Minimally Invasive Neurosurgery As Minimally Disruptive Neurosurgery

Minimally invasive neurosurgery is typically thought to be surgery through small openings. However, there is another interpretation. This interpretation suggests that minimally invasive neurosurgery is surgery minimally disruptive to the patient. Although it may not have a small opening in the scalp or the bone, it has as a goal the least possible effect on brain tissue around the abnormality being dealt with.

This concept of minimally disruptive neurosurgery is extremely important as a general principle for neurosurgical oncology in the last decade. Such techniques as brain mapping, functional magnetic resonance (MR), magnetoen-cephalography, and other systems that establish safe trajectories are valuable in achieving this goal.

Carrying out surgical procedures under intravenous sedation anesthesia has allowed the surgeon to operate in areas of vision, primary motor, or sensory cortex and in speech areas with significantly greater resection and lessening of morbidity (1,2). These techniques for low-grade gliomas, for example, allow resection of a tumor that may often act as an extraaxial mass, displacing tissue rather than destroying it. For larger malignant tumors, similar resection can be done with accuracy and safety (3,4).

Carrying out surgery under intravenous sedation allows direct mapping of the brain. However, a number of preoperative technologies that have also been used for achieving this kind of minimal invasiveness with minimal disruption. These include magnetoencephalography, functional MR, and diffusion tensor

From: Minimally Invasive Neurosurgery, edited by: M.R. Proctor and P.M. Black © Humana Press Inc., Totowa, NJ

imaging. Magnetoencephalography (5-9) uses the magnetic field of the brain to evaluate the region where a particular function is represented and is particularly useful for motor cortex analysis. It requires very sophisticated equipment and staff.

Functional MR appears to assess the change in blood flow on the surface of the cortex that accompanies a particular activity such as arm or hand movement or speech (10-12). Again, it requires sophisticated paradigms both for testing and analysis of data, (13-15), but is an extremely useful technology. Diffusion tensor imaging allows analysis of the fiber tracts leading from the cortex to the brainstem (16-18) It can be extremely helpful in defining motor and sensory tracts noninvasively (19,20).

Taken together, these techniques, which emphasize minimal disruption and therefore minimal invasiveness in the patient's life, have made neurosurgical oncology a newly revitalized specialty. For glioblastoma multiforme, they allow resection of discrete tumor, which markedly improves the morbidity after surgery and seems to increase survival (21-23). For low-grade gliomas, they have similarly revolutionized our ability to resect tumors. For metastatic tumors, it is now possible to combine them with localization techniques to be able to remove tumors even from eloquent areas (24).

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