ENNeurosurgery in Germany is not a single operation but a whole field, in which the decision to operate is almost always made together with a neurologist and a radiologist. People come to it with an unexpected MRI finding, with seizures, or with headaches that no longer have an explanation.
This page covers what neurosurgeons operate on, which imaging comes first, what technology is used in theatre and how the route from abroad works; pages on single diagnoses are listed under it. No technology decides the outcome by itself: what is possible becomes clear only after imaging and an examination.
What neurosurgeons operate on
Neurosurgeons operate on tumours, vascular findings, disorders of fluid flow in the brain, some forms of epilepsy and the spine. The main brain tumours are gliomas, meningiomas, which grow from the brain’s coverings, and metastases of cancers elsewhere; skull base tumours lie beside cranial nerves and large vessels and need a carefully planned approach. Pituitary adenoma, a benign tumour of the gland at the base of the brain, is usually removed through the nose without opening the skull. The wider treatment of brain tumours is covered under brain tumour treatment in Germany.
Vascular findings are the second area: aneurysms, bulges in an artery wall, and arteriovenous malformations, tangles of vessels where arteries run straight into veins. There are two routes. In open surgery the neurosurgeon clips the aneurysm or removes the malformation; in a catheter-based procedure a neuroradiologist seals the finding from inside the vessel with coils or an embolic agent. The two choose the safer route together, and sometimes watchful waiting is wiser.
Hydrocephalus, excess fluid in the brain’s ventricles, is usually treated with a shunt, a thin valved tube that drains the fluid into the abdomen; see hydrocephalus treatment in Germany. Neurosurgeons also treat syringomyelia, a fluid-filled cavity in the spinal cord, epilepsy when medication no longer holds the seizures, and the spine: disc herniation, canal stenosis, stabilisation. In deep brain stimulation (DBS), a method of functional neurosurgery, thin electrodes are placed deep in the brain and a pulse generator under the skin below the collarbone. It is discussed with the neurologist when medication no longer smooths out the symptoms of Parkinson’s disease or tremor; see Parkinson’s disease treatment in Germany. Pituitary adenoma, arteriovenous malformation, hydrocephalus, syringomyelia and epilepsy surgery each have their own page below.
Imaging comes before the operation
Imaging comes first because, as a rule, a German neurosurgeon operates from fresh images made to the department’s own protocol, even if the patient brings a disc from home: the navigation system needs thin slices in a set sequence, and the lesion may have changed. MRI, usually on a 3 Tesla scanner, is the basis; CT shows bone, fresh bleeding and calcification; cerebral angiography shows the arteries.
When the lesion lies next to the speech or motor areas, more is added. Functional MRI shows which parts of the cortex work when the person speaks or moves a finger; tractography maps the nerve pathways. Both maps go into the navigation system, so during the operation the surgeon sees on screen the boundary that must not be crossed.
If the tumour was biopsied at home, the histology is reviewed again from the slides and paraffin blocks and molecular testing is added: under the current WHO classification, brain tumours are diagnosed by their genetic features as well as their cells. The diagnosis decides how complete a removal is worth aiming for and what follows: radiotherapy, chemotherapy or observation. German doctors follow the medical societies’ recommendations in the AWMF guideline register.
How the operation is done: technology in theatre
Precision rests on several technologies, and neuronavigation comes first. The images are matched to the patient’s actual head, so the surgeon sees on screen where the tip of the instrument is, much as a driver sees the car on a satnav map. That helps to find a short, safe path even to a deep lesion.
The second is monitoring function. In intraoperative neuromonitoring, the surgeon stimulates the brain with a weak current and reads the muscles’ response to locate the motor pathways. Near the speech centres, the operation is sometimes done with the patient awake (awake surgery). It sounds unusual and goes calmly: the patient sleeps or is sedated at the start and is then woken; the anaesthetist makes sure there is no pain, and a speech therapist asks the patient to talk, name pictures or move a hand. Where speech falters, the surgeon spares that spot. The German Society of Neurosurgery (DGNC) explains this monitoring.
The third shows the tumour’s border. A few hours before surgery the patient drinks 5-aminolevulinic acid (5-ALA); malignant glioma cells take it up, and under the microscope’s blue light the tumour glows red while normal tissue looks blue. Intraoperative MRI, available in some hospitals, shows during surgery whether tumour remains that can still be removed safely. Pituitary adenoma is often removed endoscopically, with a thin camera tube passed through the nose.
The fourth is radiosurgery, without an incision: a Gamma Knife or a linear accelerator delivers a high, precisely aimed dose in one or a few sessions, sparing the surrounding tissue. It is discussed for small, well-defined lesions, usually no more than 3 cm across, such as metastases, acoustic neuromas, meningiomas, pituitary adenoma remnants and arteriovenous malformations, even deep ones. It is not chosen for a large tumour already pressing on the brain, as radiation works over months, and over years for a malformation. Nor does it yield tissue, so an unclear diagnosis needs a biopsy or surgery first.
