What is brain tumor surgery?
Brain tumor surgery is conducted to remove a growth from the brain. Brain tumors are abnormal growths in the brain, for which the main treatment is often tumor resection.
Patients with brain tumors are best treated at high-volume institutions with experienced neurosurgeons who specialize in brain tumor surgery. At Columbia’s Brain Tumor Center, patients receive specialized and coordinated care from our world-class neurosurgeons who perform, on average, 400 to 500 brain tumor resections each year.
Brain tumors can be surgically resected several different ways, and the recommended approach often depends on tumor type, location and size, in addition to several other factors. The main approaches are described below.
- Craniotomy 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.
- Transsphenoidal surgery, a minimally invasive operation, is done either through the inside of the mouth or through the nostrils with the aid of an endoscope. This procedure results in very small incisions that are often not visible.
When is this procedure performed?
Brain tumor surgery is usually performed after a brain tumor is found on an imaging scan. For certain tumors that are small and asymptomatic, close observation may be recommended without further intervention, but for most brain tumors, including pediatric brain tumors, the first step in treatment is surgery to remove the tumor.
Surgeons resect as much of a tumor 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. Our highly skilled neurosurgeons remove as much tumor as possible while maintaining brain function.
Common brain tumors that may be treated with surgery include gliomas, meningiomas, acoustic neuromas, pituitary tumors, primitive neuroectodermal tumors, medulloblastomas, craniopharyngioma, pineal region tumors, clival tumors and esthesioneuroblastomas.
How is this procedure performed?
At Columbia, our neurosurgeons 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 procedure:
- Head and neck surgeon
- Oral and maxillofacial surgeon
- Plastic surgeon
Immediately before surgery, general anesthesia is administered so that the patient does not feel pain during the operation. The surgeon then starts performing one of the two main surgical approaches—craniotomy or transsphenoidal surgery.
For craniotomy, 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, the neurosurgeon makes a small opening and removes the bone flap, 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 tumor, and our experienced neurosurgeons create the smallest opening possible.
With the bone flap removed, the dura mater is exposed; using surgical scissors, the neurosurgeon delicately creates an incision in this membrane, revealing the brain.
Now that the brain is accessible, the neurosurgeon carefully navigates around brain tissue, nerves and blood vessels to the tumor. To help during navigation, the neurosurgeon uses stereotactic techniques, 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, to see the structures in the brain, such as nerves and blood vessels, in fine detail, the neurosurgeon uses an operating microscope and other specialized technology.
Upon reaching the brain tumor, the neurosurgeon begins dissecting the tumor 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 tumor as possible without harming normal tissue or other structures. A biopsy of the resected tumor is obtained and sent to a pathologist for tissue analysis in order to confirm a diagnosis.
After removing as much tumor as is safely possible, the neurosurgeon sews the cut made in the dura mater and replaces the bone flap, securing it in place with titanium plates and screws. The neurosurgeon then closes the incision on the scalp with stitches. The operation is now complete.
In contrast to craniotomy, transsphenoidal surgery is performed through the nose or mouth and rarely has visible incisions.
The procedure starts with the insertion of the tip of an endoscope through one of the nostrils. If the operation is done through the mouth, an incision is made on the upper gums and then the tip of the endoscope is inserted through the incision.
Next, an opening is made in the sphenoid sinus at the back of the nasal cavity. By using an endoscope or microscope, the surgeon is able to have a well-lit and magnified view of the surgical field deep inside the nose. While navigating to the tumor, the neurosurgeon achieves the highest precision possible by using stereotactic techniques to create a 3-dimensional map of blood vessels, nerves and other structures.
Upon reaching the tumor, the neurosurgeon uses high-tech instruments meticulously to break up and aspirate small sections of the tumor. The neurosurgeon removes as much tumor as is possible, while also prioritizing the continued function of brain tissue and other structures. During tumor resection, the neurosurgeon also biopsies the tumor and sends it to a pathologist to confirm a diagnosis.
