100 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

RESIDUAL DISABILITY AFTER THE EXCISION OFBRAIN TUMOURSl

By DONALD SIMPSON, M.B., B.S. (Adel.), F.R.C.S. (Eng.),Senior Neurosurgical Registrar, Royal Adelaide Hospital.

The mere preservation of life is not theonly aim of surgery, or even its chief aim.There are few people who will welcome'Continued existence at the price of con­tinued misery, and in assessing the resultsof any kInd of surgical intervention it isnecessary to consider the preservation offunction even more than the mortality.

This is particularly true of the surgeryof cerebral tumours. Neurosurgeons andphysiotherapists caring for neurosurgicalcases are constantly made aware that thevictims of these formidable growths gainvery little if their lives are prolonged atthe cost of a profound aphasia or a totalmotor disability.

The figures which I would like to present'Concern the meningiomata. This com­pact group of tumours illustrates verywell the general problems of disability andrehabilitation arising after brain surgery.They are usually considered to be amongthe most favourable of cerebral neoplasms.They are comparatively benign; they arisefrom the coverings of the brain; theyusually compress the brain tissue ratherthan infiltrate it; and, although they ofteninvade bone locally, their metastasis to other1>arts of the body is exceedingly rare. They-:can usually be relTIoyed in entirety; the<operative mortality attending their removalis not negligible (in most published seriesat least 10 per centum) ; but, on the otherhand, their recurrence rate is low, at leastwhen compared with other cerebral tumours:such as the gliomata. They constitute, there­fore, admirable material for the study ofresidual disability, since the majority ofpatients survive operation and live reason­ably long. Moreover, these tumours arisein relation to almost all parts of the brain:

"1 Read at a meetlng of the SIxth Session ofCongress of the Austrahan PhysIotherapy AssocIa­tion at Adelaide on September 28, 1956

although they originate from the meninges,and are therefore superficial in genesis,their continued expansion can bring theminto relation with any of the cell masses andfibre tracts on which our cerebral functionsdepend. The disabilities they inflict (andalso, one must confess, the disabilities whichthe surgeon inflicts in removing them)therefore comprehend the whole range ofneurological misfortunes: dementia, hemi­plegia, paraplegia, blindness, and so on.

Between 1938 and 1953, 235 patients withintracranial meningiomata came to opera­tion at the Radcliffe Infirmary, Oxford, and205 survived operation for six months.These people were all traced in the courseof a research investigation recently, and anattempt was made to assess and grade theirresidual disabilities. Where possible, thiswas done by personal interrogation, but,much more commonly, it was necessary torely on letters either to the patient or tohis general practitioner.

It is very hard to find units for humansuffering and happiness. What is a cripplingdisaster for one man may spur another intoachievements previously impossible. Tem­perament, age, sex, income, and, it must beadmitted, nationality can all modify theresponse to a disability. The people I amdiscussing are an unselected sample. Theiraverage age at operation was in the middleforties; the extremes were a boy of 13 anda spirited gaffer of 73 years. There was apredominance of women (62% ), whichonly expresses the well-known and un­explained sex predilection of the meningio­mata. I do not think there was any greatsocial selection. Most of the patients camefrom Oxfordshire and surrounding countiesthough a few were foreigners from remoteplaces like London. The best introductionto an analysis of the disabilities in thisgroup is a simple statement of workingcapacity (Table I).

DISABILITY AFTER EXCISION OF BRAIN TUMOURS 101

The first group are those happy patientswith no symptoms, or none conceivablyrelated to operation.

The second group, those whose dIs­abilities are considered slight, are thosewith some complaint or some neurologicalabnormality who are nevertheless workingat their old jobs (or jobs comparable inearning power). If they are housewives,then they are still managing their accuS­tomed duties; if they are retired, then theyare as active and happy in their potteringsas one might reasonably expect.

TABLE I.Disability.

I. None o....... 328S~ol63%2. Slight .o.... 7( }

3· Moderate 23%14· Severe 9% ~ 37%5· Total 4%J

These two groups constitute only 63%of the whole series. One may say of thesepatients that they have been successfullytreated. It is otherwise with the remaining37%·

The patients with a moderate disability(23%) can still work, but have had toadmit a definite limitation in their powers.For a man this usually means a poorer-paidjob; for a housewife, the need for helpwith some household chores previouslymanaged. Into this group would come menworking in such special protected factoriesas those provided by Remploy Limited; ona higher social scale it includes the seniorstaff officer whose memory now needs muchskilled prompting.

The patients with severe disability (9%)are wholly unable to work, though still ableto care for themselves. Those with totaldisability (4%) cannot care for themselvesand need some degree of nursing either athome or in an institution.

It will be seen, then, that in more than athird of these cases the functional resultleaves much to be desired. Moreover, thefigures which I have given represent thepatient's maximal achievement. Some ofthose whose disabilities are categorized asslight only reached this level after longperiods of rehabilitation. A certain numberagain have subsequently developed recur-

rences of the tumours and now suffergreater disabilities than at first.

