You can read his full bio at: http://www.columbianeurosurgery.org/doctors/alfred_ogden/
We asked Dr Ogden some of the thorny and challenging questions that have come up among members of our group…below are both the questions and answers. Our sincere thanks to Dr Ogden!
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1) Many people who have been diagnosed with Schwannoma feel that they are in a bit of a lose-lose situation. They understand that if the tumor grows, they will likely experience greater pain and neurological deficits as it progresses. They also understand that if they go ahead with the surgery, they may also have declined abilities or potential neurological deficits from the surgery. From your perspective, what would you say to a person who feels like this? People who are newly diagnosed, and who are trying to decide between two kinds of options – both of which have risks and potential significant downsides?
Although there are always surgical risks, these
are often far exceeded in the long run by the neurological risk of allowing a
nerve sheath tumor to grow. This is
usually the case for tumors that are large enough to produce neurological
symptoms or tumors that demonstrate significant growth over a period of time. The difficulty for patients often is that,
with surgery, the risks are “up front” whereas without surgery the effects of
tumor growth are more insidious and drawn out. Tumors that are small and
asymptomatic can often be watched radiographically until they demonstrate
significant growth. Some tumors will not
grow enough within an individual’s lifetime to cause a problem and do not
require surgery. Patients do need to understand however that a definitive
diagnosis cannot be made without actually looking at the tumor histologically
(under a microscope), and the possibility exists for alternate diagnoses. Therefore, in some cases where the
radiographic appearance is less specific for a nerve sheath tumor, surgery may
be advised because of the possibility of an alternate diagnosis for which the
indications for surgery on a small asymptomatic tumor may be stronger.
2)More than one person in the group has expressed concern about Cerebrospinal Fluid leaks (we sometimes refer to this as CSF leaks). We had one member of our group with a confirmed CSF leak, who suffered astonishingly painful headaches in the days after surgery. What questions would you advise a person to ask their doctor if they suspect they may have had this kind of post surgical complication?
Cerebrospinal fluid (CSF) leak is a potential
complication in any spine surgery, particularly in cases of intradural tumor
surgery, which probably includes the majority of surgeries for spinal
schwannoma. The dural is a thin sleeve
of tissue that forms an envelope containing the spinal cord and associated
nerve roots. These structures are bathed
in a clear fluid called CSF. Spinal
schwannomas can grow inside the dural sleeve (intradural), outside the dural
sleeve (extradural) or exist in both compartments (often called “dumbbell”
tumors because of their characteristic shape).
Extradural tumors have almost no risk of CSF leak because the dura does
not need to be opened to effect their removal.
The others require a dural opening.
In cases of dumbbell tumors, the dural closure can be challenging as these
tumors can create defects that may require patching. Often bedrest is ordered to reduce the
pressure on dural closures in the immediate postoperative period. Sometimes a
drain is placed as a way to divert CSF in order to further reduce this
pressure. Unfortunately, whenever there
exists a reduction in CSF pressure, headaches can result. These are usually distinguished from other
types of headaches because they are exquisitely exacerbated by sitting up or
standing and relieved by lying down. It
is not uncommon for patients to have these so-called “spinal headaches” in the
immediate postoperative period especially if a drain is placed. This does not necessarily mean that a “leak”
exists. However, positional headaches
that are persistent, when all drains have been removed, are concerning for a
leak. CSF that exits the wound is by definition a “leak” and needs to be
addressed immediately.
3) Many people complain of numbness, tingling, and a pins and needles feeling after surgery. (I had the same experience, especially pins and needles – and it did dissipate in the weeks after surgery). Can you shed any light on what causes this post surgical set of sensations – and is there anything that you would recommend a recovering patient do to lessen these sensations and regain strength and movement?
Sensory disturbances are relatively common after
surgery. The causes of these are
myriad. Most of the time these are the
result of nerve irritability in response to the unavoidable manipulation that
occurs during surgery and the equally unavoidable inflammation that occurs
after surgery as part of the healing process.
Usually these sensations abate as the nerves relax and the inflammation
subsides. If these sensations are
painful or cause discomfort, they can be mitigated with medications.
4) Schwannoma patients are also very concerned about what may happen to them and their tumor if surgical intervention was only able to remove part of the tumor. Our understanding of Schwannomas is that though they are slow growing, they do grow – and therefore what suggestions, general or specific, might you give a patient who comes out of surgery only to find, for example, that 50% of the tumor was able to be removed?
Gross total resection should always be the goal
in schwannoma; however, since they are benign, slow growing tumors, this goal
should be pursued only if the tumor can be removed safely. A partially resected
tumor can always be reoperated on and small residual tumors often will not grow
back.
5) A more general question; what strategies have you found, in the years that you have been treating Schwannomas, that have proven to be most effective in bringing about the best possible recovery in patients? That is to say, among those patients who gained back the most ability and function, did you notice any strategies employed that worked best?
Recovery is very individualized. There is no one size fits all. In general, recovery can be thought of in terms
of neurological recovery and surgical recovery.
Patients with significant neurological deficits require therapy to begin
immediately to promote recovery of strength and balance. In patients without deficits, other than a
modicum of walking and getting out of bed to prevent medical complications that
are related complete inactivity, a period of convalescence until the surgical
area heals is needed, then physical therapy to rehabilitate the paraspinal
muscles in the surgical area is often helpful.
For most patients, especially ones with neurological deficits, recovery
is faster and more complete the more effort they put into therapy. Having said this, patients can “overdo it”
and there is a certain amount of the recovery process that simply cannot be
expedited.
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*Disclaimer: Dr. Ogden and Columbia University Medical Center assume no liability whatsoever for the comments or advice offered in the content of this blog. Dr. Ogden has offered his advice generally on the issues relating to treatment of Schwannomas - however Dr Ogden and the Schwannoma Survivors & Schwannoma Fighters group always insist that a person should make all major medical decisions in consultation with one's own physician.
