Types of neurosurgery

Following a brain tumour diagnosis, one of the treatment options that you will be offered may include neurosurgery.

The type of neurosurgery that you will be offered will be dependent on many factors including tumour type and location. This will all be discussed with you by your clinical team beforehand.

On this page, you will find information about some of the different types of neurosurgery that are offered to people following a brain tumour diagnosis. This information, combined with our Patient Guides, will help you to feel better resourced and more engaged with your clinical care.

An awake craniotomy is an operation performed in the same manner as a conventional craniotomy but with the patient awake during the procedure. This is a preferred technique for operations to remove lesions close to, or involving, eloquent (functionally important) regions of the brain. This allows us to test regions of the brain before they are incised or removed and allows us to test patient’s function continuously throughout the operation. The overall aim is to minimise the risks of such operations.

How is an awake craniotomy performed?

There are different techniques but the most commonly used here is described. In the anaesthetic room you will have a drip inserted with some drugs that make you feel comfortable and relaxed. In theatre, the neuronavigation system will then be used to mark out the incision and a very small amount of hair shaved along the line of the incision before it is cleaned with antiseptic solutions and then local anaesthetic is inserted around the incision. This will sting a little for a few seconds and then go numb.

Some drapes are placed around the wound but you will be able to see the anaesthetic team and talk to them and be able to move your arms and legs freely during the operation. The operation then continues and you will hear some noises and the drilling sound briefly.

When the brain is exposed we will perform a procedure called cortical mapping. This involves stimulating the brain surface with a tiny electrical probe. If we stimulate a motor region of the brain it may cause twitching of a limb or your face; a sensory area will cause a tingling feeling; the speech areas will prevent you from speaking very briefly. By mapping out the important regions of the brain first we can aim to avoid and protect them during the operation. Whilst we remove the tumour we will continuously test your function, and if anything changes we will be able to stop.

This does not eliminate the risks of surgery but does likely reduce them.

After the tumour has been removed, all bleeding is stopped, the dura is closed with sutures, the bone is replaced with 3 mini-plates and the scalp is closed. The skin is closed with staples, the wound is dressed and often a head bandage is applied.

Channel 4 previously aired the programme, ‘The Operation: Surgery Live’ which showed consultant neurosurgeon Paul Grundy perform an awake craniotomy. Although the programme itself is no longer available to watch, you can still find information about the procedure, including questions answered by surgeon Paul Grundy on the website.

‘The Operation: Surgery Live’

This procedure will be performed either with a general anaesthetic or sedation (see awake craniotomy).

In the operating theatre you will be positioned on an operating table and your head will be supported by a headrest. The neuronavigation system (like a satellite navigation system) will then be used together with your pre-operative scan data to precisely locate the site for the tumour (target) and to determine an entry point, which can then be marked on the scalp. A small incision can then be marked on the scalp and a very small amount of hair shaved along the line of the incision before it is cleaned with antiseptic solutions and then surrounded by surgical drapes. A small injection of local anaesthetic is used: this stings for a few seconds only if you are awake.

The skull is exposed by making an incision in the scalp and then a high-speed drill is used to make a small burr hole through the skull to reveal the underlying dura (the outermost layer of the brain). A special drill (craniotome) is then used to cut a disc of bone, which is removed from the dura. The dura can then be incised to reveal the underlying brain (and tumour). If the tumour lies on the surface of the brain (e.g. a meningioma) it is carefully dissected from the brain and removed. If the tumour lies within the brain substance then it is necessary to incise the surface of the brain and open the brain down onto the surface of the tumour and then the mass can be removed.

For some tumours it is possible to remove the entire tumour and likely produce a cure (e.g. meningioma). This is called a gross total resection. For many intrinsic brain tumours the surgeon aims to remove as much of the tumour as possible (and safely) but there will inevitably be microscopic remnants of the tumour in the surrounding brain (e.g. glioma).

After the tumour has been removed, all bleeding is stopped, the dura is closed with sutures, the bone flap is replaced with 3 mini-plates and the scalp is closed. The skin is closed with staples, the wound is dressed and often a head bandage is applied. It’s all done!

This technology was pioneered by Prof. Peter Black. This technique supports neurosurgeons in the attempt to enhance resection, even in the most delicate and inaccessible areas of the brain. Sometimes it is difficult for a surgeon to distinguish the tumour from the tissue surrounding it. It does not make a neurosurgeon a better neurosurgeon; it’s just another tool to be used.

An intraoperative MRI works between the magnets in the open space, which is an operating theatre. Because the magnets can be used at any time during the surgery real time images of the brain can be seen as the surgeon operates. The extent of the resection can be monitored with periodic images throughout, which ensures a more accurate resection and is safer because any brain bleeds can be dealt with quickly.

This technology is now available in the UK. To find out more, speak to your consultant or clinical team. 

This is a new technique and sometimes using lasers can help to remove a brain tumour. Laser interstitial thermal therapy (LITT) uses an MRI-guided laser probe, passed through a small bur hole in the skull, to deliver heat and coagulate the tumour from the inside.It involves a craniotomy.

It is not available on the NHS.  It is not likely to make inoperable tumours removable and there is no good quality evidence to show that lasers improve the safety and efficiency of surgery.

Did this information make you feel more resourced, more confident or more in control?

Date published: 17-05-2009
Last edited: 28-02-2018
Due for review: 28-02-2021

sidebar brainbox

Introduction

The Brain Tumour Data Dashboard lets you explore up -to-date, population level data about the brain tumours diagnosed in England between 2013 and 2015. Using the drop down menus on the left you can select different groups of patients to view in the charts below. In these charts the number of patients for every 100 diagnoses is displayed as images of people. Patients have been grouped by date of diagnosis, type of tumour, age, gender, and region in England.

