No one likes the thought of undergoing brain or spine surgery. Traditionally, a neurosurgeon would create a four- to six-inch incision and peel back the scalp before drilling through the skull to expose the brain…or make a similar-sized incision in your back, where muscles are then moved to expose the spine.
Recent development: Endoscopic, or minimally invasive, surgery, which has long been offered for such common procedures as gallbladder removal and knee surgery, is now widely available at major US medical centers for neurosurgical operations that involve the brain, spine and peripheral nerves.
Whether it’s the removal of a brain tumor or the repair of herniated disks, spinal stenosis or carpal tunnel syndrome, neurosurgeons can now use sophisticated instruments to operate through an incision that’s smaller than a dime or even through a natural opening such as a nostril.
This approach allows for a faster recovery and less pain and swelling than the traditional “open” procedures. Older patients frequently respond better to surgery that has minimal blood loss and requires less time under general anesthesia.
Why this matters: Even though endoscopic (sometimes known as “keyhole”) neurosurgery is now available, not all surgeons have the training and experience to perform it. This means that you may not be offered endoscopic neurosurgery when it would be a better option than a traditional procedure—or a surgeon may attempt the endoscopic operation without adequate training and/or experience. What you need to know…
What makes most types of surgery so challenging has less to do with repairing a problem—whether it’s replacing a joint or removing an appendix—than simply getting access to the specific body part.
With endoscopic neurosurgery of the brain, the surgeon makes one or two incisions ranging from one-third to three-quarters of an inch and drills into the skull. A tube (endoscope) is passed through the narrow opening. Everything that’s needed to complete the procedure, such as a lighted camera and cutting and scraping tools, is guided into place through the endoscope. Surgeons enter through the nostrils or above the eyebrow to operate on pituitary adenomas and tumors in the front of the brain.
The benefits of endoscopic surgery are largely due to the smaller incision, which is obviously less painful than a large one and has less risk for infection. Since there is less blood loss, there is less need for blood transfusion—another benefit.
Because endoscopic procedures can usually be done faster than traditional surgeries, patients also spend less time under general anesthesia, which reduces postoperative complications, such as cognitive dysfunction and nausea, and improves recovery.
In my practice, at least 30% of brain surgeries (including treatment for hydrocephalus—buildup of fluid in the brain that is drained via a shunt…and removal of skull-base tumors) are minimally invasive. Deep areas of the brain cannot be accessed with endoscopic neurosurgery. Most of our spine surgeries and virtually all carpal tunnel procedures are done this way.
Examples of when endoscopic neurosurgery can be used…
• Herniated disk. Computerized image guidance creates a three-dimensional image of the spine so surgeons can achieve a superb view of the operating field with an endoscopic incision that’s barely more than a half-inch long. They use microinstruments to remove the damaged part of the disk.
• Spinal stenosis. This narrowing inside the spinal canal (usually due to arthritis) often causes leg pain or other symptoms. It’s relatively easy to “open up” the spinal space with endoscopic surgery. Patients often make a full recovery within a month—and may be symptom-free almost immediately—while traditional surgery usually requires a recovery period of at least three months.
In general, endoscopic surgery is a good option for most patients, especially those who are too old, ill or frail to have traditional surgeries.
One patient’s story: My oldest patient was a 96-year-old woman whose spinal stenosis was so bad she could barely walk. She might not have done well with a lengthy open procedure, but I knew that I could complete the operation in about 90 minutes—half the usual time. Her pain was gone almost instantly—and a month later, she was bowling and dancing with her boyfriend.
The complication rate (infections and/or bleeding) for endoscopic surgery is at least as good as—and sometimes better than—that of traditional procedures. The numbers will only get better as surgeons gain experience and new approaches and technologies are developed.
Before agreeing to any type of neurosurgery, ask the surgeon whether the procedure will be open or minimally invasive. While some operations, such as certain brain tumors, still require a traditional approach, most do not.
Chances are that you’ll recover much more quickly—and experience less postoperative pain—if you go with endoscopy. If your surgeon doesn’t do endoscopic surgery, get a second opinion. You can find a surgeon at the American Association of Neurological Surgeons, aans.org.
Experience and training are crucial for surgeons who perform endoscopic surgeries. Compared with traditional operations, endoscopic surgeries require the surgeon to overcome such issues as poor depth perception (from the endoscopic camera) and limited range of motion to manipulate surgical instruments. Make sure your surgeon has several years of experience in performing the procedure you’ll be getting and has received endoscopic neurosurgical training.
