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General Decision-Making Process

Aaron Cohen-Gadol, M.D.

November 13, 2021

Patients suffering from a brain tumor or other disorder of the central nervous system may become frustrated by differing medical opinions on the treatment plan for their condition. In the end, the decision to proceed with surgery is up to the patient after he or she has secured an objective opinion about the treatment options. Here, I discuss possible factors that can influence whether neurosurgery is right for you and, if so, how to determine with which neurosurgeon to proceed.

Is Neurosurgery Right for You?

Operating on the brain carries mild to moderate risks of long-term complications, especially if the tumor lies within a critical area that is difficult for the surgeon to reach surgically. Although the chance of getting worse after surgery is low, surgery can become too risky in certain situations, and other treatment options, such as radiation therapy, should be pursued. The surgeon should be intimately familiar with all options and offer these options to the patient objectively. The surgeon’s preference for treatment options that are reasonably equal should not be the final factor.

Neurosurgeons often consider the following information when determining whether surgery is appropriate.

Tumor Characteristics

During an operation, the surgeon must first reach the tumor with surgical instruments and then remove as much of it as safely possible. This procedure poses the least risk to the patient when a tumor is easy to reach and visualize, isolated from critical structures, and immediately differentiable from the brain and does not stick to surrounding structures.

  • Location and Accessibility: Tumors in areas that are difficult to reach surgically (for example, deeper in the brain or at the skull base) may require extensive manipulation of brain tissues and surrounding structures. Once reached, the tumor still might be difficult to visualize and remove completely, which can allow the tumor to grow back. Special expertise for surgery of such tumors is required.
  • Proximity to Critical Structures: Tumors near or infiltrating specific areas of the brain that control critical functions such as movement, speech, sensation, and vision (“eloquent areas”) increase the risk of functional impairment after the procedure.
  • Size: In some cases, smaller lesions of the brain can be treated with radiation therapy or other treatments alone. In other rare cases, radiation can be used to reduce the size of a larger lesion before surgery.
  • Type: Some tumor types are known to grow very slowly. Observation, focused radiation (radiosurgery), or other treatments might be sufficient alternatives to surgery in these cases. It is important to emphasize that small, slow-growing tumors that do not produce symptoms may simply be observed over time. Just because you have an incidental small tumor does not mean that you need surgery.

Patient Characteristics

Patients undergoing surgery must be able to physically tolerate the surgery and recovery process, which could include physical therapy to regain maximal functioning. If the tumor is found incidentally and the patient is experiencing no symptoms, treatment might not be necessary. Observation might be the preferred option for benign and slow-growing tumors in older patients. Such patients might undergo periodic magnetic resonance imaging (MRI) to ensure that the tumor is not growing.

How to Choose a Neurosurgeon

Choosing the right neurosurgeon for your procedure is critical. Patient reviews and hospital and/or institute reputation for a specific condition can be taken into consideration, but they should not be the final deciding factors. The decision to proceed with a neurosurgeon depends on multiple other factors. Although there are no set criteria for determining the neurosurgeon whom a patient should trust, we encourage considering the following:

  • Specialized Experience: Find a neurosurgeon with extensive experience in treating your condition based on discussions with other physicians. The best hospitals might not provide you with the best surgeons.  Ask if the neurosurgeon has received additional training, such as a fellowship, in the specialty of your surgery (for example, skull base tumors). Although the amount of research that the surgeon has performed on the topic might be important, it is especially critical to know the clinical volume of patients who have been under their care.
  • Honesty and Integrity: Patients need to find a neurosurgeon who prioritizes the patient’s best interest, is willing to discuss all possible treatment options, and is completely honest about his or her own surgical experience with a condition. Such surgeons may offer valuable referrals to a colleague with more knowledge on the specific condition or surgical approach. Open communication is critical for the patient to decide on the best possible path of treatment and know what to expect.
  • Continuing Education: Neurosurgery is a dynamic field that is being updated constantly with new research, surgical techniques, and treatment modalities. Find a neurosurgeon who stays well informed of advances in the field and can offer you the best that the field currently has to offer. Have a discussion with your surgeon about current treatment option risks and benefits.

Securing second and third opinions is a critical pathway for finding your best treatment option.

Seeking the right treatment plan and neurosurgeon for the diagnosis of a brain tumor or any other central nervous system lesion can be an extremely challenging journey. Explore our other chapters to learn more about your condition and read about inspiring patient stories to see how life can continue after a safe and effective surgery.

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