Surgery for Tumors of the Brain and Spine

Advances in neurological imaging modalities, computing capabilities and surgical techniques have lead to development of different approaches to treatment of brain tumors. The choice of a given technique described below depends on the patient’s tumor type and specific location within the brain. The surgeon’s ability to choose among the various available treatment options and tailor the treatment to a specific patient and disease process leads to superior outcomes. A multi-disciplinary team of physicians, including radiation oncologists , medical oncologists, and pain specialists participates in developing and tailoring each patient’s plan of care.

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Stereotactic Radiosurgery

Stereotactic radiosurgery (SRS) is a minimally-invasive approach for treatment of benign and malignant brain tumors, and other neurological diseases such as vascular malformations, pain syndromes and movement disorders. The most common neurological diseases to be successfully treated with radiosurgery include meningiomas, acoustic neuromas, pituitary adenomas, brain metastases, craniopharyngiomas, arterio-venous malformations, and trigeminal neuralgia. Recent technological advances such as the CyberKnife radiosurgical system also allow treatment of benign and malignant tumors of the spine, including spinal metastases.
Radiosurgery involves computer-guided, extremely precise delivery of high doses of radiation. By avoiding open craniotomy or spine surgery in appropriate patients, radiosurgery frequently decreases the risks associated with traditional treatment of neurosurgical conditions. In situations where a brain lesion cannot be safely approached by a craniotomy, because of its association with critical brain structures, radiosurgery may represent the only treatment option. Radiosurgery is typically an outpatient procedure and patients usually resume normal activities immediately after treatment. Over the past decade there have been significant advancements in the field of stereotactic radiosurgery in conjunction with enhanced imaging capabilities and computing power. These technological advancements have resulted in improvement in patient outcomes and have extended the capabilities of radiosurgeons to safely treat a wider variety of neurosurgical conditions. Currently the most widely used systems for delivery of radiosurgery are linear accelerators, CyberKnife and Gamma Knife.

Powerpoint Presentation Describing Indicactions for Stereotactic Radiosurgery and Radiosurgery procedure thumbnail

Image-Guided Craniotomy

Image-guided craniotomy allows the surgeon to minimize the size of required scalp incision and skull opening by enabling real-time computer assisted intra-operative correlation of the patient’s anatomy to the pre-operative imaging studies such as MRI or CT. Image guidance also makes intracranial surgery safer and more effective by helping the surgeon avoid critical brain structures during the operation, while allowing him or her to achieve a more complete removal of the tumor.

Suprasellar Epidermoid Tumor Resection Performed by Dr. Fineman

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Transnasal and Endonasal Transsphenoidal Surgery

Transnasal transsphenoidal (TNTS) surgery is currently the preferred method of removing a pituitary adenoma (tumor) or cyst. It is also used for certain suprasellar tumors (above the pituitary gland), retro-sellar (behind the gland) and infra-sellar (below the gland) tumors, craniopharyngiomas, meningiomas, chordomas and epidermoid masses.

Using this approach, the surgeon enters through the sphenoid sinus, an air space behind the nose, to remove a mass. As a result, there is no external incision or scar. This approach is less invasive than a craniotomy because it is the most direct route to the pituitary gland. The operative time is typically shorter and patients recover more rapidly.

Endonasal (through a nostril) transsphenoidal surgery is a more minimally-invasive approach for removal of pituitary adenomas, Rathke’s cleft cysts, craniopharyngiomas and midline suprasellar meningiomas. With this approach, there is no incision under the lip and minimal nasal mucosal dissection, as the surgeon makes an incision in the back wall of the nose and the sphenoid sinus is entered directly. Because there is less dissection, a shorter and more comfortable post-operative recovery is typical.

Both transnasal transphenoidal and endonasal techniques employ microscopic or endoscopic assistance and surgical navigation techniques to assist with tumor removal and reduce the risk of injury to adjacent structures within the brain.

The decision regarding which procedure is most appropriate is based on the specific type, size and location of the tumor, and is typically made after review of a brain MRI scan.