Neurosurgery

Neurosurgery

Neurosurgery is a branch of surgical expertise that treats diseases of central nervous system (brain and spinal cord) and peripheral nervous system (nerves that provide a connection between external environment and central nervous system). Neurosurgery is the field of medicine requiring the most experience. 

Major Areas of Interest of Neurosurgery

Brain Tumors

Brain tumor means abnormal or uncontrolled growth of cells in the brain.  Tumors grow inside the skull and pressurize the brain. They show symptoms depending on the region they are in and the area they apply pressure to. 

It is not definitely known what the factors that cause brain tumors are. However, exposure of people to a number of hazardous chemicals is thought to be effective in the formation of brain tumors. 

Brain tumors can be benign or malign. Benign brain tumors do not contain cancer cells. 

Whether benign or malignant, surgical treatment is always the best treatment method for brain tumors.  However, some brain tumors may be very close to the brain and at high risk for surgery. For this reason, surgical operation can not be performed, chemotherapy and radiation therapy are applied.

Spine and Spinal Cord Tumors

Spine and spinal cord tumors are tumors that appear in the bones or nerves or other soft tissues that make up the spine and spinal cord. It is possible to divide spinal cord tumors into two groups, which are those outside the dura mater (extradural) and those between dura mater and spinal cord (intradural extramedullary). Spinal cord tumors may arise from cells that make up the structure of the spine and spinal cord as well as spread of tumors developing in other parts of the body (breast, prostate, lung, etc.) to the cord.  

Radiological imaging is essential in the diagnosis of spine and spinal cord tumors. Direct radiography, computed tomography, magnetic resonance imaging, angiography, bone scintigraphy are the methods used in diagnosis. Once a tumor is detected by imaging methods, biopsy should be performed to determine the type and source of the tumor. 

Spinal cord and spine tumors are tumors which are treated by branches, including brain and nerve surgery, neurology, radiation oncology, medical oncology, pathology by deciding among themselves. After the location and type of the tumor are determined, methods such as surgery, radiotherapy, chemotherapy, immunotherapy can be utilized individually or in combination.  Benign tumors can be monitored by regular follow-ups. Especially tumors showing neurological symptoms or those which have caused or poses a risk of causing a fracture must be surgically removed. Options, including radiotherapy, chemotherapy, immunotherapy can be employed before or after surgery depending on the type of tumor.

Aneurysm

Cerebral artery aneurysm is a permanent ballooning that emerges with weakening of cerebral vascular structure. They are frequently seen in bifurcation regions of the vessels and the structure that has ballooned out is less stable than a normal vessel.

Aneurysms do not usually show symptoms without bleeding. Due to the pressure applied by the aneurysm to the region in which it has developed, the following very rare symptoms may occur:

  • Speech disorders 
  • Gait disorders 
  • Loss of strength or sensation on one side of the body
  • Visual disturbances and pain in the eye region
  • Regional and persistent headaches
  • Dementia

When bleeding occurs as a result of brain vessel aneurysm, it manifests itself by a sudden, persistent headache with a severity that has never been experienced before, which is unmitigated by any means.   This pain is accompanied by nausea and vomiting, stiffness in the nape which is so severe that the patient can not bend his head, sensitivity to light, and loss of sensation. 

Today, there are three major treatment options for patients who are diagnosed with an aneurysm:

  • Observation and non-surgical treatment ( follow-up only )

The only treatment for an unruptured brain aneurysm is a medical treatment. Control of blood pressure is essential in medical treatment. Moreover, smoking and alcohol, which are among the factors causing aneurysm, should be given up during this process. Planning administration of drugs that lower blood pressure to control blood pressure and supporting the treatment by a proper diet and exercise program are essential.  In this process, size of aneursym and whether it has grown or not should be monitored and for this purpose, radiographic examinations need to be done.

  • Surgical treatment and closure of the aneurysm ( clipping )

It is a permanent treatment method. A small window is opened in the skull and a metal clip is placed between neck of the aneurysm and the relevant vessel so entry of blood into the aneurysm is prevented. Clip application in the treatment of cerebral aneurysm  performed for the first in 1937 and since then, it has been a frequently used method. 

  • Stenting and blocking by intravenous ( endovascular ) treatment 

Endovascular aneurysm treatment is based on reaching inside of aneurysm using catheters with very small diameter by angiography device, filling aneursym sac with metal wires with a very soft structure, called coils, and preventing entry of blood into the aneurysm. This process is called ”coiling aneursym”. It is the most widely used method in the treatment of aneurysms worldwide.

