Frequently Asked Questions:
CRANIAL OPERATIONS:
What is a craniotomy?
Crani = skull and otomy = hole or opening. It means opening of the skull. The size and location will depend on the nature of the condition being treated. The bone is put back at the end of surgery and secured with titanium mini plates and screws.
When can I fly after a craniotomy?
Usually about 3 weeks after surgery. This time allows all air to be absorbed so it does not interfere with the mild pressurization changes associated with commercial air travel.
Is it normal to hear clicking sounds after a craniotomy?
Though your skull is firmly secured at the end of surgery, it is not uncommon to hear clicking sounds during the first week or two after surgery. Sometimes pulsations of the scalp may also be visible.
What is stereotactic craniotomy?
Stereotaxy is a method in neurosurgery to localize a point in space using 3 dimensional coordinate system. This can be achieved using frame based systems such as CRW, BRW or Leksell systems or by frameless navigational techniques such as Stealth, Brainlab, Stryker software. These methods allow precise planning for the placement of the craniotomy on the skull and provide a safe corridor to reach the target without injury to vital brain structures.
What conditions require the operation of craniotomy?
Craniotomies are used in the treatment of benign and malignant brain tumors, evacuation of blood clots after trauma, cerebral hemorrhage from aneurysms, arteriovenous malformations or stroke, microvascular decompression for relief of pain in trigeminal and glossopharyngeal neuralgia, removal of brain abscess and other infections and in the treatment of epilepsy.
What are the risks of craniotomy?
All surgeries carry certain risks and side effects or complications. You should discuss the specifics of your condition with your surgeon. In general craniotomies today are safe with low risks of complications compared to say 2 or 3 decades ago. In general risks of craniotomy include but are not limited to:
- Hemorrhage – early or late
- Stroke – at the site of surgery or remote from it
- Infection – in the scalp, skull or the brain
- Seizures – early or late
- New neurological deficits – weakness, numbness, impaired memory, cognition, language, vision, hearing, balance or coordination
- Headaches, nausea, vomiting, dizziness
- Spinal fluid leakage and wound breakdown
- Hydrocephalus and fluid build up
- Cosmetic issues such as dimples, loss of hair, bumps over the scalp, numbness and sensitivity over the scar
What are the risks of anesthesia?
Present day general anesthesia is very safe with a low risk of complications. You should discuss any specific concerns that you may have with your anesthesiologist prior to surgery, especially if you have had other operations in the past or had complications after a general anesthetic. In general terms anesthetic risks include damage to teeth, eyes, breathing or swallowing difficulties, heart attack, stroke, allergies to medications and other rare complications.
What are the general surgical complications?
These include wound infection, chest and urinary tract infections, deep vein thrombosis, pulmonary embolism, drug allergies etc
What is an awake craniotomy?
At times craniotomy is performed under light sedation and local anesthesia. Once the drilling and skull opening is concluded, sedation is withdrawn so the surgeon can speak and communicate with the patient to monitor vital functions such as speech, language, motor skills and sensation over the face, body and limbs.
What is the consent process?
The patient or his/her legal power of attorney will be asked to sign a consent form prior to surgery. You should only sign the form after you have fully understood the risks and benefits of the proposed surgery, alternatives to surgery, short and long term outcomes and have had all your questions and doubts answered / clarified.
What precautions do I take prior to my surgery?
Stop taking medications (including herbals) that are likely to thin your blood or affect normal clotting at least 1 week prior to the date of your surgery. Take all your hypertension, diabetes and seizure medications as prescribed till the morning of surgery.
What does the operation involve and how long does it take?
After anesthesia is established, you are positioned appropriately on the operating table. Your head may be held on pins to prevent any movement during surgery. Areas of the scalp may be shaved at the site of proposed incision. After the scalp is separated, drill hole(s) are made and connected using a surgical saw (craniotome) to remove a portion of the skull. The dura (parchment like covering of the brain) is opened and the brain exposed. Subsequent steps depend on the type of surgery. Tumors are commonly removed using a cavitron ultrasonic aspirator (CUSA). After the surgery is complete, the dura is sewn back together, bone replced and secured with titanium mini plates and screws and the scalp closed with sutures or staples.
