This document discusses principles of surgical approaches to central nervous system (CNS) lesions. It covers brain and spine lesions and various surgical techniques. For the brain, it describes common lesion types and goals of surgery. It then explains different surgical approaches like craniotomy, craniectomy, endoscopy, and stereotactic procedures. For the spine, it outlines common lesion locations and types of tumors. It also discusses posterior and anterior surgical approaches to access different spinal regions. The document provides examples of various patients who underwent these procedures.

1. Principle of surgical approach to
CNS lesion
Dr. Md. Shafiul Alam
Associate Professor
NINS&H
Dhaka, Bangladesh.

3. CNS lesion includes-
- Brain lesion
- Spine lesion

4. BRAIN

5. Common Brain lesions
(Surgical)
• Congenital
• Infective
• Vascular
• Tumour
• Degenerative

6. Aim of surgical tratment
• Curative
• Diagnostic

7. Surgery
Surgery is the primary treatment for brain tumors that
can be removed without causing severe damage.
Many benign (non-cancerous) tumors are treated only
by surgery.
Most malignant (cancerous) tumors, however, require
treatment in addition to the surgery, such as radiation
therapy and/or chemotherapy.

8. The goals of surgical treatment for brain tumors are
multiple and may include one or more of the following:
• Confirm diagnosis by obtaining tissue that is examined
under a microscope.
• Remove all or as much of the tumor as possible.
• Reduce symptoms and improve quality of life by
relieving intracranial pressure caused by the cancer.
• Provide access for implantation of internal
chemotherapy or radiation.
• Provide access for delivering intra-surgical treatments,
including hypertherapy or laser surgery.

9. Types
The most common types of surgery for brain tumors
are listed below. It is important to note that all of these
procedures are performed on patients who are either
asleep or heavily sedated

10. • Biopsy: The surgical removal of a sample of tumor
tissue.
• Craniotomy: The surgical removal of a portion of the
skull. Doing so allows the neurosurgeon to find the
tumor and remove as much of it as possible. The
piece of skull that was removed is replaced following
surgery.

11. • Craniectomy: Very similar to a craniotomy. The main
difference is that, in this procedure, the portion of
the skull that was removed to allow access to the
brain is not replaced.
• Debulking: The surgical reduction of the size of the
tumor.

12. • Partial Removal: The surgical removal of only part of
the tumor (due to risk of neurological damage).
• Complete Removal: The surgical removal of the
entire tumor. The surgeon often can tell if regrowth
is likely based on the type of tumor.

13. • Skull Base Surgery: Refers both to the location of a
tumor as well as a specialized technique used to
remove a tumor in that area.
• Transphenoidal Surgery: An approach often used to
operate on pituitary adenomas and
craniopharyngiomas.

14. Approach to the Brain
• Craniotomy
• Craniectomy
• Endoscopic
• Steriotactic

15. Craniotomy
Craniotomy is a surgical procedure where an opening is
made in the skull to enable to access and expose the
brain.

16. Pterional craniotomy:
-Anterior circulation aneurysm
-Basilar apex and superior cerebellar aneurysm
-Supraseller lesion
-Medial sphenoid wing tumours

18. F/25, Pituitary adenoma

19. M/25, Craniopharyngioma

20. Temporal craniotomy:
-Temporal lobe biopsy
-Temporal lobectomy
-Tumour and AVM of temporal lobe
-Small laterally located vestibular schwannoma
-Access to floor of middle cranial fossa

22. Frontal craniotomy:
-Access to frontal lobe
-Approach third ventricle and sellar tumour
-Repair of ethmoidal CSF fistula

24. M/40, Olfactory groove Meningioma

26. Parietal craniotomy:

27. M/50, Meningioma

28. Histipathology

29. Craniectomy
Craniectomy is a surgery done to remove a part of skull
in order to relieve pressure in that area when your
brain swells. It’s also done to treat conditions at CP
angle region.
-Decmpresive Craniectomy
-Suboccipital Craniectomy

30. Suboccipital Craniectomy:
-To gain access to cerebellum and CP angle
-To one vertebral artery
-Posterior brain stem, fourth ventricle, pineal
region
-Extreme lateral posterior fossa approach

