In this blog post, using the controversial “awake surgery” scene from the drama as a starting point, I’ll explain in simple terms what this surgery is and how it’s performed, along with real-life examples.

The Difference Between the Drama Scene and Reality

A scene from a recently concluded hit drama became a hot topic: a patient, while awake, had his skull opened and reacted to electrical stimulation by shooting an arrow. While there was debate online asking, “Isn’t this a huge exaggeration?” and “Is this actually a possible surgery?”, this type of procedure does indeed exist. Commonly referred to as “awake surgery,” this method is characterized by the fact that surgeons can perform the procedure while monitoring neurological function while the patient is conscious but feels no pain.

The Brain and Why Surgery Is Necessary

The brain, enclosed within the skull, is the central hub of the nervous system and consists of neurons and nerve fibers. Connected to the spinal cord and peripheral nerves, it receives sensory input and issues commands, performing various functions such as motor control, sensory processing, language, learning and memory, maintenance of homeostasis, and hormone secretion. Because it is responsible for these vital functions, tumors or lesions in the brain often require surgical removal; however, there is a risk of post-operative changes or impairments in functions such as speech, walking, and emotional regulation.

The Advancement of Brain Surgery and the Background of Awake Surgery

Although the history of cranial surgery dates back a very long time, brain surgery in the modern sense became possible thanks to the dramatic advancements in 19th-century medicine, such as the development of anesthesia, the establishment of aseptic techniques, and the discovery of blood types. Combined with advanced imaging technologies such as MRI and CT scans, as well as accumulated medical knowledge, it has become possible to identify previously invisible brain structures and perform precise surgeries. Nevertheless, because the brain contains a dense network of neural circuits, functional sequelae can occur even after a successful operation, and efforts to minimize these have continued.

Purpose and Procedure of Awake Surgery

Awake surgery follows the same basic procedure as conventional brain surgery, involving the opening of the scalp and skull and an incision in the dura mater. The most significant difference is that regional anesthesia is used instead of general anesthesia, allowing the patient to remain conscious. This enables surgeons to immediately detect any neurological abnormalities—such as speech or motor dysfunction—during the procedure through the patient’s responses, thereby minimizing damage to healthy brain tissue.
Although the patient does not feel pain, they can perceive sensations when tissue is incised with a scalpel or when movements are induced. Since this can be a very difficult experience for sensitive patients, thorough explanation and psychological preparation are necessary. Before and during surgery, functional MRI (fMRI) or electrical stimulation is used to identify the brain regions that become active when the patient performs specific tasks—such as speaking or moving their hands. If the risk of damaging areas closely associated with that function is identified during tumor removal, a conservative decision—such as leaving part of the tumor in place—may be made.

Real-Life Cases

In 2009, American violinist Roger Frisch underwent awake surgery to treat hand tremors; during the procedure, he actually played the violin to verify whether his tremors had improved. This case is a prime example of how real-time functional monitoring contributed to the surgery’s success, allowing the patient to return to playing the violin relatively quickly after the procedure. In South Korea, there has also been a reported case where surgeons stopped the procedure after noticing that a patient’s singing pace suddenly slowed down while singing during surgery, thereby preventing damage to language function.
These cases demonstrate that immediate detection of functional changes—which would be difficult to identify under general anesthesia—can help reduce permanent damage.

Significance, Limitations, and the Future

Awake surgery is not a panacea that eliminates all risks. It cannot be deemed a perfect or the safest surgical method, and it can impose significant psychological and physical burdens on patients. However, for patients with tumors in areas where preserving function is a top priority, it is an important option that increases the likelihood of returning to a normal life.
Medical science and surgical techniques continue to advance, and safer, more precise methods—such as robot-assisted surgery—are being developed. Nevertheless, awake surgery, which allows surgeons to monitor the patient’s function in real time during the procedure, has established itself as a technique that greatly helps preserve quality of life for patients who meet the appropriate criteria.