Craniotomy vs. Craniectomy vs. Cranioplasty

Learning about your upcoming surgery is a great way to help alleviate some of the stress you might be feeling during this time. However, some of the terminologies can be confusing, particularly when the words sound very similar. One particular example is trying to understand the differences between craniotomy vs. craniectomy vs. cranioplasty. The key difference between craniotomy and craniectomy is whether the skull bone is replaced after the procedure; in a craniotomy, the bone is replaced during the operation, while in a craniectomy, it is not replaced or may be replaced with a custom material or titanium mesh to cover the defect. The following information will further explain the differences between each, including the actual procedures, risks and benefits of each and what to expect during the recovery period.

The Procedures

The first step in understanding the differences between craniotomy, craniectomy and cranioplasty is to learn about the actual procedures. Each involves the skull (cranium) but the methods and treatment goals are unique.

Craniotomy

During a craniotomy procedure, the neurosurgeon makes a window in the bone to provide access to the area of interest. The craniotomy procedure provides access to various brain structures, including brain, fluid spaces, and blood vessels. Before the surgery is over, the bone window is replaced and secured with titanium plates and screws. There are no special precautions required for daily life when the bone is replaced, and the metal is MRI safe and does not alarm in a metal detector.

A craniotomy is typically performed as part of another procedure, providing a temporary window through the skull. Craniotomies are common as part of surgeries to treat brain tumors, vascular malformations and many other conditions of the brain where access is needed. Some surgeries to access the brain are performed through the nose, or endonasally, and the thin bone removed in these areas does not need to be replaced.

Craniectomy

A craniectomy is similar to a craniotomy, but the primary difference is the bone is not immediately replaced. A craniectomy is typically needed in an emergency situation, such as a traumatic brain injury, where a section of the skull is removed to relieve pressure. In these situations, a second surgery (cranioplasty) typically occurs once the swelling is gone. However, a craniectomy may also be necessary if there is a tumor within the bone itself or Craniectomy may be used in procedures to relieve chronic pressure as in the case of a Chiari malformation.

It is also used in the back part of the brain, where the bone is much thicker and it is safer to remove the bone than to make a window. Additionally, a craniectomy may be required for treating brain cancer, particularly when a tumor is present within the bone. When this occurs, the cranioplasty occurs during the same surgery as the craniectomy.

Cranioplasty

While craniotomy and cranioplasty involve removing bone, cranioplasty involves replacing it. If the bone has been removed during a craniectomy, the same piece may be preserved and replaced at a later time. However, if the bone has been damaged due to trauma or has cancer cells present, or is too thick as in the case of the posterior parts of the head, synthetic materials can also be used. Options include titanium, acrylic or synthetic bone substitute. Modern 3-D printing technologies are also used to create custom replacements that are a perfect fit.

Risks and Benefits

Your personal doctor will discuss the risks and benefits of your specific brain surgery as they relate to your individual case. However, understanding the general risks and benefits of craniotomy vs. craniectomy vs. cranioplasty can help you during that conversation.

Craniotomy

The primary benefit of a craniotomy is that it allows your neurosurgeon immediate access to the area within the skull requiring treatment. The bone is replaced at the end of the procedure, so no second surgery is required and no synthetic materials are used.

The risks of a craniotomy are both general surgical risks and risks specific to the procedure itself. Overall risks, which are shared amongst craniotomy & craniectomy & cranioplasty, include the following.

• Reaction to anesthesia
• Infection
• Bleeding
• Blood clots
• Craniotomy-specific risks have more to do with the definitive surgery that is performed in the brain.

Craniectomy

The immediate benefit of a craniectomy is the relief of pressure in an emergency situation. When a craniectomy is performed, it is often to preserve life, brain function or both. Similarly, if a craniectomy is performed to remove a section of skull containing a tumor, this can prevent the further growth and/or spread of cancer cells. When a craniectomy is performed in the posterior portion of the skull, it helps to keep the underlying veins and brain safe during removal.

A craniectomy also carries general surgical risks listed above, including infection, bleeding, blood clots and reactions to anesthesia. Similar to craniotomy, risks have more to do with the underlying condition being treated. However, risks more related to craniectomy include the following.

• Swelling of the brain
• CSF leak (may require treatment or repair)
• Skull defect or soft spot

Cranioplasty

A cranioplasty is used to repair a defect of the skull following surgery or trauma. By replacing the missing bone, the brain will be protected once again. Cranioplasty can also improve esthetics by restoring the contour of the skull, and some patients experience improved neurological function following cranioplasty if the bone has been off for a period of time.

Again, cranioplasty carries general surgical risks. These include reactions to anesthesia, bleeding, blood clots and infection, and are more related to the underlying condition. However, there are also risks particular to cranioplasty, which includes the following.

• Infection
• Implant rejection or inflammation
• Subdural hematoma
• Impaired brain function

Recovery

Because craniotomies, craniectomies and cranioplasties are performed for a number of different reasons, your recovery is going to vary from the next person’s. Generally speaking, most patients spend a few days to a week in the hospital following a major procedure that involves a craniotomy, craniectomy or cranioplasty, but this can vary greatly. Likewise, many people will spend 6-8 weeks on activity restrictions after surgery, but your recovery may be longer if there was an incident such as trauma or stroke. Your personal doctor will be the best person to discuss what you can expect during your individual recovery period.

Your Individual Procedure

Now that the differences between craniotomy vs. craniectomy vs. cranioplasty are a little clearer, you can continue the conversation with your personal doctor about your treatment plan and what to expect during your recovery. Remember:

• A craniotomy is the temporary removal of bone during another procedure. The bone is replaced before the surgery is complete.
• A craniectomy is the removal of bone, commonly in an emergency situation or in certain areas of the skull. The bone is not immediately replaced.
• A cranioplasty is the replacement of bone. Your surgeon may use your own bone or other material, such as titanium, synthetic bone or acrylic.

As you continue to move forward along your treatment path, continue to learn about your condition and procedure. Educating yourself and maintaining open communication with your doctor will help you have peace of mind before, during and after your surgery.