32. M/30, Rt. CP< lesion

33. M/48, Rt. CP< complex lesion

34. F/35, Rt. CP< meningioma
Pre-op MRI Post-op CT

35. M/32, Post. Fossa SOL (Midline)

36. Endoscopic
Use of endoscope in Neurosurgery is increasing day by
day.

37. Indication of Neuroendoscopy:
-ETV for obstructive hydrocephalus
-Marsupialization of arachnoid cysts
-Excision of colloid cysts of the third ventricle
-Removal of small intraventricular tumors
-Biopsy of some intra- and paraventricular lesions.

38. Transsphenoidal approach:
-pituitary adenoma
-treatment of CSF leaks of the anterior skull base

39. F/34, Pituitary macroadenoma

40. Transesphenoidal Approach
Post-op CT

41. Stereotactic
Stereotactic neurosurgery involves mapping the brain
in a three dimensional coordinate system. With the
help of MRI and CT scans and 3D computer
workstations, neurosurgeons are able to accurately
target any area of the brain in stereotactic space (3D
coordinate system).

43. Stereotactic brain biopsy is a minimally invasive
procedure that uses this technology to obtain samples
of brain tissue for diagnostic purposes.
This procedure is used by neurosurgeons to obtain
tissue samples of areas within the brain that are
suspicious for tumors or infections.

44. The main indications for stereotactic biopsy are:
-deep-seated lesions
-multiple lesions
-lesions in a surgically poor candidate who
cannot tolerate anesthesia.

45. M/60, Multiple SOL

46. M/12, Brain stem lesion

47. Awake craniotomy
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 done under short acting anaesthetic agent and
regional skull block.

48. Indication:
-Surgery in eloquent brain
-Removal of brain stem tumour
-Some seizure surgery

49. M/46, Meningioma
Per-op MRI Post-op CT

50. SPINE

51. Common spine lesion
(Surgical)
-Congenital
-Infective
-Vascular
-Tumour
-Degenerative

52. Types of Spinal Tumors
According to location:
-Extradural
-Intradural extramedullary
-Intramedullary

53. Extradural:
These tumors involve the bones of the vertebral column.
- Secondary or metastatic: Most common
The most common metastatic spinal tumors in women
are from the breast and lung. In men, metastatic spinal
tumors are most often from the prostate and lung.

54. M/45, Secondaries

55. CT Guided FNAC

56. -Primary:
Tumors arising from vertebral bone and cartilage cells
also occur in the spine.
-osteoid osteoma
-osteoblastoma
-giant cell tumor
-osteogenic sarcoma
-chordoma
-chondrosarcoma
-Ewing’s sarcoma

58. M/83, Sacral Chordoma

59. F/21, Aneurysmal bone cyst

61. Intradural extramedullary
These tumors are located inside the dura, but outside the substance of the
spinal cord.
-Meningiomas
-Nerve sheath tumors (schwannomas and
neurofibromas)
These tumors are usually benign.
-Filum terminale ependymomas
arise just below the spinal cord, in the lumbar (lower) and sacral
(lowest) spinal canal. Nearly all are benign.

62. M/28, IDEM (Schwannoma)

63. Histopathology

64. M/29, IDEM

65. F/17, IDEM (Neurofibroma)

66. Intramedullary tumor:
are located inside the substance of the spinal cord.
-Astrocytoma
-ependymoma
-Hemangioblastoma

67. F/34, Ependymoma

69. Approach to the spine
Posterior:
-Laminectomy
-Laminotomy
-Laminopasty
Anterior:
-Cervical
-Thoracic (Transethoracic)
-Lumber (Transperitoneal)

71. Laminectomy:
A laminectomy is a surgical procedure that removes a
portion of the vertebral bone called the lamina. The
back muscles are pushed aside rather than cut and the
parts of the vertebra adjacent to the lamina are left
intact.

72. F/29, Intradural abscess (Tubercular)

73. Histopathology

74. M/43, Spinal arachnoid cyst

76. Thank You