Brain & Spine Tumour Surgery
What is a tumour?
Our bodies are made from building blocks called cells, each with its own structure and function. Cells grow and multiply naturally and normally as we grow and when the body repairs tissue damage (for example, when skin heals after a cut).
A tumour is a swelling or lump that forms when certain cells grow and multiply abnormally.
Brain Tumour Surgery
Brain tumours are abnormal growths in the brain, for which the main treatment is often surgical resection.
Brain tumours can be surgically resected by different ways, and the recommended approach often depends on tumour type, location and size, in addition to several other factors. The main approaches are described below:
- Craniotomy: This is a procedure in which a section of skull bone is temporarily removed to allow the neurosurgeon access to the brain and the tumor. Although traditionally an open surgery technique, craniotomy can now sometimes be performed using minimally invasive techniques, resulting in a smaller opening in the skull and faster recovery.
- Endoscopic Transsphenoidal Surgery: This is a minimally invasive operation, through the inside of the nostrils with the aid of an endoscope. No incision is required for this surgery. This technique is usually used for pituitary tumours.
Mr Al-Mahfoudh is one of few consultants in the UK performing this specialised procedure.
Initial management includes a clinical evaluation along with complete imaging studies.
Brain tumour surgery is usually performed after a brain tumour is found on imaging scans. For certain tumours that are small and asymptomatic, close observation with interval scans may be recommended without further intervention.
When surgery is indicated, the general aim is to resect as much of a tumour as possible while preserving brain tissue and overall function. Complete resection may be the outcome; however, sometimes, only subtotal resection is advisable because otherwise normal brain tissue could be at risk of harm.
Common brain tumours that may be treated with surgery include metastasis, meningiomas, gliomas, acoustic neuromas, pituitary tumours, primitive neuroectodermal tumours, medulloblastomas, craniopharyngioma, pineal region tumours, clival tumours and esthesioneuroblastomas
We take a multidisciplinary team approach when planning and performing the operation, resulting in the best possible prognosis. In addition to the neurosurgeon, any combination of the following doctors may be involved in the overall management:
- Head and neck surgeon
- Oral and maxillofacial surgeon
- Plastic surgeon
The neurosurgeon starts by making a small incision on the scalp, often behind the hairline, and then carefully reflects the layer of skin and muscle, exposing the skull. In the exposed skull, following small openings in the bone, the bone flap is temporarily removed, setting it aside so that it can be secured back in place toward the end of the procedure. The size of the opening depends on what is needed to remove a particular tumour; I always aim to create the smallest opening possible to complete the operation safely.
With the bone flap removed, the dura mater is exposed; using surgical scissors, the neurosurgeon creates an incision in this membrane, revealing the brain.
Now that the brain is accessible, the tumour is approached by careful navigation around brain tissue, nerves and blood vessels. A localisation, Stereotactic technology is used, combining imaging studies such as computed tomography (CT) scan and magnetic resonance imaging (MRI) with computer technology to create three-dimensional pictures of the brain. Also, an operating microscope is used to visualise the structures in the brain, such as nerves and blood vessels in fine detail.
Upon reaching the brain tumour, the tumour is dissected away from the normal brain tissue, blood vessels and nerves to which it may be attached. The neurosurgeon is careful to excise as much of the tumour as possible without harming normal tissue or other structures.
After removing as much tumour as is safely possible, the cut made in the dura mater is closed and the bone flap is placed back, secured in place with titanium plates and screws. The incision is the closed with stitches or clips.
Endoscopic Transsphenoidal Surgery
Transsphenoidal surgery is performed through the nose and requires no incision.
The procedure starts with the insertion of the tip of an endoscope (small camera) through one of the nostrils, then the approach is repeated through the other nostril.
An opening is then made in the sphenoid sinus at the back of the nasal cavity. The sphenoid sinus is fully opened and the floor of the skull is then identified and a small opening created. A small opening is made in the dura to expose the tumour.
While navigating to the tumour, the neurosurgeon achieves the highest precision possible by using stereotactic techniques to create a 3-dimensional map of blood vessels, nerves and other structures.
High-tech instruments are then employed to meticulously break up and aspirate small sections of the tumour, dissecting it carefully away from the normal surrounding structures. The tumour is removed as much possible, while also prioritising the continued function of brain tissue and other structures.
After tumour resection, the space the tumour had previously occupied may need to be sealed. If so, the neurosurgeon sometimes takes a tissue graft from the patient’s thigh or abdomen. Often, synthetic grafts and biologic glue can be used instead of creating an incision in the thigh or abdomen. If incisions were made, they are closed and stitched.
A video of Mr Al-Mahfoudh performing and explaining the technical steps of endoscopic transsphenoidal surgery can be viewed here:
What to expect after these procedures:
Following transsphenoidal surgery, the hospital stay is usually 2-3 days. Following a craniotomy, the hospital stay is typically about one week.
Resumption of exercise and daily activities
Patients who undergo transsphenoidal or craniotomy surgery usually return to light forms of exercise about 2-4 weeks after the operation and return to their regular exercise and routine day after about 4-6 weeks. Each patient is unique in his or her recovery and we always advise patients to follow their own pace. The day after surgery, patients are usually up and walking around but may tire quickly and need to sit down and rest frequently. Feeling this way is normal and to be expected.