Cranial operations in general take 3-4 hours but may be as short as 1 hr or longer than 12 hours depending on the complexity of surgery.
What should I expect after surgery?
After most craniotomies, patients are awake but groggy, spending 2-3 hrs in the recovery room. Over the next several hours, you are closely monitored in an ICU for control of blood pressure, level of consciousness and other neurological functions. A postoperative CT / MRI scan is obtained to confirm optimal results before you are transferred to a regular room.
How long will I be in the hospital?
On an average after an un complicated craniotomy the length of stay is 5 days (3-7 days).
After surgery do I go home or will I need rehabilitation?
If you are independent in most day-to-day activities and safe on your feet you could go home. If you have difficulties with speech, language, motor skills or walking you may be discharged to an in-patient rehabilitation center. Some patients may be discharged to a sub-acute care facility depending on the level of supportive services that they require.
What is the usual follow up?
You will be seen in our office between 1-2 weeks after your discharge from the hospital. If you are in a rehabilitation center your follow up may not be till after discharge from that facility. There after you will see your surgeon about once a month.
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DEEP BRAIN STIMULATION:
What is DBS?
Deep Brain Stimulation (DBS) is a surgical treatment for Parkinson’s Disease, essential tremor and dystonia. It has been FDA approved in the US since 1997 and there have been over 55,000 implants performed worldwide for the treatment of movement disorders. DBS can be thought of as a brain pacemaker. The surgery entails placing a small wire in the area of the brain affected by Parkinson’s disease. The wire is then passed under the skin down to the chest under the collar bone where the pacemaker is implanted. This brain pacemaker system, continuously delivers an electrical stimulus to the affected regions of the brain. The electrical pulse is small and is not felt by the patient, however it is able to affect the activity of the brain to improve the symptoms of Parkinson’s disease.
What are the benefits of surgery?
For someone considering surgery for Parkinson’s Disease, it is very important to understand how DBS affects the different symptoms of Parkinson’s Disease. DBS is not a cure for Parkinson’s disease. The stimulation can help treat some but not all of the symptoms of the disorder. As a good rule of thumb, DBS works for symptoms that respond to levodopa. DBS is a very good treatment for tremor associated with Parkinson’s Disease, for the rigidity or stiffness, for bradykinesia or slowness, and for dyskinesias which are the uncontrollable movements that are side effects of long term levodopa use. It also is great for minimizing the ON/OFF fluctuations that occur when someone has been taking medication for a long time. ON time is when a person has relatively good mobility and OFF time is when the mobility is lost as the medication effect wears off. Stimulation can smooth out the day and make more of the day as ON time for the patient. DBS does not help problems with speech, problems with balance or problems with cognition such as forgetfulness, decreased decision making abilities and difficulty with language and in fact it may worsen these if they are pre-existing.
When is someone considered a candidate for surgery?
Most patients with Parkinson’s Disease respond well to medication and get relief of their symptoms. Patients are considered for surgery when the symptoms become difficult to
manage with medication alone. When someone is taking a lot of levodopa or its equivalent on a daily basis, or have a medication frequency which is difficult to manage, or are having adverse side effects to the medications, they are considered good candidates for surgery. In addition, surgery is a good option when patients develop the uncontrollable movements called dyskinesias or are having multiple ON/OFF fluctuations during the day.
Is there an age limit for surgery?
While most people who undergo deep brain stimulation are under seventy years old, there is no real age limit for the surgery. If the individual is healthy and they are otherwise a good candidate for DBS, then most centers would consider doing the surgery.
Why is surgery needed on both sides of the brain?
