Intradural spinal tumour resection

If you have existing medical conditions, such as high blood pressure or diabetes, you may like to visit your GP practice to make sure that you are as fit as possible for your surgery.

Make sure you arrange your domestic and social situation so that it will be possible and comfortable for you to go home at the correct time.

For instance:

• Arrange for somebody to collect you on discharge
• Make sure you have shopped for adequate food supplies for when you get home
• Tidy your house so you do not need to do housework when you get home
• Ensure you have a supply of simple pain killers available at home, such as paracetamol
• You will be expected to dress in normal clothes after surgery, so bring in loose fitting clothes and non-slip shoes.
• If you think you will need some social support after discharge please speak to your GP and let us know as soon as possible

We will:

• Arrange a pre-assessment check to make sure you are fit for an anaesthetic
• Organise appropriate scans or x-rays for your operation
• Write to you to let you know when your operation will be
• Answer any questions you may have about your operation

The dura is a thin, tough, fibrous membrane that covers the brain and spinal cord.

It separates the bones of the spine from the neural (nerve) tissue inside. In the spine, tumours can be located either outside (‘extradural’) or inside the dura (‘intradural’). Intradural spine tumours are uncommon, but can arise from the nerve roots, the lining of the spinal cord or within the spinal cord.

Resection means removal. Intradural tumours take up space and cause compression on the spinal cord. This means that spinal cord function is disturbed and can result in new or worsening neurological deficits. Your neurosurgeon will talk to you about this and how fast this may occur if left untreated.

Sometimes a complete removal of the tumour is not possible and part of the tumour is left behind. This is called a ‘biopsy’ and or ‘debulking’. The reason for this is usually due to the risk of damage to the surrounding spinal cord which could result in permanent and serious injury (neurological deficit).

All treatments and procedures carry some risks and we will talk to you about the risks of spinal intradural tumour resection. This operation is performed under a general anaesthetic and your anaesthetist will talk to you about the risks of general anaesthesia.

Female patients must tell their anaesthetist and surgeon if they are or could be pregnant. Anaesthetic drugs and x-rays used during the procedure can be harmful to unborn babies.

Problems that may happen during the operation

Major risks occur in two to five per cent of patients. Spinal cord or nerve root injury. This may result in temporary or permanent neurological deficit, including arm, leg, bowel, bladder or sexual problems. The type of deficit depends on the location of the tumour.

Bleeding or disruption of the blood supply to the spinal cord resulting in neurological deficit.

Problems that may happen later

These include but are not limited to:

• Leakage of cerebrospinal fluid (CSF) increasing the risk of meningitis or poor wound healing.
• Spinal instability or ‘slip’ requiring further treatment
• Wound infection, which can be treated with antibiotics
• Scarring around the nerve roots
• Chronic pain which may require referral to a pain specialist
• Tumour recurrence

If you choose not to have surgery then a formal diagnosis of the tumour will not be possible and there is a significant chance of worsening of your symptoms as the tumour grows.

Your neurosurgeon will weigh up and discuss the risks and benefits of the procedure with you. If the risks outweigh the benefits then surgery is not likely to be the best option for you. In this situation it would be better to have a period of surveillance or watchful waiting.

The alternative is not to have surgery and to enter a period of surveillance, which includes repeated clinical assessment or imaging or both.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the benefits, risks and alternatives before they ask you to sign a consent form.

If you are unsure about any aspect of your proposed treatment, please don’t hesitate to speak with a senior member of staff again.

Before the procedure we will give you a gown and anti-embolic (elastic) stockings to wear and a nurse will complete a safety checklist. The nurse will accompany you to the operating theatre. The operation length can vary considerably, but on average usually takes around two to three hours.

Once the anaesthetic is started and you are ‘asleep’ you will be moved to the operating theatre and positioned on the operating table on your front. X-rays will be used to guide the surgeon to the part of the spine to be operated on. In order to reach the tissue beneath the bone of the spine the neurosurgeon will remove a section of the bone. This is called a ‘laminectomy’. If the section of bone is replaced after surgery, this is called a ‘laminoplasty’.

