up Howard Dully or Rosemary Kennedy.

 

[JJR512]

Oh, I definitely know that lobotomies do serve a valid purpose. They're not (or at least, aren't anymore) the gross hack & scoop affair that most people seem to imagine. I believe that they're fairly rare today, with doctors looking towards medications or other treatments as preferred over removing brain.

My father, who was in the Air Force during Viet Nam, once told me about a friend of his who got shot in the head. The bullet went clean through, I think one of the holes was above one eye, and I forget where the other hole was. The only consequence was that he had a great deal of trouble with math. Other than that, you would never know anything had happened to him.

 

[zmedic]

By rare you mean are never done. There is no medical indication for lobotomy and you'd be sued for doing one.

 

[Seaglass]

By rare you mean are never done. There is no medical indication for lobotomy and you'd be sued for doing one.

Depends on what you mean by lobotomy. If you mean cutting or removing stuff, not correct. The term's not often used anymore, but you still hear it occasionally, like with this study. The most usual indication is otherwise intractable epilepsy.

If you mean lobotomy as in randomly cutting things until the patient becomes incoherent, then yeah... not so cool anymore.

 

[VentMedic]

Massive brain injuries are indeed survivable--in fact, one neurosurgeon at a conference I got to attend quoted a ~60% survival rate for penetrating trauma to the brain, if the patient got to the operating table alive. Of course, 'survival' doesn't mean much in terms of recovery of function, and he never discussed final outcomes. The most famous case here is Phineas Gage.

Which is why no matter how "obvious" a head trauma might seem to you as dead, you should always check for vital signs and confirm death. Anybody remember the San Antonio incident where they left they young girl at scene as dead? There have been numerous such incidents in EMS where people have been wrongly pronounced dead.

Here's another one that happened yesterday with a GSW to the face:
http://www.emsresponder.com/article/article.jsp?id=11396&siteSection=1

I have seen many TBIs come in to the ED to where at first glance I thought, "no way". A few months later the may be discharged from the hospital with only a few deficits.

Neurosurgeons have an extensive scope of practice although many have limited themselves due to malpractice. However, if they work at an accredited trauma and/or stroke center, they must be able to perform whatever is expected of them. This can be anything from initiating the ventricular drain in the ED to removing the necrotic tissue or clots to finding the pathways that may cause seizures. EEG technologists are often present in the OR for many of these procedures. The neurosurgeon will also be the one to surgically stabilize a spinal cord injury.

A neurologist may be the one that consults for a neurosurgeon and/or manages the patient pre and post surgery. Neurologist don't do the surgery. It is similar to a cardiologist and cardiothoracic surgeon.

The frontal lobotomy was done for impulse or behavior control. Those who sustain an injury there will be more subdued with considerable personality changes as well as some other deficits.

We do still utilize Electroconvulsive therapy(ECT), also known as electroshock, to treat disorders such as depression.

 

[Seaglass]

Which is why no matter how "obvious" a head trauma might seem to you as dead, you should always check for vital signs and confirm death. Anybody remember the San Antonio incident where they left they young girl at scene as dead? There have been numerous such incidents in EMS where people have been wrongly pronounced dead.

One of the exercises the same doctor had us all do was put pictures of GSWs to the head and have us guess whether they were dead on scene or survived. That was precisely his point... all of us got at least a few wrong. Scary.

The frontal lobotomy was done for impulse or behavior control. Those who sustain an injury there will be more subdued with considerable personality changes as well as some other deficits.

Not always subdued... patients with impulse control problems after frontal lobe injuries often behave similarly to patients with impulse control issues from other causes. Some with acquired frontal lobe damage can also become violent.

We do still utilize Electroconvulsive therapy(ECT), also known as electroshock, to treat disorders such as depression.

Also as a last resort, at least ideally--but it definitely has its place. Though there's a very recent case with a patient who claims that ECT was administered unnecessarily and against his will, while he should've had the right to refuse.

 

[VentMedic]

Not always subdued... patients with impulse control problems after frontal lobe injuries often behave similarly to patients with impulse control issues from other causes. Some with acquired frontal lobe damage can also become violent.

I am not talking about the elective lobotomies like you may have seen on TV but rather what you seen everyday in a busy stroke and trauma center. A few may become violent but there is often damage to another section of the brain besides just the frontal lobe.

Also as a last resort, at least ideally--but it definitely has its place. Though there's a very recent case with a patient who claims that ECT was administered unnecessarily and against his will, while he should've had the right to refuse.

Not necessarily. Some doctors refer their patients for ECT after a couple of sessions. Some patients come from all over the world seeking this therapy at the clinics here and they come voluntarily. RTs have been doing the airway management for these cases for many years at a couple of the hospital based clinics which is where I have had a chance to see more than my share of these procedures. However, again, it is not at all like what is displayed in the movies.

 

[MMiz]

I think the real question that should be answered in this thread is where you've been for the past six months. Good to see you. Happy Holidays!

 

[Seaglass]

I am not talking about the elective lobotomies like you may have seen on TV but rather what you seen everyday in a busy stroke and trauma center. A few may become violent but there is often damage to another section of the brain besides just the frontal lobe.

In general, yes--head injuries often involve several areas, and damage to the amygdala is more common in patients who become violent. But I have seen a few patients who developed serious impulse control problems after sustaining an injury that was limited to the frontal lobe, according to their medical records. In some cases, those problems were manifesting in rather violent ways. I saw them several months or years after sustaining TBI, in a facility where the focus was on social/behavioral rehabilitation. It isn't equipped to handle fresh injuries. As such, its patients are often rather different from those in a stroke/trauma center.

Not necessarily. Some doctors refer their patients for ECT after a couple of sessions. Some patients come from all over the world seeking this therapy at the clinics here and they come voluntarily. RTs have been doing the airway management for these cases for many years at a couple of the hospital based clinics which is where I have had a chance to see more than my share of these procedures. However, again, it is not at all like what is displayed in the movies.

I've heard of it being used relatively quickly in cases where the patient was extremely despondent or suicidal, but I'd still consider that a last resort. Haven't heard of it being approved based on a patient's request, though, unless the patient would otherwise qualify. Would you be willing to elaborate on those cases?

And yeah, sure hope it doesn't look like the movies...