Patients are advised to walk around every day if they have the energy, but should not return to exercise, even light forms, until the neurosurgeon approves such activity. A craniotomy is a more invasive procedure than transsphenoidal surgery, therefore craniotomy surgery usually requires a longer recovery period.
After the operation, patients will be scheduled for several follow-up appointments with the neurosurgeon. Depending on the type of brain tumour and whether any new symptoms develop, appointments may be scheduled with other specialists, such as a neurologist, an endocrinologist, otolaryngologist or ophthalmologist.
During these appointments, the specialist will evaluate the patient and record recovery progress. Also, the neurosurgeon usually orders imaging tests to visualise the brain and monitor for tumour recurrence.
The need for rehabilitation or physiotherapy largely depends on the location of the excised brain tumour. Some patients have little to no change in physical and cognitive abilities and therefore require no rehabilitation or physiotherapy.
Some patients may notice changes in cognition or changes in physical ability, such as reduced motor control or changes in speech. If any of these changes occur, patients will likely need rehabilitation.
The good news is that a change in cognition or physical ability is not necessarily permanent and may improve with time and therapy. If changes are permanent, rehabilitation can help patients learn how to manage these changes.
Spine Tumour Surgery
A spinal tumour is a growth that develops within the spinal nerve membranes, spinal cord or within the bones of the spine.
Spinal tumours may be classified broadly as one of three different types depending on where they occur relative to the protective membranes of the spinal cord:
- Intramedullary Tumors
These tumours arise inside the substance of the spinal cord itself. Examples include: gliomas, astrocytomas, ependymomas and haemangioblastomas.
- Intradural Extramedullary Tumours
These tumours grow inside the membrane (dura) surrounding the spinal cord or the nerve roots that branch out from the spinal cord. These tumours are outside the substance of the spinal cord however. Examples include: meningiomas, neurofibromas and schwannomas.
- Vertebral Column Tumours (Extradural Tumours):
These tumours involve the bones of the vertebral column.
The majority of vertebral column tumours are metastatic. Meaning that the original, or primary, tumour developed in another organ and has spread to the vertebral column, usually through the bloodstream. The most common metastatic spinal tumours in women are from the breast and lung. In men, metastatic spinal tumours are most often from the prostate and lung.
Tumours primarily arising from vertebral bone and cartilage cells also occur in the spine, although less frequently. Examples of these include benign tumours e.g. osteoid osteoma, osteoblastoma, and giant cell tumour and malignant e.g. osteogenic sarcoma, chordoma, chondrosarcoma and Ewing’s sarcoma.
Spinal tumours can lead to pain, neurological problems and sometimes paralysis.
Treatment for a spinal tumour may include monitoring, surgery, radiation therapy or chemotherapy.
Some spinal tumours may be discovered before they cause symptoms (incidental finding on a scan for another reason). If small tumours aren’t growing or pressing on surrounding tissues, watching them carefully may be all that’s needed.
During observation, we usually recommend MRI scans at appropriate intervals to monitor the tumour.
This is often the treatment of choice for tumours that can be removed.
Newer techniques and instruments allow neurosurgeons to reach tumours that were once considered inaccessible. The high-powered microscopes used in microsurgery make it easier to distinguish tumour from healthy tissue.
I also use modern nerve monitoring equipment (SSEPs, MEPs, direct nerve stimulation and sphincter monitoring) to continuously assess the function of the spinal cord and nerve roots during surgery, thus minimising the chance of injuring them and make sure they are responding well throughout the surgery. In some instances, very high-frequency sound waves might be used during surgery to break up tumours and remove the fragments.
Most intradural-extramedullary tumours are treated by total resection (total surgical removal), and patients generally report minimal or no neurological problems after surgery.
Intramedullary tumours (like astrocytomas, ependymomas, and hemangioblastomas) arise within the substance of the spinal cord itself. The usual treatment for these tumours is surgical excision. The goal of surgery is to completely remove the tumour while preserving a maximum of neurological function but this remains technically more challenging due to their location and also it is also highly dependant on whether a clear margin between the tumour and normal cord substance exists. Use of cord monitoring is essential with these cases.
Even with the latest technological advances in surgery, not all tumours can be totally removed. When the tumour can’t be removed completely, surgery may be followed by radiation therapy or chemotherapy or both. In the case of metastatic tumours, removing the spinal tumour will not cure the cancer. However, advances in treatments such as radiosurgery, and chemotherapy have improved the prognosis for patients with metastatic tumours.
The aims of surgery for metastatic spinal tumours include decompressing the spinal cord, preserving neurological function, reducing the tumour bulk, relieving pain or neurological symptoms caused by the tumour, and maintaining the stability of the spine.
Surgery to decompress the spinal cord, called decompression surgery, consists of removing the portion of the vertebra involved with the tumour. When either decompression surgery or the tumour itself renders the spine unstable, bone grafts and metallic implants are used to restore the stability of the spine.
Radiation therapy, either conventional or stereotactic radiosurgery, may be used as an alternative to surgery if there is no compression of the cord or as an adjuvant treatment after surgery to achieve local control of the tumour. This treatment uses highly-focused beams of radiation to disrupt tumour cells and shrink the tumour. Radiation therapy may be used alone to treat painful tumours if they do not compress the spinal cord or destabilise the spine.
Recovery from spinal surgery may take weeks or longer, depending on the procedure, location of the tumour, pre-operative symptoms and postoperative course.