A laminoplasty may require the bones of the spine to be stabilised or ‘fused’ using metal plates. Your neurosurgeon will discuss which of these procedures and techniques they will use before surgery. The dura is opened and the tumour is carefully dissected (cut away from) the surrounding neural (nerve) tissue. The surgeon will use a microscope to help identify the tumour. As much of the tumour as possible is removed without damaging surrounding healthy tissue.

Sometimes specialist monitoring of the spinal cord called ‘intraoperative neurophysiological monitoring’ is used during the surgery to help prevent damage to the spinal cord. The dura is closed with a stitch or fine clips and often an artificial tissue or special sealant (glue) is used to help seal the wound. The wound is closed carefully to minimise leakage.

Sometimes a thin plastic tube called a lumbar drain is inserted to drain cerebrospinal fluid (CSF) away from the site of surgery and prevent leakage. Your neurosurgeon will discuss this with you before surgery, including the risks and how long it may be needed.

Following your operation, you will be monitored in the recovery room before returning to the ward. Sometimes, patients need to lie flat for a period of two to five days after the operation to minimise the risk of CSF leak. You may have a urinary catheter in place during this time and you will need to use a bed pan.

You will be prescribed regular pain relieving medicine. Please tell your nurse if you still have pain; we want you to be comfortable and reduce the risk of complications. Good pain relief is important to your recovery. You may still experience discomfort on movement, this is normal.

We will assess the strength in your limbs regularly to check for complications. You will be mobilised under the instruction of your neurosurgeon and if necessary will be seen by physiotherapy. Before going home, you will be given an information booklet concerning your wound care. It is important to know how to care for your wound so please do not hesitate to ask any questions you may have.

On the journey home, you may find sitting in a car seat for long periods uncomfortable, so if you have a long journey home, try to plan regular stops so you can stand up and walk about.

You may find that you need to take regular painkillers for two to three weeks after the operation to ease the pain at the wound site. This should improve over time and you can cut down the number of tablets you take.

It is normal to feel tired after an operation. Try to do a little regular activity such as walking, rather than attempting to do too much at once.

Avoid strenuous exercises and activities until you have been reviewed in clinic. It is normal to experience some pain after surgery. This usually settles with pain killers, rest and time.

However, if you develop:

• symptoms such as headache, that worsens when you are up and about and improves when you lie down
• arm/leg weakness or numbness
• new difficulty with bladder or bowel control, or problems with sexual function
• any wound problems such as redness, excessive soreness, swelling or wound discharge

Contact your consultant or clinical nurse specialist via their secretary (during working hours). The ward, your GP or local accident and emergency department can give help and information at other times.

You can start driving again when you feel comfortable and confident enough to operate a vehicle safely and you are confident you are in full control of the vehicle. This varies between individuals after surgery. Contact the DVLA and your insurance company for further information about driving restrictions.

Please discuss your return to work, daily or leisure activities with your surgeon, specialist nurse or therapist. Most people will return to work six weeks after the operation, depending on their work. Y

ou may need to contact your Occupational Health Department if you need to make adjustments to your working arrangements, such as different seating for a desk job or if you are unable to do heavy manual work.

Your surgeon will write to your GP to inform them of the operation you have had. You will be asked to attend an outpatient clinic at the hospital six to eight weeks after surgery so that we can check on your progress.

• www.brainandspine.org.uk
• www.spine-health.com
• www.spineuniverse.com
• www.back.com
• www.patient.co.uk

UCLH cannot accept responsibility for information provided by other organisations.

Victor Horsley Neurosurgery Department
National Hospital for Neurology and Neurosurgery
Queen Square London
WC1N 3BG

Switchboard: 0845 155 5000 / 020 3456 7890
Secretary’s direct line: 020 3448 3568/3150/3395
Fax: 0203 3448 3340