Spine Tumor Removal
Why is this surgery done?
Spine tumors in children can occur outside of the spinal sac (extradural), inside the spinal sac but outside of the spinal cord (intradural), and/or inside the spinal cord (intradural intramedullary). They can occur anywhere along the spine and spinal cord:- in the neck (cervical), mid-back (thoracic) and/or the lower back (lumbosacral). Spinal tumors can be benign (non-cancerous) or malignant (cancerous). Spinal tumors can cause pain, numbness, loss of function (weakness or paralysis) and/or bowel and bladder dysfunction due to involvement of or pressure on the spinal cord or spinal nerves.
Surgery is recommended to improve symptoms, prevent further loss of function and make a diagnosis. Surgery can usually cure benign tumors. Surgery cannot cure malignant tumors, but can help preserve function.
How is spine tumor removal done?
The surgery is typically done by a pediatric neurosurgeon. The surgical approach for a spinal tumor is usually by way of an incision made on the back of your child’s neck or back. The exact location of the incision depends on the location of the tumor.
After making the incision, bone and ligament are removed to gain access to the spinal canal, which contains the spinal cord and spinal nerves. These are covered by a layer of dura. In children, the bone is typically cut on both sides, keeping the ligament between the bones intact. The bone is lifted up and out of the way during the surgery, and then put back at the end of the operation with small titanium plates and screws so that it can fuse back into place and protect the spinal cord.
After opening the bone and exposing the dura, the tumor is removed if it is located in the epidural space. If it is inside the dura or spinal cord, a high-powered microscope is used to help remove the tumor. This will help make the surgery as safe as possible and enable the neurosurgeon to remove as much of the tumor as is safely possible. If the tumor is inside the dura, the dural membrane is opened. Then, using very fine instruments, the tumor is separated and carefully removed from the dura, spinal cord and/or nerve roots. If the tumor is inside the spinal cord, special nerve-monitoring equipment is used to locate the midline of the spinal cord. An incision is then made in this space to get to the tumor. Special instruments are used to suction the tumor away from the spinal cord while using nerve monitoring to perform the surgery as safely as possible.
Sometimes, a tumor cannot be fully removed because it may cause more harm and loss of function to remove the entire tumor than to leave a small amount behind. After the tumor is removed, the dura is carefully closed with sutures. The bone is returned to its normal position and attached as described earlier. The incision is closed with sutures beginning with the muscles next to the spine, followed by all other layers and skin. Typically, the skin is closed with sutures that will dissolve over time and a layer of skin glue. Once removed, the tumor is sent to a pathologist, who will examine it and make a diagnosis.
What are my child’s risks? What are common complications?
The risks of surgery depend on the location and size of the tumor and whether it is epidural, intradural extramedullary or intramedullary. The risks include but are not limited to bleeding, infection (especially if your child picks open the incision), cerebrospinal fluid leak, new neurological deficits (such as worsening bowel and/or bladder function, leg and/or arm weakness, loss of sensation or pins-and-needles feeling) or persistence or worsening of existing deficits and complications from anesthesia. These will all be discussed with you.
What do I need to know before surgery?
Prior to surgery, there may be additional testing done to look at the bladder, for example, if there is a preexisting bladder dysfunction or the tumor is at the lower end of the spinal cord.
You will receive communication before coming to the hospital with specifics about where to go the day of surgery and instructions for the day before and day of surgery. This information will include details about home medications and when to stop eating and drinking.
The length of surgery will depend on the degree of difficulty. Your child will spend at least 2 – 3 nights in the hospital. The first night will be in the pediatric intensive care unit (PICU) for close monitoring. Your child will come out of surgery very sleepy, and their medical team will likely give them medicine that makes them extra sleepy for the first 12 hours after surgery to help with pain control.
Your child will be given intravenous (IV) fluids, pain medications and anti-nausea medication until they are able to take medications by mouth. IV antibiotics will be given for 24 hours after surgery. No further antibiotics will be required after surgery and no antibiotics will be needed before surgery. Steroids will be ordered for the first 48 hours through the IV. Steroids can upset the stomach, so your child will be given medication to help to decrease stomach upset. Your child will be started on a stool softeners immediately after surgery to prevent constipation.
Your child will have a rubber tube in their bladder (Foley catheter) to drain their urine while sedated and additional monitoring devices to closely watch their blood pressure and heart rate. The Foley catheter will remain in place until the child can get out of bed to go to the bathroom. Following the removal, the nurse will do a bladder ultrasound after each time your child urinates. This will be done at least three times after surgery. If your child is not able to empty the bladder or has a hard time urinating, this could be due to spinal cord swelling and/or the narcotics being given for pain control. As a result, you may be shown how to do in and out catheterizations on your child, since these may need to be done at home for a period of time until the bladder function returns to normal.
Your child will be allowed to drink and eat slowly as soon as they are able, and they will be allowed to get up out of bed as soon as they are awake and the extra monitoring devices and bladder catheter have been removed.
In some circumstances, your child may have drainage tube placed at the site of surgery for draining blood away from the wound. The drainage will be monitored and removed when drainage slows. Once removed, the area is closed with a stitch.
A postoperative spine MRI will be done within 24 to 48 hours after surgery to see if there is any tumor remaining.
Our team is specially trained on this diagnosis and expert in the care of spinal cord tumors. We know it can be a scary time, and we have a team of medical professionals available to answer any questions or discuss any concerns that you might have.
General discharge instructions
In order to be discharged from the hospital, your child will need to be able to urinate without any problems, or you will need to show that you can do bladder catheterizations, as discussed earlier.
Your child must be able to tolerate oral/tube feeds without vomiting. Their pain must be controlled with oral pain medications. They need to be passing gas and have a bowel movement. Your child should be fever free for 24 hours.
The course and length of stay can range from 3 – 5 days to up to a month, depending on any complications present prior to or after the surgery.
Your child may need to go to outpatient physical and/or occupational therapy once discharged from the hospital. The social worker will help set this up as close as possible to your home.
A child is usually out of school for at least two weeks while they heal. Some children may require a more specialized timeframe.
A child is not to participate in any sports, and must keep their feet on the ground at all times (no swinging, jumping, climbing or running) for 4 – 6 weeks after surgery, until they are seen again in clinic and given permission to do so.
Reasons to call the neurosurgery office include:
- The incision has any swelling, redness or drainage
- Fever of 101.5 degrees F or higher
- Persistent vomiting
- Worsening pain
- Trouble going to the bathroom
- Any numbness, tingling or weakness in the arms or legs
What should I expect while my child is recovering?
There will be a follow-up appointment with neurosurgery two weeks after the surgery or sooner if needed.
The region of the incision is typically sore after surgery. This should gradually improve and be relieved by the oral pain medications prescribed for your child.
Tiredness and fatigue are also very common and will gradually improve with time. It is common for it to take up to three months before your child feels back to normal. Make sure they have plenty of rest during the day and eat healthy foods (avoiding candy, soda and fast food). Set a regular bedtime and wake-up time to ensure they get plenty of sleep.
Possible physical therapy exercises
Your child will be seen by a physical therapist and occupational therapist, typically on the first day after surgery, to help with walking and to determine what is needed for home. If the need for physical and occupational therapy is extensive, they may be referred for intensive inpatient rehabilitation.