Q. What is the recovery like from brain surgery like?
Brain surgery is unlike most other major surgeries in that the recovery can be deceiving. The brain does not experience pain, and the skin incision usually is not painful either. You may feel the day after surgery that nothing has changed. However, you have to remember that with any major surgery like brain surgery you need time to recover beyond the time needed for the incision to heal. You may look like your old self and your family may feel that you look like you have completely recovered relatively recently after surgery. Also, it is very common for all patients to have significant emotional reactions to big surgery such as this- particularly depression and anxiety, and this too is normal and will subside with time.
Q. How soon after surgery can I resume ‘normal’ activities? When can I return to work?
From the day of surgery until the initial post-op visit (around two weeks after surgery) you should not lift anything heavier than a gallon of milk, and avoid any activities that could increase brain pressure, like straining or bending over at the waist. After your staples are out (roughly two weeks after surgery) you can liberalize your activities considerably. You can fly on a plane, you can do basically anything that you feel comfortable doing. You must use common sense and not overstrain yourself. You may find that you are still easily fatigued, that is normal. You may also find that your level of energy and other surgery related symptoms - dizzyness/ lightheadness, etc. wax and wane in severity. Some days may be better than others. This is also normal. For brain tumors, most patient feel able to return to work between six and twelve weeks after surgery.
Q. When can I drive after surgery?
If you are not taking narcotics, and you were driving before surgery, than you should be able to do so again. The main message should be to start things in moderation and increase your activity as well as you can tolerate. As a genereal rule, you should not drive for two weeks after surgery.
Q. What is the role of minimally invasive techniques in skull base surgery? What about the surgical endoscope?
For anterior skull base procedures, including surgery for pituitary tumors, the role of minimally invasive surgery has been steadily expanding in recent years, predicated largely on the availability of a natural anatomic corridor to the the anterior skull base: the nose! The limitation of minimally invasive anterior skull base surgery has not been so much with performing the surgery successfully, but rather in closing the wound after the lesion has been treated in a fashion that is water-tight and prevents the migration of bacteria from the nose into the brain. This can cause meningitis, often with permanent consequences and even risk of death. There have been several advances in recent years that have dramatically improved our ability to get good closure, and consequently the use of minimally invasive techniques has increased.
For what we call lateral skull base procedures, including surgery for cerebellopontine angle tumors, the use of minimally invasive techniques has been much more controversial. In my opinion, minimally invasive techniques including the use of intra-operative image guidance to guide craniotomy site selection, minimize exposures, and limit the use of retraction have contributed immensely to improved outcomes in posterior fossa surgery. However, I would go so far as to say that for most posterior fossa surgery, the endoscope adds little additional benefit. That is not to say that it is not useful in some situations.
Q. What is ‘radiosurgery’, or ‘stereotactic radiosurgery’
Stereotactic radiosurgery is a technology developed over the last fifty years where precisely focused radiation beams are used to destroy cells deep within the body, without requiring any actual brain exposure. It has been developed as an alternative to ‘external beam’ radiation therapy, or conventional radiation therapy, in which the body and the target tissue both receive equal doses of radiation. Because the beams are so compactly focused in radiosurgery, they do not contribute a clinically significant dose of radiation to any structures outside the target field. This allows very high doses to be delivered to the target tissue with a minimal risk of injury to the surrounding brain or spine.
Q. Are there any risks with radiation?
One cannot underestimate the importance of realizing that even though you cannot, see, smell, taste, or feel radiation, its effects are powerful. Whether radiosurgery is being used for metastatic disease, benign tumors, an arteriorvenousmalformation, or another indication, there is always the risk of radiation complications. In general, these can be divided into immediate, delayed, and late complications.
Immediate complications include swelling of the brain at the border of the radiation target site. This may cause headache, nauseas, or if severe an altered level of consciousness.
Delayed side effects are reactions to the radiation that occur in weeks to months after treatment. These include hair loss (as opposed to conventional radiation, it is very rare to see hair loss after radiosurgery), as well as more serious side effects such as cranial nerve problems and necrosis (or cell killing) of normal brain tissue. Some delayed ‘adverse radiation effects’ may be permanent and even disabling, but in general they can usually be successfully managed with oral steroids.
Late complications of radiation treatment are principally thought to be radiation induced tumor formation. Importantly, this is a life-long risk, meaning that the younger a patient is irradiated, the higher the chance of them developing a radiation induced tumor. I generally am biased against radiation for younger patients, as well as for patients with tumor syndromes in which there the body’s mechanisms of tumor suppression are already compromised (e.g. neurofibromatosis).
Q. Is radiation appropriate for patients with NF-2?
Firstly, there is evidence that radiation is less effective in NF2 than in the ‘general population’. Secondly, the risks of radiation in NF2 are much higher, particularly the risk of causing a cancer. This is though to be very rare in the general population (1:1000?) no one knows for sure. But in NF2 it is thought to be as high as 4-5%. This would be a fatal complication, and is much less than the mortality associated with surgery. Of course, this is a 'late complication', meaning you have to live long enough for it to happen. Hence in 'otherwise healthy' patients with NF2, in other words not end-stage patients, or in the young in general, radiation should be used with caution.