the scan images both the tumor and the frame, it is able to show the exact location of the tumor in three dimensions in relation to the head frame. The neurosurgeon takes these coordinates and precisely inserts a probe through a small incision in the skull to perform the biopsy or other procedure. The patient’s head is in the stereotactic frame on the left side of the photo. John Ruge, MD, Midwest Children’s Brain Tumor Center at Advocate Lutheran General Hospital, Park Ridge, Illinois 22 AMERICAN BRAIN TUMOR ASSOCIATION It also has some limitations: The frame can sometimes obstruct the neurosurgeon’s view of the site; it can be time-consuming to manually set the frame and read the scans; there is a limited space to work within the radius of the arc; and the scans and surgery usually need to be performed the same day. Frameless Stereotactic Surgery (Surgical Navigation, Neuronavigation) Instead of using an external frame as a reference point, frameless stereotactic surgery uses tiny markers, called fiducial markers, that are taped or glued to the head before the brain is scanned. The scan is then loaded into a planning and navigation computer, producing a three-dimensional representation of the head, brain and tumor. During surgery these markers are touched with a pointing device, called a “wand.” Identified on the scan, the computer “knows” where the surgical instrument is during the procedure in relation to the brain and tumor. There are many FDA-approved neuronavigation systems. Most are fully computerized guidance systems that give the neurosurgeon fast, continuous, “real-time,” three-dimensional information about the location of the tumor. Some use the patient’s own anatomy (eyes and nose) as reference points instead of the above-mentioned fiducial markers. These tools are particularly useful for complicated areas like skull base surgery and when multiple tumors must be removed. Microscope-Based Devices Also used during stereotactic surgical procedures are microscope-based devices. This technology tracks the exact position of the operating microscope with the fiducial markers placed on the head, giving precise coordinates for the tumor. Previous CT or MRI scans are superimposed in the microscope so the neurosurgeon can see the tumor’s image as they work. SURGERY www.abta.org 23 ROBOTIC SURGERY The use of robotics to help surgeons perform delicate and prolonged surgeries is an important advancement in the field of microsurgery. Commonly called telerobotics or telepresence surgery, the system consists of a computer, microscope and mechanical arms that hold the appropriate instruments. The robotic arms move by hand-operated controls that look and feel like the instruments a surgeon uses for surgery. The computer reads the hand control movements and precisely moves the robotic arms in like manner to perform the procedure. Telerobotic surgery is projected to be a great advance in neurosurgery once the technology has been refined. For now, telerobotic surgery is largely limited to research purposes. In the future, the use of telerobotic surgery could: • Reduce the demands on the surgeon during long and difficult procedures • Increase technical performance with greater precision • Allow surgeons to perform surgery from remote locations Prototype of a surgical robot Hunter Downs, PhD, NovaSol, Robotics Research 1607 test platform 24 AMERICAN BRAIN TUMOR ASSOCIATION ULTRASONIC ASPIRATION This tool uses the vibration created by ultrasonic waves to break tumors apart and then suction out, or aspirate, the pieces. Suctioning minimizes the possibility of spreading tumor cells to other parts of the brain. This technique does not work as well on tumors that have a hard consistency. DO I NEED A SECOND OPINION ABOUT SURGERY? A second opinion is not always necessary. Many people obtain a second opinion and some get several opinions before proceeding with treatment. Common reasons for searching out a second opinion include: • The peace of mind that comes with confirming the diagnosis and treatment plan with another doctor • Exploring other treatment options • Satisfying your insurance company’s requirement for a second opinion (some insurers require a second opinion before paying surgical claims) If you decide to seek another opinion there are several ways to do so: • Ask your doctor to suggest someone with the expertise you need. • Check with a hospital physician referral service that can direct you to members of their staff with a specialty in treating brain tumors. • Confirm whether your insurance company requires you to stay within their network of providers. If so, they can provide you with names of physicians with experience in brain tumor treatment. If you choose to be treated out of network, be clear about what your costs will be. • You can also visit ABTA’s website, www.abta.org, for a listing of brain tumor treatment centers throughout the United States. SURGERY www.abta.org 25 WHAT IS BOARD CERTIFICATION? HOW DO I KNOW IF MY NEUROSURGEON IS BOARD CERTIFIED? Board certification is an advanced credential that indicates a high degree of competence and training in a certain medical specialty. A neurosurgeon seeking board certification within the American Board of Neurological Surgery (ABNS) must submit to a rigorous