This depressing incidence 0 f serious dis­ability has been the experience of everysurgeon concerned with these tumours..Olivecrona (1955) reports that of 222patients surviving a year or longer, 127were well and working, but 52 were only"partially well" and 30 were invalids..Grant (1954) mentions that more than 40of a series of 219 cases were crippled.Fincher (1954) found significant residualdisability in 44 of 68 cases.

Nobody can be complacent over tumourswhich, despite technically perfect surgicalremovals, leave so large a minority ofcrippled patients.

The pathological basis for these cripplingsis sufficiently obvious. Brain tumours pro­duce symptoms in two ways: by raising theintracranial pressure generally, and by localneural compression, invasion, or vascularinterference. Both mechanisms may leadto irreversible damage; and it is the clinicalmanifestation of such irreversible dalnagethat constitutes the patient's disability. Athird factor is the damage, usually unavoid­able, incurred during the excision of thetumour: to remove a meningioma it is oftennecessary to excise brain tissue, and it issometimes impossible to avoid sacrificing amajor artery or vein. Damage of this kindis essentially irreparable: dead neurons donot regenerate. But it must be said thatthe brain has a great though unpredictablepower of compensating for the destructionof one cell-mass by the functional substitu­tion of another. Moreover, it is only thedead cells and fibres which are beyondregeneration: many cases of brain tumoursuffer disturbances of cell function short ofcell death, and these disturbances are com­monly quite reversible. One must notdespair of functional recovery after theremoval of a tumour until at least sixmonths have elapsed; this is especially trueof the higher intellectual functions.

The actual physical disabilities seen inthis group of patients are not easilyclassified. For convenience, I present themunder four headings: ( I) menta1 disturb­ances, including dysphasic impairment ofspeech; (2) motor disabilities; (3) visualdisabilities; and (4) epilepsy (Table II)Qo

102 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

You will see in Table II the relativeimportance of these fOUf groups of dis­ability. It must be confessed, however, thatthese are very arbitrary comparisons. Manypatients had more than one kind of dis­ability, and I have only guessed which wasthe main incapacity.

Epilepsy, to take the least first, is a verycommon sequel to any operation on thebrain. Scarring of the cerebral cortex isunavoidable, and the brain scar, for reasonsnot "veIl understood, causes the sudden,explosive, nervous discharge which we call

TABLE II.DIsabilIty. Moderate. Severe Complete.Mental II 5 5Motor ... 24 5 3Visual .. 6 8 IEpilepsy 5 Nil Nil

46 18 9

epilepsy. In one form or another this wasa post?perative complaint in fully 43% ofcases tn the Oxford series, being (as is tobe expected) especially common in thosewith a history of preoperative fits. It isalways an unpleasant inconveniencefrightening to the victim, and often dis~gusting to his acquaintances. If the fits arenot heralded by a constant and reliablewarning sensation, they can be acutelydangerous, and such epilepsy is, or ought to~e, a bClr to driving a car and to any occupa­tIon that exposes the patient to risk if heloses consciousness suddenly. One womanin this series is belteved, adluittedly onpurely circumstantial evidence, to have hadher first and, unfortunately, her last fit whendriving ~n automobile. Epileptics may also,rarely, dIe from the exhaustion of continuedan.d uninterrupted fits-status epilepticus;thIs happened to at least one patient in thisseries. Nevertheless, epilepsy was classedas a cause of lTIoderate disability in fivepeople only, and in several of these theclassification is disputable. With the aid ofanticonvulsant drugs the tendency toepilepsy can usually be controlled,,, and itssignificance as a cause of economic dis­ability is much less than one would suppose.All patients surviving the excision of a

meningioma are now routinely given small,regular doses of phenobarbitone.

Visual loss is, of course, a terrible andobvious disability. Intracranial tumours caninvolve the optic pathways in two ways:either directly, by compressing the opticfibres at some point in their course, orindirectly, by producing prolonged, raised,intracranial pressure, to which the opticnerves are sensitive. In the bad old daysthe victims of cerebral tumours very com­monly went blind from unrelieved intra­cranial hypertension. Nowadays this ismuch rarer, but it is sad to find that therewere some six patients disabled in this way.I would like to emphasize that in manypatients with visual failure, even if short ofblindness, the visual disability is aggravatedby a coexistent defect in another part ofthe nervous system. One poor woman inthis series has poor sight and a moderatecerebellar incoordination, the legacy of acerebella~ meningioma removed some yearsago. Etther would be a moderate dis­ability; together they wholly incapacitateher, because she cannot compensate for themotor incoordination by watching her steps.Another even more tragic patient, not inthis series, went blind from a brain tumour(not a meningioma) in the right parietalregion. She is an intelligent, well-educatedschool-teacher and might have made a goodlife for herself as a blind person. But thetumour had deprived her of the discrimina­tive powers of her left hand; although thereis no actual weakness, she has such a defectof sensation that she cannot master thecrafts by which the blind live. She canread braille, which is, of course, a one-handfacility in most instances, but she cannottype accurately or make any but clumsyhandwork.