In general, one side of the brain controls the opposite side of the body. So DBS on one side of the brain will affect Parkinson’s symptoms on the other side of the body. Patients with symptoms on both sides of their body will get their best relief with surgery on both sides of the brain. DBS leads can be placed on both sides during the same operation. The decision to go ahead with one side versus two, is usually made before the surgery and it depends on the patients symptoms, health and age. Some patients have symptoms that are mostly on one side of the body and these patients may get very good relief with one sided surgery. In patients who may be more elderly or have health issues and need stimulation on both sides, the two sided surgery can be staged with one side done in one operation and the other done several weeks later.
What are the risks of surgery?
Any surgery has risks and this is no different with DBS. The responsibility of the treating team is to weigh all the risks of surgery and the benefits that DBS may provide for the patient and decide if it is reasonable to offer surgery to that particular patient.
Risks of anesthesia. Risks of allergic reaction to medication, heart attack, airway problems and death. These risks are extremely small (less than 1%) and are minimized by a preoperative medical evaluation.
There is a risk of hemorrhage during surgery however this risk is quite small (about 2%), even if it occurs, it is usually something that does not affect the patient and is only seen on a CT scan of the brain. Very rarely hemorrhage may need to be surgically evacuated, or cause stroke like symptoms.
Risk of infection. Just as in any other implant procedures such as heart pacemakers or even knee replacements, there is a risk that an infection will occur after the surgery. We are always extremely diligent and adhere to a strict sterile technique to minimize infections. Some centers prefer to place patients on oral antibiotics for a few days after the surgery. Despite this infections do happen in about 4-5% of patients, and it is important to be aware of this risk as well.
There is also a risk of developing neurological complications such as weakness, paralysis or difficulty with speech. These risks are very small and are minimized by the use of computer guidance during the procedure.
In addition there are reversible side effects as the result of the stimulation such as tingling, tightening of muscles and double vision which can be reversed by changing the stimulation settings.
How is the surgery performed?
Surgery is generally done in two stages. The first stage is the placement of the DBS lead or wire. To obtain the best result from surgery, the exact location of the DBS lead is very important. To this end most centers that do DBS surgery use state of the art computer guidance and brain mapping techniques to identify the perfect location for the DBS lead. To help find that exact location rigid frame or a “halo” is placed on the patients head during the surgery. The lead is placed through a small incision in the scalp and a small opening in the skull. The patients cooperation during the surgery is also very important in finding the perfect location for the DBS and therefore patients remain awake during the parts of the surgery where we would need their participation. For the remainder of the surgery, patients are under some anesthesia. Patients should not have any discomfort during any part of the procedure and part of the goal of the surgical team is to make sure that is the case for all patients. After the surgery, patients usually stay in the hospital about 2 to 4 days. They are then discharged to home.
The second stage of the DBS procedure is the implantation of the battery and it is done usually about one to two weeks after the First stage. It is an outpatient surgery and patients are placed under complete anesthesia. Once the surgery is done, patients are discharged home on the same day.
When will the DBS start working?
About 4 weeks after surgery, the stimulator is turned on by the team. This is done in the office, with remote control communication with the brain pacemaker. About once a month, the stimulator is adjusted and within 4-6 months the settings will be stabilized. After this initial programming session, the required visits are for checking the system and are about once or twice a year.
Is there maintenance required for the system?
Once the settings are stabilized, the system should be checked about once or twice a year to ensure that it is working properly. The battery will need to be changed in about every 4-5 years, and this is also done as a same day procedure, and only requires a battery change and not any replacement of the brain lead.
What if I have undergone DBS and a cure is discovered?
DBS does not destroy or damage any part of the brain. It can be removed to allow for other procedures if gene therapy or transplant therapy prove to be better treatments or a cure for Parkinson’s disease.
Do I have to limit my activities after DBS?
The purpose of surgery is to restore a patients quality of life, and not to limit them from activities they enjoy. Patients can be active and even engage in sports after DBS.
How can I get more information about surgery?
There are some excellent sources of information for surgery for Parkinson’s Disease. The American Parkinson’s Disease Association, The Parkinson’s Alliance, and the National Parkinson’s foundation have great resources for people with Parkinson’s in general and also for surgery for Parkinson’s disease. Also reach out to a support group in your area, they could be a valuable source of information.
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