Brain surgery assessments

A pioneering approach to using physiotherapists during awake craniotomies may improve patient function and quality of life, according to a case study by University Hospitals Coventry and Warwickshire NHS Trust.

During ‘awake’ surgery to remove a brain tumour, a patient undertakes physical tasks while specific areas of the brain are stimulated with electrodes. The neurosurgeon uses feedback from theatre staff on changes in strength or agility to help distinguish the tumour from functional parts of the brain.

In one of the first documented trials of its kind, physical tasks were assessed by a physiotherapist and occupational therapist, which allowed the neurosurgeon to remove a larger amount of the tumour, cutting it out to within 2mm of the brain’s motor function area.

The patient reported minimal sensory changes post-operatively, and the success of the procedure has led to three more awake craniotomies using physiotherapists at the same trust, with funding secured for one such operation every month.

Katy Padden, team lead physiotherapist neurosciences at the hospital, was asked to participate in the first surgery last November by neurosurgery consultant Sandeep Solanki in only her second week in the job. 

‘He was really keen for physiotherapy and occupational therapy to participate in his awake craniotomies to improve his patients’ outcomes,’ says Padden. ‘I’d never heard or seen physiotherapists doing that before. I’m not squeamish at all, so I thought, “let me in there, let’s see this brain”.’

Fortunately she had a wealth of experience to draw on, having worked in neurosurgery, neurology, neurotrauma and neuro-outpatient departments within two large major trauma hospitals.

Improving outcomes

Solanki was due to operate on a 26-year-old man who had experienced seizures, retrograde amnesia, numbness in his left arm and blurred vision. An MRI scan revealed a brain tumour in the patient’s right parietal lobe, an area that governs sensory perceptions such as taste, hearing, sight, touch and smell.

Due to the risk of neurological damage to the brain during surgery, coupled with wanting to remove as much of the tumour as possible, the awake craniotomy technique was chosen. 

‘Evidence shows it also has the added benefit of improved neurological outcomes, increased life expectancy, reduced anaesthesia-related complications, less likelihood of nausea and delirium, and reduced hospital length of stay,’ explains Padden.

Better brain mapping  

The aim was to draw on therapists’ expertise in neurological assessment to increase the accuracy of brain mapping, enabling the neurosurgeon to remove the largest amount of tumour possible without compromising brain function. Assessments are usually carried out by theatre staff who are not specialists in completing neuro assessments or identifying changes in neurological presentations with monitoring done by clinical support staff or not at all. 

‘Physios and occupational therapists are experts in evaluation of movement and function, and assessment throughout awake craniotomies can aid preservation of muscle strength, sensation, co-ordination and proprioception, hopefully resulting in improved functional outcomes and quality of life,’ Padden explains.

During the operation, the two therapists alerted the neurosurgeon to any changes in strength, sensation and dexterity while the patient performed repetitive motor tasks of both upper and lower limb such as grasp and release, and finger-thumb opposition. 

The therapists were able to identify subtle seizure activity in the left side of the face, and changes in sensation reported by the patient that may have been missed by non-specialists, according to Padden.

‘During a task, we could recognise the difference between fatigue and weakness. We could see when the patient was getting fatigued from repetitive movements and needed a break, or identify slight changes in the quality of movement, when his dexterity was starting to slip. These are quite subtle things that someone who’s not a therapist would not pick up. Plus the seizure in the face that we spotted would have been missed by someone who was only looking for changes in the hand movements.’

Providing expert feedback

Therapists are also able to monitor changes in sensation, which is not traditionally done during such surgeries. 

‘We can ask about sensation, and recognise what’s normal swelling during surgery and what is due to what’s happening in the brain tissue,’ Padden says.

Having the knowledge and agility to give instant feedback to the neurosurgeon was critical.

‘Communication is vital as the surgeon needs to respond very quickly to the therapists – it only takes the slip of a knife for things to go wrong.’ 

Solanki agrees: ‘The process requires both surgeon and therapist to have a strong relationship and feel comfortable communicating and working together, with neither feeling afraid to speak up if a problem is detected.’

The therapists’ more detailed and accurate feedback enabled Solanki to maximise the amount of tumour removed without damaging the nervous system. 

With therapists doing the assessments we can ask about sensation, and recognise what is down to normal swelling during surgery and what is due to what’s happening in the brain tissue.

Removing too much of the tumour could have led to the patient losing the use of his left arm. 

‘If you take too little, the patient may need more chemotherapy and even more surgery, so their quality of life is not good,’ adds Padden. ‘By removing most of the tumour without a neurological deficit, we hope to prolong the patient’s life. That’s the aim and that’s the benefit.

New area for physiotherapists

As one of the risks of awake craniotomies is the patient starting to panic, move or develop breathing difficulties during the operation, building a sense of trust is also crucial. 

Together with her OT colleague, Padden spent time explaining the procedure to the patient and conducting a neuro assessment before the operation. ‘Having this pre-op time gave the patient time to ask questions and enabled us to start building a nice rapport with them,’ she says.

‘We explained that during surgery we would be sat next to him and that when we asked him to do tasks he wouldn’t always be able to do them, and that sometimes his arm may move involuntarily. 

‘He said afterwards he was really glad we’d told him because as he was expecting it he didn’t panic, thinking ‘Oh my gosh I am going to be paralysed on that side’. 

‘Not being able to move can come as a terrifying shock for a split second, so we shouldn’t underestimate how essential the reassurance we provided was.’

The patient also commented on how comforting it was to have ‘familiar faces’ present during the operation. Using assessment information, Padden could also predict the effect on the patient after surgery and help him through the recovery more effectively. ‘It was nice to be able to say to him,

“You’re likely to feel quite numb tomorrow and hopefully that is down to the swelling but we’ll assess you further”.

Padden’s involvement in the awake craniotomy was a highlight of a distinguished career. ‘I’ve been lucky enough to have worked in a wide range of neurosciences settings,’ she says. ‘But being involved in this kind of exciting opportunity is the reason I came into this job. 

‘I don’t know anyone who has done this. Being in such an intriguing area of physiotherapy has caught people’s interest as it’s not something they expect you to do.’

She firmly believes taking up opportunities like this helps widen the scope and potential of physiotherapy as a whole. ‘It’s going to be really beneficial for physios within neurosciences. We can be seen as the people who get patients out of bed and walk them to the toilet and there’s so much more to our role.’

‘Hopefully by shouting about this a little bit people will start to see just how valuable physios are, the breadth of our skills and how we can contribute to and benefit patient outcomes in a way that perhaps wasn’t realised before.’