The neurosurgery operative skill can be mastered by learning 2 basic steps
1. Starts with making Burr hole & craniotomy, corticectomy
2. Suboccipital craniectomy
2. Laminectomy
4. Laminectomy, durotomy , myelotomy
For operating all supratentorial lesions, craniotomy is done.
For operating midline posterior fossa or infra tentorial lesions, sub occipital craniotomy is performed.
For operating spinal lesions, laminectomy is very commonly performed. This is basic neurosurgical skill.
The surface marking and understanding of the applied neuroanatomy is important. Once you reach the brain surface after craniotomy and opening of the dura, all he cortical surface looks similar, i.e., clci, gyri, CSF in subarachnoid space, and cortical vessels. So, there is only one way of identifying intracranial cerebral structures, like frontal lobe, parietal lobe , temporal lobe or occipital lobe is by surface marking of the skull, before start of the surgery. Similar principle is applied for identifying motor strip, speech area, hearing area, visual area or any other eloquent area of cerebral cortex, is by surface marking. So, before draping of the surgical area, a marking is made over the scalp.
Majority of the neurosurgical procedures are done through non eloquent area of the brain, especially, right middle frontal gyrus or right superior parietal lobule.
Twist drill and ventriclostomy is a life saving procedure in patients of acute hydrocephalus.
In pyogenic meningitis with hydrocephalus, external ventricular drainage (EVD) is done.
Vemtriculo-peritoneal shunt surgery (VP shunt) is very common neurosurgical procedure. This procedure must be mastered and it must be repeated many times. Everyone should be well versed with all complications associated with this procedure.
Endoscopic third vetriculostomy (ETV) is another neurosurgical procedure for treatment of hydrocephalus.
During surgery, lamina terminals is perforated to drain CSF.
So, if any neurosurgeon regularly practices these 5 procedures, namely twist drill, EVD, VP shunt, ETV, opening of laminate terminals, it means that he or she has perfected the art of CSF diversion procedure.
The management of head injury involves 5 neurosurgical procedures, 1. Depressed fracture, 2. Evacuation of Extradural hematoma, 3. Evacuation of acute subdural hematoma, 4. Evacuation of intracerebral hematoma, 5. Contusectomy. Surgery for depressed fracture is easy. If there is communited depressed fractures and there if lactation over the depressed fracture segment, a linear incision is made in the scalp and retracted. Bone fragments are removed. Sometimes a small bur hole is made just adjacent to the depressed segment, in order to elevate it. Sometimes, dural repair is also required. CT scan is the investigation of choice of managing head injury patients. For evacuation of extradural hematoma a preoperative planning is done to make a craniotomy just over the EDH. Dural hitches are applied in the dura and the incision is closed in layers. For acute subdural hematoma evacuation a very large frontoteporoparietal craniotomy is made along with duratomy to reduce the intracranial pressure. Acute subdural hematoma is very commonly associated with brain edema, so wide decompressive craniectomy is done.
In cases of intraparenchymal hemorrhagic contusions associated with midline shift, craniotomy and contusectomy is done. Sometimes frontal or temporal lobectomy is done to reduce mortality. Management of head injury is challenging as it requires prompt neurosurgical decisions in emergency situations. Neurosurgeons may be the first responder during management of neurotrauma patients. It necessitates the availability of neurosurgeon round the clock, 24X7, 365 days. This situation makes a neurosurgeon indispensable. It is not only the surgical procedure which matters but it involves management of emotional trauma of the patients and their relatives and managing medicolegal issues.