Narrowing of the Neck Arteries (Carotid Stenosis)

Carotid stenosis is described as narrowing or blockage of carotid artery in the neck. Carotid artery is the main vessel that supplies blood to the brain. The cause of this blockage is fats that form a plaque by accumulating on each other. This fatty substance accumulates in the inner wall of the vessel and causes vessel contraction as well as formation of blood clots that break and cause blockages in the veins of the brain.

Cutting blood flow to the brain means cutting off nutrients and oxygen to the brain, and the stroke occurs. If blood flow is not re-established, brain cells die soon and a permanent brain damage occurs. Causes

Anticoagulant drugs and blood thinners are prescribed in order to prevent clots from reaching a brain with a less than 50% narrowing in its carotid artery. 

If narrowing is above 70%, the most effective treatment method is surgical treatment.  During surgical treatment, fat plaque formed in the vein is removed. 

Herniated Disc

There are 5 pieces of vertebrae in waist part of the spine, and between these bones, there are cartilages with a special connective tissue, called disc. This is the place which carries the body weight the most. The disk, consisting of a core in the middle and a capsule protecting it, is torn under any strain. Herniated disc is formed as a result of overflowing of 

At initial phase of a hernia, surgery is not recommended. The person is often recommended to take muscle relaxant medications, avoid certain movements (bending, lifting a load, etc.), lie in an orthopedic bed and rest. 

If hernia progresses, it’ll be right to perform physical therapy in the company of an expert. If the pain persists and no improvement is achieved despite physical therapy, a surgical treatment should be carried out.  The purpose of herniated disc surgery is to empty the section that has herniated along with core of the disc, and remove the pressure on the nerve. 

In the case of conventional surgical treatment, which is less frequently used nowadays, under general anesthesia, the hernia is reached through an incision of 4-5 cm made in the waist and the disk is removed. 

In the case of microsurgery, which is frequently used today, applications are performed with a microscope. It has advantages, including that the incision is as small as 2-3 cm and a muscle tissue with less volume is dealt with. The patient stays in the hospital for one day. Rate of recurrence or complication is very low.

In the case of endoscopic surgery, surgery is performed through a tube inserted into a small incision in the waist.  

Brain Hemorrhage

Brain hemorrhage is bleeding into the brain due to rupture of one of the arteries in the brain. When bleeding occurs, the brain inside the skull, which is an inflexible structure, is exposed to the pressure induced by the fluid filling it, crushed and accordingly, various symptoms appear.

There are two types of brain hemorrhage: bleeding into the brain (intracerebral), and into the bottom of the brain membranes (subarachnoid), i.e., bleeding into surroundings of the brain.

In the case of bleeding into the brain, one of the small arteries inside the brain is torn. In this case, pressure occurs on the brain tissue where bleeding occurs, and dysfunctions in the body region governed by that area of the brain emerge. The most common cause of bleeding into the brain is hypertension. Blood vessels become weak and prone to tearing as a result of the effect of high blood pressure on small veins that has lasted for years. The most effective way of protection against this type of brain hemorrhages is to keep blood pressure within normal limits.

In the case of bleeding under meninges, one of the major arteries in basis of the brain is torn.  In this case, the flowing blood spreads into all surroundings of the brain and into the cerebrospinal fluid. Cause of most subarachnoid hemorrhages is rupture of an aneurysm existing in the brain.  Approximately 5 to 10% of all strokes occur due to subarachnoid hemorrhage. 

The most effective way to prevent brain hemorrhages is to take control of the blood pressure and keep it in normal limits. To do this, one should use prescription drugs properly, lose extra weights, if necessary, and exercise regularly. 

Epilepsy 

Epilepsy is a disorder that manifests itself in the form of seizures by over- stimulation of cells that make up the brain as a result of temporary abnormal electrical spread. Patients display behavioral, emotional, movement or perception disorders such as loss of consciousness for a certain period of time, body convulsions, fainting, incontinence, shaking off arms and hands, etc.  

This disease requires a long-term treatment and significantly affects the quality of life.  In majority of patients, seizures can be controlled with correct treatment and the patient resumes a normal life. However, in 25% of patients, despite the use of appropriate drugs, seizures can not be controlled.  If epilepsy couldn’t be controlled and drug treatment has failed, surgical methods are used. 

There are two main types of epilepsy surgery method. The first and the one preferred is removal of the epileptic focus (resective surgery). The other is the surgical method for reducing spread, frequency and severity of seizures by cutting seizure propagation paths(functional surgery, palliative surgery). Resective surgery is mainly applied in resistant epilepsies in which medication therapy has been tried. 

