Ependymoma Surgery

Ependymoma is a rare tumor that can occur in the brain or spine. Surgery is typically the mainstay of treatment, with safe and complete removal being the most important factor for long-term control. In this article, we review the surgical approaches for ependymoma removal.  

Ependymoma is a type of tumor that originates from ependymal cells lining the ventricles of the brain and the central canal of the spinal cord. Ependymomas can occur at any age. In children, ependymomas are more often found in the brain. In adults, ependymomas are more often found in the spine. 

Surgery is typically the first line of treatment for ependymomas. Safe and complete tumor removal is the primary goal. Other treatment options such as radiation therapy and/or chemotherapy may also be used to kill and prevent growth from any remaining cancer cells.

The best treatment option is one that aligns with your health goals. If your goal is to maximize survival, complete surgical removal is often the best initial choice if safe to do so. The success of the procedure depends on a variety of factors such as tumor size, location, and the skill of your surgeon.

A competent and skilled surgeon can make all the difference when it comes to ensuring complete and safe tumor removal. Learn more about how you can choose an expert surgeon for your case here.

For brain ependymoma, the area of surgery is typically at the base of the skull and thus this procedure will be described below. The exact approach will differ depending on the location of your tumor. Brain ependymoma surgery can take 4 to 6 hours or even longer depending on the complexity of the case

The patient is positioned on the operating room table and given general anesthesia. Once asleep, a breathing tube is placed into your trachea, or windpipe, (intubation) and connected to a ventilator to pump oxygen during the procedure. A 3-pin skull clamp is fixed to the table and the patient’s skull for immobilization.

The skin around the planned incision line is scrubbed with an antiseptic solution. A skin incision is made through the scalp to the outer surface of the bony skull. Clips are applied to the skin edges to minimize bleeding and muscles are retracted.

Small openings in the skull (burr holes) are made with a surgical drill. A blunt tool may be inserted into the hole to separate the outer covering of the brain (dura) away from the inner skull bone. Another instrument called a craniotome is then used to saw through the bone from burr hole to burr hole. Eventually this creates a removable bone flap.

The dura is incised, then flapped back. Surgical instruments are used to carefully dissect and retract parts of the brain to reach the ependymoma.

Once the ependymoma is removed, the dura is stitched back together. The bone flap is reattached and fixed to the skull using small metal or titanium plates and screws. These will remain there permanently. Muscles and connective tissues are sutured back to their original position, scalp clips are removed, and the edges are sutured or closed with staples.

For spinal cord ependymoma, surgery is performed on the back. Spinal cord ependymoma surgery can also take 4 to 6 hours or longer depending on the size of the tumor and complexity of the case.

For spinal cord ependymoma, the patient is positioned face down on the operating table, with the neck and back slightly flexed. This position allows the surgeon to access the spinal cord.

The back is scrubbed with an antiseptic and a midline incision is made over the affected area of the spine. The incision length and level depend on the tumor’s location.

Using a high-speed drill and other surgical instruments, the surgeon removes a portion of the lamina (the bony arch covering the spinal cord) to expose the spinal cord. Screws may be placed during the operation in levels where bone was removed and connected with a metal rod to stabilize the spine.

The surgeon carefully opens the tough outer layer surrounding the spinal cord (dura) to expose the spinal cord. An incision is made in the spinal cord, and the tumor is carefully dissected from the surrounding nerve fibers.

Once the tumor is removed, the dura is closed using sutures. The overlying muscle and connective tissues are secured back in position; then the skin is stitched back together or closed with staples.

The success of the surgical resection is assessed by postoperative imaging studies, which can determine the extent of tumor removal and guide further treatment. In some cases, additional treatments such as radiation therapy or chemotherapy may be necessary to prevent tumor recurrence.

After surgery, the patient will be closely monitored for pain and any neurological deficits, such as weakness, numbness, or changes in cognitive function. In addition, patients may have difficulty eating and drinking because of nausea or swallowing difficulties after the surgery. Nutritional support, such as enteral feeding or intravenous fluids, may be necessary to ensure that the patient receives adequate nutrition.

Complications from surgery for ependymoma are rare but include bleeding, infection, and neurological deficits from damage to surrounding tissue or structures. Physical rehabilitation may be required to help regain lost functions.

Two weeks postoperatively, a lumbar puncture (LP) may be performed to look for "drop metastasis," which are tumor cells that have spread through the cerebrospinal fluid (CSF). A small amount of CSF is collected and analyzed for the presence of malignant cells, which may be used to follow treatment. If the LP is positive for drop metastasis, it indicates that the tumor has spread beyond the primary site and may require additional treatment. 

The recovery outlook differs from patient to patient. After treatment, some patients may experience fatigue and cognitive changes, such as difficulty with memory, concentration, speech, pain at the surgical site, or neurological deficits such as weakness or numbness.

However, these symptoms typically improve over time as the brain or spine heals. In some cases, physical therapy, speech therapy, or rehabilitation may be necessary to help recover strength, mobility, and coordination.

There is no single cure for ependymoma cancer. However, some patients experience long-term survival after one or more treatment modalities. Research is ongoing to optimize treatment options and determine what factors can be modified to produce the best possible outcomes.

Patients and their families should work closely with their healthcare team to set realistic recovery expectations and develop a plan for ongoing care and monitoring. With the proper support and treatment, many patients with ependymoma can live productive lives.

• Surgery is a primary treatment option for ependymomas of the brain and spine
• Risks and potential complications of surgery include bleeding, infection, and worsening of neurologic deficits
• Outcomes of surgery can be influenced heavily by the skill and experience of your operating neurosurgeon

• Collaborative Ependymoma Research Network (CERN)
• American Brain Tumor Association (ABTA): Ependymoma
• The Childhood Brain Tumor Foundation 
• Pediatric Brain Tumor Foundation