For each group of patients you can explore the different routes to diagnosis, the proportion of those who received chemotherapy or radiotherapy, as well as the survival of the patients within each group. For more information about what these metrics mean please see the glossary.

How to use

  1. Select the year of diagnosis using the drop down menu.
  2. Select your patient group of interest from the four drop down menus in the following order:
    1. Tumour group
    2. Age at diagnosis
    3. Region of England
    4. Gender of patient
  3. To view a second chart to compare different groups of patients, click the ‘compare’ button.The second chart will appear below the first chart.

*Note that the tool is best used on a laptop or tablet rather than a mobile phone*

Unavailable data

Some of the data in these charts is not available.There are two main reasons for this:

  1. How the data has been grouped

If you cannot select a patient group from the drop down menus, the data is unavailable because of how the data has been organised.

Public Health England has grouped the data like a branching tree. The bottom of the tree contains all the patients with brain tumours, and then each branch divides the data by a certain characteristics, like age, or location of tumour. But the data is divided in an order, starting with location of the tumour (endocrine or brain), then by age, region, and gender. Age is at the start because it makes a bigger difference to survival rates and treatment rates than gender or region. Sometimes, after the data has been split by type of tumour and age, there is not enough data to be split again. This is because to protect patient confidentiality groups cannot contain less than 100 patients. Because some groups cannot be split further, you cannot create ‘totals’ for everyone by region or gender. For example, you cannot see results for all ages by region, or all brain tumours by gender. If these totals were calculated and released, it might be possible to identify patients, which is why Public Health England cannot release this data.

  1. Statistical reasons and data availability

If you can select a patient group from the chart menus, but the chart does not display, the data is unavailable for one of several reasons:

  1. Data is not yet available for the selected year from Public Health England.
  2. Data is not available because the data quality is too poor to release this statistic.
  3. Data is not available as the statistic is not appropriate for this group.
  4. Data is not available because the standard error of the estimate was greater than 20% and so the estimate has been supressed.

Up to date brain tumour data

Brain tumour data may influence the decisions you make about your care. Data also helps you understand the bigger picture, or landscape, in which you find yourself.

Brain tumour data and statistics influence the focus, and work of organisations like brainstrust. The information helps us to understand the scale and impact of the problems we are setting out to solve.

This tool helps you understand the landscape in which you find yourself having been diagnosed with a brain tumour. This landscape can be particularly tricky to navigate as there are many different types of brain tumour, all of which have a different impact.

The information you see represents the most up-to-date, official, population level brain tumour data available for England. Over time we will be adding to the brain tumour data available and publishing reports, with recommendations, as a result of what we learn from this data.

The data behind this content has come from Public Health England’s National Cancer Registration and Analysis Service (NCRAS) and is a direct result of the ‘Get Data Out’ project.

This project provides anonymised population level brain tumour data for public use in the form of standard output tables, accessible here: http://cancerdata.nhs.uk/standardoutput

Incidence

The number or rate (per head of population) of new cases of a disease diagnosed in a given population during a specified time period (usually a calendar year). The crude rate is the total number of cases divided by the mid-year population, usually expressed per 100,000 population.

Malignant

Malignant tumours which grow by invasion into surrounding tissues and have the ability to metastasise to distant sites

Mortality

The number or rate (per head of population) of deaths in a given population during a specified time period (usually a calendar year). The crude rate is the total number of deaths divided by the mid-year population, usually expressed per 100,000 population.

Non-malignant

Not cancerousNon-malignant tumours may grow larger but do not spread to other parts of the body.

Survival

The length of time from the date of diagnosis for a disease, such as cancer, that patients diagnosed with the disease are still alive. In a clinical trial, measuring the survival is one way to see how well a new treatment works. Also called ‘overall survival’ or ‘OS’.

Routes to Diagnosis

Under the ‘Routes to Diagnosis’ tab in the Brain Tumour Data Dashboard, you can explore the ways patients have been diagnosed with brain tumours. There are many ways, or routes, for cancers to be diagnosed in the NHS. A ‘route to diagnosis’ is the series of events between a patient and the healthcare system that leads to a diagnosis of cancer. The routes include:

  1. Two Week Wait

Patients are urgently referred by their GP for suspected cancer via the Two Week Wait system and are seen by a specialist within 2 weeks where they are diagnosed.

  1. GP referral

Diagnosis via a GP referral includes routine and urgent referrals where the patient was not referred under the Two Week Wait system.

  1. Emergency Presentation

Cancers can be diagnosed via emergency situations such as via A&E, emergency GP referral, emergency transfer or emergency admission.

  1. Outpatient

Outpatient cancer diagnoses include diagnoses via an elective route which started with an outpatient appointment that is either a self-referral or consultant to consultant referral. (It does not include those under the Two Week Wait referral system).

  1. Inpatient elective

Diagnosis via an inpatient elective route is where diagnosis occurs after the patient has been admitted into secondary care from a waiting list, or where the admission is booked or planned.

  1. Death Certificate Only

Diagnoses made by Death Certificate Only are made where there is no more information about the cancer diagnosis other than the cancer related death notifications. The date of diagnosis is the same as that of the date of death.

  1. Unknown

For some patients with a cancer diagnosis, there is no relevant data available to understand the route to diagnosis.

 

More information

If any of the statistical terms in this section of the brainstrust website are hard to understand, we recommend looking them up here:

Cancer Research UK’s Cancer Statistics Explained

http://www.cancerresearchuk.org/health-professional/cancer-statistics/cancer-stats-explained/statistics-terminology-explained#heading-Seven

If you are looking for help understanding terms relating specifically to brain tumours, and treatment, then the brainstrust glossary is available here:

https://www.brainstrust.org.uk/advice-glossary.php