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It IS Brain Surgery: Part I – Brain Surgery 101

Published on May 17, 2017 in Brain Tumor Information

Welcome to NBTS’ first “Expert Series.” Throughout the remainder of the year, we’ll be utilizing this “Expert Series” blog format to tell the story of – and/or explain and educate on – issues relevant to the brain tumor community. 

For the inaugural series we wanted to tackle the issue of neurosurgery during Brain Tumor Awareness Month. We chose this topic and this month, because neurosurgery – commonly referred to as “brain surgery” – is often just an abstraction to the general public; people who have not experienced it first-hand or through a loved-one. They know it isn’t simple – as illustrated by the common use of the phrase, “It’s not brain surgery,” to explain the ease of a task….But they probably don’t quite know just how difficult it is for both practitioners and patients. Well for us, in the brain tumor community, we DO know all-too-well. For us, ‘it IS brain surgery.’ And we want the rest of our friends, family, co-workers, and fellow Americans to understand it, too! 

In Part I of this series, we talk to Dr. Ian Dunn of Brigham and Women’s Hospital (BWH) about the basics of neurosurgery as it relates to brain tumors – often referred to as “brain tumor resection” or a “craniotomy.” Note: neurosurgeons at BWH also treat Dana-Farber Cancer Center patients.

Dr. Ian Dunn

Dr. Ian Dunn is a Board Certified neurosurgeon in BWH’s Department of Neurosurgery. He is also an Associate Professor of Neurosurgery at Harvard Medical School. He received his medical degree from Harvard Medical School and then completed his residency at Boston Children’s Hospital and Brigham and Women’s Hospital, followed by fellowships at University of Arkansas and Saint Vincent Infirmary Medical Center.

Dr. Dunn has been practicing neurosurgery for 15 years now, after deciding in medical school that he liked the thought of being able to help patients immediately and “fell in love” with the subject during a neuroanatomy course.

Having a brain tumor operation is one of the pivotal moments in life…None of my operations are optional – so this makes the dynamic between surgeon and patient and family a very special one. The operations can be technically demanding and challenging and this requires us to stay at the top of our games…The challenge of delivering legitimate world class neurosurgical care to patients who absolutely need it sustains all of us in this field. This requires continued training, education, and unbelievable teamwork. There is absolutely nothing like a successful neurosurgical outcome after preparation and execution with a great team – experiencing patients’ and families’ gratitude is one of the greatest feelings around. It’s priceless. The chance to do research with a goal to improving the care we deliver is also a huge highlight.

Attribution: Dr. Dunn

The following is a lightly edited Q&A with Dr. Dunn about his profession:

Q: Describe the training you have to go through to become licensed to perform neurosurgery?

A: It’s long and requires a deep fundamental commitment to the field. In general, after college, it’s at least 4 years of medical school, followed by 7 years of neurosurgical training.  If one wishes to be very specialized, one can do an extra year in a chosen specialty. I did an extra year of skull base neurosurgery training, and it was one of the best decisions I’ve ever made.

Q: What are the surgical method(s) that you currently use for brain tumor patients?

A: We [at BWH] use conventional craniotomy where portions of the skull are removed; we specialize in additionally complex bone removal to access tumors that are difficult to reach (skull base tumors, such as meningiomas or scwhannomas); and we are one of the leading centers in using the endoscope, allowing unparalleled visualization of the brain anatomy.  We also use intra-operative MRI and advanced microsurgical techniques for maximally safe handling of the brain, nerves, and blood vessels.

Q: What are the reasons for your method of choice? What are the limitations?

A: It is a multidimensional decision – the tumor qualities and location; the goals of surgery; and patient comfort. We are at times limited by the biology and behavior of the tumors themselves.

Q: What are the biggest challenges of the job, in general?

A: We ask ourselves, on behalf of our patients, to perform at a supreme level of excellence every single day. Our teams are committed to this level of performance so that we do the very best jobs for our patients and families. The challenge is to stay at – and exceed – this level, to keep improving so that we can enhance the lives of our patients. Experiencing a part of the journey our patients travel once a tumor is diagnosed is an unbelievable privilege as well as responsibility; it requires that we give them the best we have, always.

Q: How is a craniotomy different from other neurosurgical interventions? And what are the challenges unique to brain tumor resection?

CT images of the brain

A: The craniotomy is just the start of the operation – it refers to the removal of the specific region of the skull or base of skull that will provide us the very best access to the tumor for maximal safe resection. We think deeply about which approach is best for each patient – no two operations are exactly the same. We prepare for all eventualities, but ultimately each operation presents different challenges – perhaps the tumor is more adherent to critical structures than we imagined or other unique anatomical features arise that require constant thinking and processing. It is not dissimilar to a sophisticated military operation – one draws on all the training and preparation so that unexpected events or findings can be dealt with effectively.  

Q: How long can a typical craniotomy last?

A: They can be as short as a few hours or much longer; my longest has been 24hrs.

Q: What percentage of craniotomies are patients required to be awake for?

A: Surgeons consider awake craniotomy if a tumor is arising within the brain tissue close to either the movement area or speech areas.  There are ways to monitor the critical movement pathways with patients asleep, so I would say the most common indication is if a tumor is near speech centers – there aren’t great ways to monitor speech function asleep.  So overall it is not a large percentage.

Q: What are the key questions that a patient/caregiver should ask their neurosurgeon about their surgery?

A: What are the risks? What are the benefits? Are there other options? Is this surgery something you specialize in? Do you think you can remove the tumor / what are the goals of surgery?  There are many other questions that are encouraged, but these are especially important ones. I also try to get a sense as to whether patients are considering second opinions – if there is the slightest urge; I encourage them strongly to do so.

Many of the other questions are specific to the type of tumor involved.

Q: Finally, many people’s only experience with brain surgery is, luckily seeing it depicted on TV and in movies. The popular show Grey’s Anatomy comes to mind. What you tell the public about biggest differences between Hollywood studios and real operating rooms?

A: First of all, Derek Shepherd is such a good neurosurgeon — it’s hard to compare!

TV operating rooms are rife with gossip and innuendo. But in reality, really good operating rooms are examples of really good teams working together. There is a level of comfort and familiarity with all team members, but the tone is professional and all are focused on a great outcome. Everyone has his or her role in ensuring this. We are constantly interacting with our nursing and scrub tech teams and anesthesia to address issues and problems as they arise. We may be working with a separate team helping us to monitor the function of the brain and spinal cord while we are working.

There are lighter moments and more serious moments, and all are in tune as to when those should be. The work is really symphonic – nursing, anesthesia, and surgery all work in parallel, and so much is happening smoothly at one time. There is a period of time to get the patient ready, and then surgery starts. Expectedly the tone of the room shifts somewhat – advancing to a tumor or its removal can take hours and hours, and it’s all business at this point.

Overall, it’s probably not as dramatic as portrayed on TV. But that’s really what you want – ideally, it’s a group of people, with the surgeon at the helm, who are great at what they do, and do it with enthusiasm. When this happens, there is not a better example of a functioning neurosurgical team. A well-oiled operating room with great people is really something to behold.

Next week, in Part II, we’ll look at brain surgery from a patient’s perspective.

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