Cranitomies

Definition

Craniotomy: The surgical removal of part of the skull (skull flap) in order to gain access to the brain.

Intro

A craniotomy is done whenever a surgeon needs to gain access to the brain, and this can be done for a number of reasons (see “Use-case” section), and the removal of the part of the skull is usually not a very high risk process, with low mortality and morbidity rates. This surgery is usually performed by a neurosurgeon, as most of the issues that would require a craniotomy would be neurological by nature. By definition, a craniotomy is usually a gateway to many other procedures, and is necessary for the majority of neurological surgeries. The word “craniotomy” (CRAY-NEE-AW-TOM-EE) can be traced back to primarily Greek roots, although one of the roots has been latinized. This latinized root is “Kranion”, which means “of the skull”, and the second part of the word comes from the root “-tomy”, which essentially means “a cutting”.

Use-case

Craniotomies can be used for a vast number of procedures, and a few are as follows:

To remove a brain tumor
To retrieve a sample of brain tissue for further testing
To remove blood clots that reside in the brain
To relieve built up pressure in the brain after a traumatic incident
To repair skull fractures
To repair brain aneurysms

(www.cancer.gov)

The list of procedures made possible by craniotomies is long, and the list above is just a small sample of its contents. The beauty of this procedure is that it can be the entirety of the surgery by itself (for example, by releasing pressure in the brain), or it can be the first step towards a more complicated surgery like removing a cancerous tumor or repairing a brain aneurysm.

What does this solve

This procedure mainly solves the problem of accessibility, as without it, complex neurological surgeries would be impossible.

Operation

The operation itself is quite simple, with only a few main steps. First, the surgeon must prepare their patient (anesthetic, etc.) and make the initial cut of the skin. Then, the surgeon will use a medical drill to make holes in the skull, which is then carefully cut open with the use of a medical saw. The surgeon must keep the skull flap in order to replace it after the completion of the operation. This exposes the brain, which is covered by a protective film called the dura. The dura is then carefully pulled away and cut open, fully exposing the brain. At this point, any number of different things can happen, depending on what type of procedure the craniotomy was initially used for (this can be entirely skipped if the objective of the operation has already been accomplished). After the problem in the brain is repaired, the dura must be repaired, as it will not heal on its own. This involves soft tissue grafting, and if the dura is not completely repaired, it may result in a CSF leak. After the dura is repaired, the skull flap is replaced and secured with small metal brackets. Finally, the skin is stitched over this, and the operation is complete.

Potential difficulties

Where procedures have gone wrong in the past

Some potential complications of craniotomies are potential seizures and strokes, a CSF leak, swelling of the brain, and nerve damage. These complications greatly contribute to the mortality and morbidity rates of a craniotomy.

Human error

Although craniotomies are performed by highly skilled neurosurgeons, there is still an aspect of human error that has to be accounted for at all times, no matter the surgery or the degree of difficulty. Surgeons are humans too, and although it is uncommon, they do make mistakes sometimes, and these might contribute to some eventual complications.

High difficulty of brain surgery

In addition, brain surgery is also notoriously difficult, and a higher degree of difficulty brings a shortage of people who can perform the task efficiently or even at all. This is slightly nullified in this case though, given the fact that a craniotomy is an entry level operation for almost all neurosurgeons and has been done thousands of times but many different surgeons, making it a generally safe procedure.

Difference in difficulty between use-cases

Something can also be said in the difference in difficulty between the different use cases of a craniotomy, with simply performing one to relieve pressure on the brain being much less of a risk than performing one and then proceeding to perform an operation on the brain itself.

Post operative needs

Duration for hospital stay

The duration of a patient’s hospital stay will vary on the type of procedure performed, as well as how they are doing post-op, but generally after a craniotomy the stay in hospital is roughly a week (www.my.clevelandclinic.org). Your healthcare professional will also provide you with information regarding how long of a break from work or school there must be, with some estimates ranging from 6-8 weeks, although a return to school, work or regular everyday life will mostly likely begin before this mark (again, depending on the advice given by your healthcare professional).

Medication

The general medication that is prescribed post-op for a craniotomy consists of steroids and anticonsulvant. The steroids are used to control the swelling after the operation, while the anticonsulvant is used in order to stop potential seizures before they happen. Do not start taking your usual medication without asking your doctor first, and do not start taking any new medication without receiving the ok from them either. This can result in further harm to your body, so always make sure to talk to your healthcare provider/doctor before taking any new medicine, especially after a surgery.

Warning signs

Some signs that you might want to look out for are:

Imbalance/problems with coordination
Seizures
Speech difficulty
Partial Paralysis
Infection

These are just a few of the many warning signs, and some of them may be par for the course of brain surgery, but always check with your healthcare provider.

Assistance

After brain surgery, you will most likely need to have someone stay at home with you for a couple of days to prevent the risk of any injury.

Side effects

There will be some side effects after a craniotomy. Some of the potential side effects are as follows:

Soreness on points of incision (where the surgeon has cut into the scalp)
Swelling of the eyes
Itchiness of the scalp

(www.myhealth.alberta.ca)

*Icing may help with soreness and itchiness.

Conclusion/Wrap-up

Craniotomies are one of the most essential procedures in the field of neurosurgery, if not sitting at the number one spot. It can either be the entirety of the procedure by itself, or simply the beginning of a much more complicated surgery to follow. It almost functions as a gateway to brain surgery and to the brain itself, and there is so much more that we can learn about both.

Vocab

Skull Flap: The part of the skull that is removed during a craniotomy (replaced upon completion of procedure)

Aneurysms: An excessive localized enlargement of an artery caused by a weakening of the artery wall.

Dura: The tough outermost membrane covering the brain and the spinal cord.

CSF: Cerebral Spinal Fluid.

Post-op: Post-operative.

Anticonsulvant: A drug used to prevent/reduce the severity epileptic fits or other convulsions.

Sources

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8860674/#:~:text=Systemic%20signs%20include%20urinary%20tract,%2D12%25%20%5B2%5D.

https://www.cancerresearchuk.org/about-cancer/brain-tumours/treatment/surgery/remove-brain-tumour

https://mayfieldclinic.com/pe-craniotomy.htm

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/craniotomy#:~:text=A%20medical%20drill%20may%20be,open%20to%20expose%20the%20brain.