Parkinson’s Disease

Parkinson’s disease resulting from reduction in or damage to dopamine -secreting cells in the brain as one gets older causes movement disorders and involuntary movements. The disease manifests itself by shaking hands and feet, movements slowing down, muscle stiffness and difficulty with walking.

The first treatment to be applied in Parkinson‘s is drug treatment. If the patient has given a positive response to medication, he may live a problem-free life for a long time. However, over the years, due to the progression of the disease and the development of tolerance to the drug, drugs taken in former dose and frequency become inadequate.  If the disease cannot be controlled despite higher doses and more frequent administration, i.e. drug treatment gets blocked, then surgery is brought to the agenda.  

There are two methods for surgical treatment of Parkinson’s. If symptoms of the disease are in one side, burning technique which is similar to laser is applied.  But if the symptoms are in two sides, patients can no longer get up from a seated position or in general terms, both sides have to be treated, then treatment is applied to both sides and often a brain battery is implanted.

The cells responsible for the disease and location of the surrounding anatomical structures are found by a method called ‘ Microelectrode Recording and Stimulation Technique ‘, which is used in surgical interventions and by which electrical activity of the cells in the brain can be listened. Therefore, during this procedure, the patient is kept awake and the procedure is performed while talking to the patient. Hence it will be easier to reach the problem area by measuring the patient’s response. After reaching the corresponding region, burning method is applied or a brain battery is implanted.

Scoliosis

Scoliosis is the general name given to the curvature of the spine to the right or to the left. Scoliosis usually displays no symptoms in the early stage; as it advances, the following symptoms occur: 

  • One shoulder higher than the other is one of the most common symptoms. One shoulder blade can be higher or more pronounced than the other.
  • When arms dangle on both sides, presence of more space between the arm and the body on one side is one of the symptoms.
  • One hip can be higher or more pronounced than the other.
  • When the patient is viewed from behind and is asked to bend forward until his spine becomes parallel to the floor, one side of his back can look higher than the other and it may look as if he has a hunch. 

Scoliosis is a disease that threatens the future of children growing. A high rate of success in the treatment of the disease can be achieved if it is detected at an early stage. However, if curvature of the spine that can not be diagnosed in time has proceeded, this prevents normal development of children. In adulthood, waist and back pains, heart and lung function abnormalities are seen.

Although scoliosis treatment varies depending on the type and size of scoliosis, the most common treatment options include:

  • Observation: Only observation and check at regular intervals is adequate for patients with a curve below 20 degrees whose skeletal development is close to completion. Observation continues until his skeletal system development is completed.
  • Corset Treatment:  The purpose of corset treatment is to try to hinder increase of the curve. Corset is especially effective on children with a curve above 25 degrees whose growth still continues. 
  • Surgical Treatment: Surgery is inevitable for children with a curve of 50 degrees who still grow.  Curves above 50 degrees continue to increase after growth is completed. 

Peripheral Nervous System Disorders (Nerve Compressions)

Nervous system is made up of nerves that convey messages and transmit necessary orders from the body to the brain and from the brain to the body. Nervous system is divided into two systems which are central nervous system (brain and spinal cord) and the peripheral nervous system (nerves associated with spinal cord). Peripheral nerves pass through muscles in the body and arms and legs. Along this process, they go through fine and narrow passages in certain body parts. However, in certain cases, nerves undergo compression while going through such passages and nerve compressions may take place. 

The most common type of nerve compression is known as “Carpal Tunnel Syndrome” and affects fingers along with wrist. This disease emerges as compression at the level of the wrist of the nerve going into the first four fingers of the hand and is mostly seen in housewives and those frequently using their hands because of their occupation. Its most important symptom is numbness of the hand. Sometimes there can be pain.  Patients indicate relief when they shake their hands. Strength of fingers decreases with time and items held by hand begin to fall. 

A similar condition develops in especially those wearing pointed, high-heeled shoes and heavy-duty employees, and is called ” Tarsal Tunnel Syndrome”.  Symptoms of carpal tunnel syndrome occurs in the ankle and toes.

Nerve impulses are measured by a precision technique called EMG and nerve compression level is detected. Physical therapy methods are applied to cases which are not in a very advanced stage and in which loss of strength hasn’t developed yet.  In advanced cases, surgical procedures are applied.  Nerve passage is relieved by an operation on the wrist or ankle. After the surgery, physical therapy and rehabilitation program is applied in an attempt to eliminate joint stiffness and strengthen the muscles.

