The huge advances in technology we have experienced in the last 150 years are nothing short of amazing. Certainly medicine has benefited from this, and brain surgery especially so.
A century ago, surgeons had limited equipment to visualize, biopsy and operate on brain tumors.
As a result, many patients had to undergo a kind of “blind” radiation and chemotherapy, meaning that the focus of treatment had to be approximated.
The inaccuracy of this approach naturally led to undesirable and unnecessary side effects.
Today, surgeons have increasingly sophisticated technology to access some of the deepest recesses of the brain. Thanks to the development of the surgical microscope, neurosurgeons can be more accurate than ever before.
Neurosurgeons Dr. Jeffrey Bruce and Dr. Adam Sonabend of the Brain Tumor Center at Columbia University Medical Center/NewYork-Presbyterian Hospital have used these advances to pay particularly close attention to the pineal gland—a small, pine-cone-shaped area deep in the brain thought to help regulate our sleep-wake cycles.
The pineal gland lies deep in the center of the brain and can be tricky to reach surgically. When a tumor develops in the gland, the challenge is to get to it without sacrificing surrounding structures that are critical to the brain’s functioning. Once they reach the tumor, the surgeons then want to remove as much of it as possible without damaging neighboring brain tissue or blood vessels.
This is only possible because of advanced imaging technology and the advanced skill set of neurosurgeons like those at Columbia Neurosurgery. Dr. Bruce has performed surgery on more pineal tumors than anybody in the world.
Every case of a pineal tumor is unique, and the treatment must be individualized. This starts with a careful study of the patient’s anatomy and the characteristics of the tumor, using modern laboratory and x-ray studies. With the knowledge they have from these tests doctors can more accurately and with greater safety proceed with surgical removal of the tumor.
In their paper, Dr. Bruce and Dr. Sonabend explain tumor-removal approaches developed and honed at the Department of Neurosurgery, including the infratentorial supracerebellar and occipital transtentorial approaches.
The first thing to notice about the names of these approaches are the two words “infratentorial” and “transtentorial.” They both have the root word “tentorial” in common, the first meaning “below the tentorium,” and the second meaning “through the tentorium.”
The tentorium is a tough membrane that divides the upper part of the brain (cerebrum) from the brain’s lower structures, including the cerebellum—a pair of lobes that are important in coordination and balance.
Most pineal tumors are located below the tentorium (infratentorial) and can be reached by what is known as the infratentorial supracerebellar (above the cerebellum) approach. The patient is generally placed in a sitting, slouched position, allowing gravity to cause the cerebellum to separate from the rest of the brain slightly. This exposes the pineal gland tumor and allows the surgeon to enter the area between the tentorium and the cerebellum.
Alternatively, surgeons may access the pineal tumor using the occipital transtentorial approach. In this case the patient lies on his side or stomach. The surgeons enter the brain from above the tentorium and near the back of the brain (the occipital lobe). They then surgically divide (or go through) the tentorium to reach the pineal area.
Carefully planning which route to take helps the surgeons reach the tumor without affecting the critical blood vessels and tissues that commonly lie near it.
With a mastery of the advancements in technology and microsurgical techniques described in their paper, neurosurgeons like Dr. Bruce and Dr. Sonabend are now able to diagnose and treat pineal tumors better and with fewer complications than ever before.
*Full list of authors: Adam M. Sonabend, Stephen Bowden, Jeffrey N. Bruce
Read the article abstract here.
Learn more about the Brain Tumor Center here.
Learn more about Columbia Neurosurgeons and the Department of Neurosurgery at Columbia here.
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