Who operates: hospitals and neurosurgeons
A neurosurgeon in Germany usually works in a university hospital or a large municipal hospital; see neurosurgery clinics in Germany. The doctors on this site include Prof. Bernhard Meyer, Director of Neurosurgery at Klinikum rechts der Isar (Technical University of Munich); Prof. Marcos Tatagiba, Medical Director and Chief Physician of the University Department of Neurosurgery at Tübingen University Hospital; and Prof. Ulrich Sure, Director of the Department of Neurosurgery and Spine Surgery at Essen University Hospital.
Also on the site are Prof. Erdem Güresir, Director of Neurosurgery at Leipzig University Hospital; Prof. Rüdiger Gerlach, Medical Director of Helios Klinikum Erfurt, Chief Physician of its neurosurgery department and head of its neuro-oncology centre; and Prof. Jens Lehmberg, Chief Physician of Neurosurgery at München Klinik Schwabing; see neurosurgeon in Germany. Each has a narrow focus: for Ulrich Sure it includes cavernomas, also in the brainstem; for Rüdiger Gerlach, paediatric neurosurgery; for Jens Lehmberg, skull base and vascular surgery. So the choice follows the diagnosis rather than a list of names.
Paediatric neurosurgery is a separate specialty, because children have different conditions and operations are planned with growth in mind. The Altona Children’s Hospital in Hamburg has its own paediatric neurosurgery department, which treats hydrocephalus, spina bifida, premature fusion of the skull sutures and tumours of the nervous system. As for the “best neurosurgery hospitals in Germany”, the honest answer is that Germany publishes no official ranking of that kind: the official Bundes-Klinik-Atlas shows hospitals’ case numbers and staffing, not a list of the best. What can be compared is how many operations of the same type a department performs a year and whether it belongs to a certified centre, such as a neuro-oncology centre certified by the German Cancer Society.
The route of a patient from abroad
The route begins with the records: MRI and CT scans as DICOM files or on a disc, not printouts, which lose slices and sequences, plus reports, discharge letters, and the histology if there is one. From these the neurosurgeon gives a remote opinion on whether an operation is possible, which kind, and what still needs to be examined; it is a preliminary assessment, not a final plan.
On arrival the patient is examined again: fresh MRI to the hospital’s protocol, a neurological examination and, for a tumour, a histology review. A tumour is discussed at the tumour board, a vascular finding with the neuroradiologist. The plan made on site sometimes differs from the one made at home, which is not unusual: new images show the lesion as it is now, and a tissue review can refine the diagnosis.
For the visa, the hospital’s confirmation of the planned treatment serves as the invitation. How long the stay after intracranial surgery lasts depends on the operation and on recovery, and the hospital states it in the treatment plan. Patients are monitored in intensive care for at least a day after brain surgery and move to the normal neurosurgical ward after a control MRI. If deficits remain, neurological rehabilitation follows, arranged during the stay; otherwise follow-up with repeat MRI scans comes next. The bill lists tests, the operation, the inpatient stay and rehabilitation as separate lines of the hospital’s estimate; for guide figures, see brain tumour surgery cost in Germany.
Frequently asked questions
What is the difference between a neurosurgeon and a neurologist?
A neurologist diagnoses diseases of the nervous system and treats them with medication; a neurosurgeon operates. The neurologist usually sees the patient first and treats epilepsy, Parkinson’s disease or headaches. The neurosurgeon is called in when a finding must be removed or pressure taken off the brain, the spinal cord or a nerve, and the decision to operate is made together.
What should I ask the neurosurgeon at the first consultation?
Ask which operation is proposed and by which approach: an incision, the nose, a catheter or radiosurgery. Ask what it risks for speech and movement in your case, how many such operations the department performs a year, and what comes afterwards: rehabilitation or follow-up alone.
Will I need rehabilitation after an operation on the brain or spine?
Not always: it is needed when problems with speech, movement, balance or memory remain after the operation. It is then arranged while the patient is still in hospital, and neurological rehabilitation follows. Otherwise the patient goes home, with control MRI scans and appointments on the schedule given at discharge.
How AlenMed arranges treatment
AlenMed chooses the neurosurgery department from the diagnosis and the images sent in. The company works with 86 partner hospitals in 38 cities and 345 doctors, and its office is in Munich. A skull base tumour, an aneurysm and a herniated disc may each need a different department, so the finding comes first and the city second.
The team translates the records, sends the enquiry to the neurosurgery department, prepares the visa invitation, meets the patient on arrival and provides a medical interpreter for talks with the surgeon. The invoice is issued by the hospital itself, directly to the patient.
This material is for information only and is not an offer. The indication for surgery is set by the doctor at an in-person consultation after examination.