An awake craniotomy asks more of the theatre than a standard craniotomy, because the patient must be comfortable, cooperative and reachable by the anaesthetist and the testing team while the head is held still for the surgeon. This guide describes the equipment and layout decisions around awake brain surgery: positioning, head fixation, access, imaging and team placement. It is written for OR nurses, neuro-anaesthesia teams and biomedical staff, and it does not replace local clinical protocols.
What an awake craniotomy changes in the OR
In awake brain surgery the patient is conscious for at least part of the procedure so that speech, motor or other functions can be tested while tumour or epileptic tissue is approached. Different centres use different anaesthetic approaches, including asleep-awake-asleep and fully awake techniques, so the room has to be flexible enough for the protocol your team uses.
From an equipment point of view three needs dominate: a stable head position that the patient can tolerate for a long time, free access to the airway and face for the anaesthetist and the neuropsychology or testing staff, and a clear line of sight for the patient to any screen or task cards. For the standard sequence of steps, see craniotomy steps and equipment.
Patient positioning and comfort
Positioning is planned before the patient enters the room. Most teams use supine or lateral positions, depending on tumour location, with padding of pressure points and support of the shoulders and neck so that the position can be held for hours. A slightly semi-recumbent set-up is often more comfortable for a patient who must talk. General principles are covered in patient positioning for craniotomy.
Comfort is a safety issue: a patient in pain or strain tends to move or become agitated at the moment the surgeon needs cooperation. Rehearse the position with the patient where possible, check the table pads and keep communication with the patient continuous throughout set-up.
Head fixation choices for awake craniotomy
Head fixation for awake cases is a decision for the surgical and anaesthetic team. Some centres use pin fixation with local anaesthetic at the pin sites; others prefer a non-invasive approach. The DORO Multi-Purpose Skull Clamp lets the team choose a non-invasive set-up on gel pads, rigid pin fixation or a non-invasive headrest combined with pins, which is useful when the choice is made case by case.
Its universal set includes adult and pediatric pin holders, gel head and ear rings and an adjustable trio gel pad, plus an optional 90 N torque screw for finer control of lower pin forces. The DORO Horseshoe headrests support the head non-invasively on shape-taking gel pads, with adjustable width and removable, easy-to-clean pads. Compare the principles in our guide to horseshoe headrests.
- Universal set for all ages, from newborns to seniors
- Choice of non-invasive, pin or combined fixation
- Quick-Rail for retractor systems and accessories
- Stainless steel starbursts for navigation adaptors
Awake craniotomy setup: access, imaging and team layout
Plan the room around the patient's face. The anaesthetist needs permanent access to the airway, the testing staff need a position where they can see and hear the patient, and the surgeon must work above a drape that does not make the patient feel enclosed. A sterile screen with a clear window or a raised drape is common, but the exact arrangement should follow your protocol.
If intraoperative imaging or navigation is planned, check the clearance of the headrest and the table with the imaging team beforehand. Radiolucent or imaging-compatible components can be combined with DORO products through Mix & Match. See our broader neurosurgery operating room setup guide for room planning.
Checklist before the first awake case
Run a dry rehearsal with the full team. Confirm table position and weight limits, the fit of the head support on your OR table, the availability of spare pads and pin holders, suction and oxygen reach and the position of monitors. Ask the supplier for training on the head fixation system so scrub staff can assemble it quickly and correctly.
Beckfinity supplies DORO head fixation systems in the UAE and can arrange a demonstration for your neurosurgical and anaesthesia teams. Contact us to discuss your OR table and case plan.
Frequently asked questions
What is an awake craniotomy?
A craniotomy in which the patient is conscious for part of the operation so that functions such as speech or movement can be tested while the surgeon works near critical brain areas.
What are the awake craniotomy types?
Centres commonly use asleep-awake-asleep or fully awake approaches, and the choice depends on the protocol, the patient and the lesion. The OR set-up must support your team's protocol.
Is pin fixation always used in awake brain surgery?
No. Some teams use pins with local anaesthetic, others use a non-invasive headrest. The DORO Multi-Purpose clamp supports non-invasive, pin or combined fixation.
How should the team be arranged around the patient?
Keep the airway and face accessible to the anaesthetist, give testing staff a clear view of the patient and position the surgeon behind a drape that keeps the patient comfortable.
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