Functional Neurosurgery

Trigeminal Neuralgia 

Trigeminal neuralgia is known as one of the most severe pain and is extremely rare under the age of thirty.  Patient may become unable to perform daily activities and even vital functions so it is a serious condition that should be diagnosed as soon as possible and treated. 

Trigeminal neuralgia is structural differences and impairment of vascular formations surrounding the trigeminal nerve, which is one of the 12 pairs of nerves that directly come out of the brain. In addition, differences in bone structure, benign or malignant masses in the head, blows to the head, failed dental treatments, former infections may also cause trigeminal neuralgia.

The pain is short-term (from a few seconds to a minute or two), recurrent, like an electric shock in part of the face where the trigeminal nerve spreads.  Generally, there are points on the outer part of the face, inside the mouth which trigger pain.  For this reason, the patient doesn’t touch these regions and avoids functions like washing face, brushing teeth, or even eating.

Drug therapy is first-line treatment in the case of trigeminal neuralgia. When drug treatment fails to provide adequate pain control or ceases to be effective, glycerin is injected in order to cut the nerve message or fibers that transmit pain are burned. In the case of surgical treatment, the pressure on the nerve in the brain stem is removed. Keeping in mind the patient’s age and state of health, the most appropriate method is determined by the physician.

Spasticity Surgery 

In spasticity, muscles are constantly in contracted state. Solid or strained muscles due to contraction prevent normal activities such as walking, movement and speech. While there are many causes of spasticity in children, the majority is comprised of brain damage due to oxygen deficiency, brain trauma, stroke or various forms of nervous system damage. Certain metabolic disorders can also lead to spasticity. 

In spasticity, there are many symptoms, including inability to bend limbs, joints twisted in unusual angles, crossing arms or legs, speech problems. In the long term, spasticity can lead to the fact that muscles contract joints and fix them permanently in a single position.

Physical therapy is an important treatment for spasticity and a daily regimen of a series of joint movements, exercise and stretching movements that help reduce the severity of symptoms. Drug therapy can be performed by oral administration or drug injection directly to the corresponding region. Surgical treatment should be applied for severe chronic spasticity.  During surgical treatment, orthopedics and neurology disciplines should work together. Orthopedic treatment involves tendon, muscle and bone extension methods to provide movement and flexibility. Neurosurgeons contribute to the treatment by an operation which involves cutting sensory nerves that carry information to spastic limbs. 

Facial Twitches

Facial twitches refer to involuntary, painless contraction of facial muscles at intervals.  They typically begin around the eye, and then spread to other facial muscles around the mouth. Twitches may last for one or several minutes. Twitches mostly increase with fatigue, stress, anxiety and excitement while they decrease during rest and sleep.

Facial twitches are most common between the ages of 40-60 and affect women twice as much as men.

It has been reported to be more frequently seen in people of Asian descent and the reason for this is that the people living in this region have a cerebellum bone with smaller volume.  Face twitching is not inherited; it usually occurs as a result of other diseases. Head trauma, brain tumors, cerebrovascular diseases and stress are external factors that cause facial twitching.

In mild cases of facial twitching, often drug therapy and botox are applied. In case of failure of botox treatment or in advanced clinical cases, surgical method is preferred. 

Stroke

When the blood flow to the brain is interrupted in any way by a blockage of blood vessels inside the brain or neck, brain cells cannot get oxygen and nutrients that are necessary for them. If this problem is not resolved within a very short time, permanent brain damage occurs. When brain cells die, they cannot be revived and the damage is permanent. 

There are two types of stroke: Ischemic stroke and hemorrhagic stroke. Ischemic stroke is a more common type of stroke and occurs when blood flow to the brain is cut off. Hemorrhagic stroke occurs when there is bleeding into the brain or its surroundings.

Strokes can occur at any age, though it is more common in later life. Smoking, high blood pressure, diabetes, heart diseases, and high cholesterol increase the risk of stroke.

Symptoms of a stroke can be very different, but all the symptoms occur all of a sudden.  The main symptoms of stroke are as follows:

  • Very severe headache
  • Confusion, confusing people, current time and place.
  • Numbness, weakness or inability to move in any arm, leg, or face.
  • Sudden disruption of speech
  • Loss of vision 
  • Loss of balance or inability to do skills requiring coordination.

Brain surgeons have several treatment options upon an early diagnosis of stroke. These include repair of an aneurysm bleeding in the head, removal of blood clots creating blockage in the brain or of plaques that may create blockage inside the brain after separating from carotid artery in the neck.

Diagnostic Methods Used in Brain and Nerve Surgery

  • CT (Computed Tomography)

Computed tomography is a special imaging technique that gives a cross-sectional image of the tissues and organs of the body using x-rays.   In comparison to ordinary plain radiographs, CT provides more detailed information about head injuries, brain tumors and other brain disorders. Bone , soft tissues and blood vessels can also be displayed by CT.