After tumor resection, the space the tumor had previously occupied may need to be filled. If so, the neurosurgeon sometimes takes a tissue graft from the patient’s thigh or abdomen and implants it where the tumor had been. 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. The operation is finished.
How should I prepare for this procedure?
Inform your doctor of any medications or supplements, such as herbs or vitamins, you take. This is important information for your doctor to have. You may be instructed not to take certain medications or supplements, particularly those that can increase bleeding during surgery, such as Warfarin and aspirin. Also, inform your doctor of any allergies you may have to medications or food.
Because general anesthesia is used during the procedure, you will be asked to stop eating and drinking at midnight the night before surgery. If your doctor has instructed you to continue taking certain medications the day of surgery, do so with a small sip of water.
On the day of surgery, wear clothing that is loose and comfortable. You will be asked to not wear makeup, jewelry or artificial nails. Instead of contact lenses, wear your glasses.
For your hospital stay, be sure to pack lightly. A few items that patients often like to pack include toiletries, dentures and additional clothing for when they are released from the hospital.
Be sure to make transportation arrangements for returning home from the hospital because you will not be allowed to drive yourself home after surgery.
What can I expect after the procedure?
How long will I stay in the hospital?
For patients who undergo transsphenoidal surgery, the hospital stay is usually one or two days. For those who have craniotomy, the hospital stay is typically about one week.
Will I need to take any special medications?
Medications are often prescribed after brain tumor surgery. Patients who had transsphenoidal surgery typically are prescribed medication for pain and sometimes nausea. After craniotomy, most patients are prescribed medication for pain and in addition may get medication to prevent nausea, brain swelling, seizure and stomach ulcers.
When can I resume exercise?
Patients who receive transsphenoidal surgery usually return to light forms of exercise, such as swimming or jogging, about two weeks after the operation and return to their regular exercise routine after about four weeks. 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 who receive craniotomy 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. Because it is a more invasive procedure than transsphenoidal surgery, craniotomy usually requires a longer recovery period. Upon receiving approval, patients can begin with light exercise and gradually increase to more strenuous forms of exercise. However, when exercising, patients are strongly advised to work with a partner or under supervision until fully recovered.
What follow-up will I receive?
After the operation, patients will be scheduled for several follow-up appointments with the neurosurgeon. Depending on the type of brain tumor 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 neurosurgeon will evaluate the patient and record recovery progress. Also, the neurosurgeon usually orders imaging tests to visualize the brain and monitor for tumor recurrence.
It is essential that patients attend all follow-up appointments in order to optimize recovery and long-term outcome. If any new or worsening symptoms occur during recovery, patients should tell their doctors, no matter how minor these symptoms may seem.
Will I need rehabilitation or physical therapy?
The need for rehabilitation or physical therapy largely depends on the location of the excised brain tumor. Some patients have little to no change in physical and cognitive abilities and therefore require no rehabilitation or physical therapy.
However, some patients may notice changes in cognition—such as problems with memory, executing tasks and attention span—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 go away with time and therapy. If changes are permanent, rehabilitation can help patients learn how to manage these changes.
Will I have any long-term limitations due to brain tumor surgery?
Possible long-term limitations due to brain tumor surgery depend largely on the location of the tumor removed.
For instance, the removal of tumors in the cerebrum can have cognitive effects, such as learning disabilities among children. Also, the removal of a tumor near the pituitary or hypothalamus can lead to endocrine disorders, which can be managed long-term with hormone replacement therapy.
Many patients do not have long-term limitations after surgery.
Dr. Richard Anderson (Pediatric), Dr. Jeffrey Bruce, Dr. Julius Ebinu, Dr. Neil Feldstein (Pediatric), Dr. Guy McKhann, Dr. Marc Otten, Dr. Sameer Sheth and Dr. Michael Sisti are experts in brain tumor surgery for adults. Each can also offer you a second opinion.