Pinless Electromagnetic Neuronavigation During Awake Craniotomies: Technical Pearls, Pitfalls, and Nuances

Awake craniotomies are often performed with rigid pin fixation to support optical neuronavigation. Newer electromagnetic (EM) neuronavigation technology now enables unpinned cranial neurosurgery while maintaining robust intraoperative image guidance. Here, we share technical nuances, operative pearls, and lessons learned from our institutional experience using Curve EM neuronavigation during awake, unpinned craniotomies.

We describe our process for patient positioning, instrumentation setup, system registration, intraoperative navigation, and surgical adjunct use (e.g., intraoperative neuromonitoring and intraoperative magnetic resonance imaging) in detail. At each step, we provide pearls for success and tips for pitfall avoidance based on our experience.

Ten patients underwent awake pinless intra-axial tumor resection using Curve EM neuronavigation from May 2021 to August 2022 with a single surgeon. Postoperative transient neurological deficits were seen in 8 of 10 cases (80.0%), as all resections were taken to functional margins. Of the 9 patients with a 3-month follow-up visit at the time of publication, all 9 (100%) had improved or stable preoperative symptoms. No surgical complications, clinically appreciable inaccuracies, intraoperative losses of registration, unexpected postoperative magnetic resonance imaging findings, or errors related to the use of EM neuronavigation occurred.

The technical pearls outlined here will help interested neurosurgeons integrate EM neuronavigation into awake craniotomies. In our experience, using unpinned neuronavigation during awake cases provides many advantages to the patient, surgeon, and entire operative team. It has thus become the standard practice at our institution.