  • MR Imaging

MR is a painless procedure that can display internal organs and tissues in a clear and detailed manner. MR uses radio waves and a strong magnetic field, instead of X-rays.

  • MR Angiography (MRA)

MR angiography is an MR study by which the arteries in the body are displayed.  MRA proved to be very useful for detecting the problems in blood vessels and determining the best treatment option. In this method, large main veins can be viewed comfortably without administering any drug. However, image quality can be enhanced by using special agents and fine details of vascular structures can be displayed. 

  • Catheter Angiography

In catheter angiography, a catheter is inserted into the artery of the region to be examined and a substance that allows imaging by X-rays is injected.

  • Nuclear Medicine

In nuclear medicine, radioactive materials are used for diagnosis and treatment. In radiology, radiation source is on the outside and the patient is between radiation source and the film. In nuclear medicine, radioactive materials which allow imaging of the patient are administered orally or by other means to the patient and rays coming from the patient are detected. 

Positron Emission Tomography (PET Imaging)

PET shows functional changes occurring in organs and tissues and is the most advanced nuclear medicine imaging technique. 

  • By means of PET, tumor tissues which can not be detected by radiological imaging method can be determined and diagnosed earlier. 
  • Whether a tumor is benign or malignant is easily detected by PET. 
  • The stage of the tumor can be easily identified so that the appropriate treatment is applied.
  • Response of tumor to treatment can be evaluated by comparing the scan after the treatment with the scan before the treatment. Thus, direction of the treatment is determined in a healthy way.  
  • One of the advantages of this system is that it distinguishes living tumor tissue in the corresponding region after radiotherapy, chemotherapy and surgery.
  • Moreover, it is possible to assess recurrence of the disease, and locate it if there is a recurrence. 
  • Furthermore, it also helps estimate the direction of diagnosis and treatment of nervous system diseases – neurological dementia, Alzheimer’s disease, epilepsy. Cardiological viability and function can also be evaluated by this method in terms of cardiology. 

Diagnostic Methods Used in Brain and Nerve Surgery

Microsurgery

Microsurgery, by definition, involves surgical procedures performed under the microscope.  A clear and detailed image of tissues is provided by a microscope during surgery so it is possible to work with much smaller surgical incisions. By this means, minimum damage is caused to normal tissues during surgery and the success of the operation increases by performing a complete intervention on the problem tissue.

Today, a significant number of neurosurgical operations are performed using microsurgical techniques.  These operations include operations of brain tumors, aneurysms, pituitary tumors as well as spine-spinal cord operations, including cervical disc hernia and herniated disc.

Gamma Knife

Gamma knife is an extraordinary method that allows neurosurgeons to perform surgery on abnormal areas of the brain without need for any surgical incision. Gamma knife is a treatment that allows destruction by gamma rays of diseased brain tissue, coordinates of which has been determined. In this surgical method, treatment is completed in a single session. Generally, it is the preferred method in cases where open brain surgery is not possible or carries a high risk.

Drug Therapy

    • Chemoterapy

Chemotherapy is destruction of cancerous cells multiplying uncontrollably, through the use of drugs. It can be administered either alone or in addition to other therapies.  When it is applied in combination with surgery and radiotherapy, it may help these types of treatment be more effective. Chemotherapy, which is an important part of tumor treatments, can be applied to:

  • Completely destroy the tumor and treat the patient or 
  • prevent the tumor from spreading or ensure its decline
  • Eliminate the symptoms caused by the tumor. 
    • Radiotherapy

In radiotherapy, treatment is applied to cancerous region using high-powered energy beams.  The rays used in the treatment of cancerous cells can damage healthy cells.  Therefore, the methods used in radiotherapy are quite important. 

  • IMRT (Intensity Modulated Radiation Therapy): IMRT type accelerators send high-energy rays from different angles and at different intensities to reduce damage to healthy cells. 
  • IGRT (Image Guided Radiotherapy): Diseased region is detected by imaging in each session and direct application is made to this region. Its length of session is much shorter than those of other applications.

Endovascular Surgery

Endovascular treatment is applied in cases where the patient is at risk of harm because of the area with aneurysm. In this method, a microcatheter is introduced into the groin as if performing an angio and aneurysm region in the brain is reached. Then, aneursym sac is completely filled with very fine wires, called “coils”, and isolated from circulation.  Thus, bleeding risk is prevented because blood cannot enter aneurysm. 

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