Mental disorders, with which I havecoupled the aphasias, account for very manyof the disabilities~ They present a complexproblem. Some may be classed as non­specific, in that one cannot explain them asthe result of damage to some single areaof the brain.

In your own practice you will constantlyhave encountered the frustrating patientwho has a real disability and will make noattempt to overcome it. It is the casewith many of these patients that the objec-

DISABILITY AFTER EXCISION OF BRAIN TUMOURS r03

tive disability does not explain the actualincapacity; I strongly suspect that we areseeing a complex of factors. It is notenough to dismiss these people as exhibiting"functional overlay". One must if possibledetermine the patient's basic personality;when it has always been inadequate onemay suspect that the meningioma is only aprecipitating factor. In some, however, thetumour has caused an over-all reduction inmental power, perhaps difficult to identifyon casual examination, and this is particu­larly likely to occur in the elderly. Someof these patients may, again, be defeatedby disabilities which appear to the outsidernot insuperable. This mild general bluntingis much harder to cope with than the acutepsychosis which occasionally follows cranialsurgery. One patient in this series had areally terrifying depressive state after thesuccessful removal of the tumour. It waschiefly endogenous in its colouring withideas of paranoid type and threats ofsuicide; one can only speculate on thereasons for its appearance in his convales­cence.. It responded very well to electricconvulsive therapy.

Non-specific forms of mental disabilityinduce an inadequate or defeatist attitudeto a physical disability, an over-all reductionin intellect, and a true psychotic episode.There are, however, obviously specificmental disturbances due to involvement bythe tumour of an area of the brain withspecialized intellectual function. Thus,meningiomata in the extreme frontal regionmay mimic a prefrontal leucotomy, leavinga euphoric, tactless patient, careless in per­sonal habits, who is a burden to hisrelatives. Such mental changes usuallyclear, but they were unfortunately per­manent in one old man in this series andhave been of grave consequence. He ischeerful and superficially intelligent, butis completely unable to hold a job or evento refrain from wetting his bed. Meningio­mata involving the dominant hemispherewill often disturb the language function;and disturbances of this kind can beextremely crippling. It is not only speechin its narrow sense of spoken communica­tion that is disturbed: usually, though invarying degrees, all aspects are involved,including writing and so-called internal

speech, which underlies many intellectualprocesses not at first sight concerned withthe language function. These aphasias,again, may regress, and are especially likelyto do so in the young. When they do not,they cause a very horrible and frustratingdisability, and naturally aggravate anycoexistent physical disability, such as ahemiplegia, since the patient cannot makehis want clearly known or cooperate in hisrehabilitation. The retraining of aphasiasis a complex business with which I am notvery familiar, but I think it is fair to saythat the results are good only in youngerpatients and where the speech difficulty is

MOTOR PATHS

~ PYRAMIDAL

@-----+EXTRA PYRAMIDAL ea. CEREBELLAR

FIGURE I DIagrammatic coronal sectionof the braIn, to Illustrate the maIn motor

pathways

not associated with much defect in com­prehension and in general intellectualrapacity. Patients of that kind were veryrare in thi; series.

Finally, lTIotor disabilities have beenunpleasantly common. It is particularly ofthese that I would like to speak. Anyvoluntary muscular action, however simple,is the result of coordinated activity ofseveral neuronal systems-chiefly the bigcorticospinal fibres that we call the pyrami­dal tract, directed by the sensory systems,modified by the more mysterious extra­pyramidal circuits and aided by the cere­bellum. Meningiomata can and do disturbthis complex synchrony at any point. InFigure I is presented an illustration <:;how-

104 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

<J II " " ll) NON· FUNCTiON )NG

MENINGIOMA PARALYSING

ME NJNG IOMAMJD-LJ NE

FIGURE 3. DIagrammatic reconstructionof the effects of a bIlateral fronto-parietal

parasagIttal menIngioma.

of the middle or anterior cerebral arteries,or of the superior longitudinal sinus, in itsposterior course, usually leaves permanentincapacity.

There were in this series twenty-fourexamples of moderate motor disability, fiveof severe affection, and three of completeinvalidism.. The large majority (twenty-

PARALYSING BOTH LEGS

such tumours may produce varying degreesof ataxy in the ipsilateral limbs.

Now the disorders of motor function pro­duced by tumours of this kind are oftenreversible; but if they represent actual celldeath, then the only restoration of functionthat can occur is by the substitution ofother neural circuits, and there is a limit tothis potentiality~ The removal of thetumours depicted in Figures 2, 3, and 4mIght remedy the motor deficits produced,and probably would do it if they were recentand if no major vessel were divided in thecourse of their excision. But where themotor neurones have atrophied from longpressure, or died from arterial or venousdeprivation, then the result will be poor.In practice, the latter lesions are the com­moner. When there is no vascular in1pair­ment, it is amazing what excellent func­tional recovery can take place. But division

ARM&FACE

FIGURE 2 Diagrammatic reconstructionof the effects of a menIngIoma of the

fronto-parietal convexity.

of the cerebral hemisphere in the region ofthe central fissure, and there were yet otherswhic'l caused pyramidal dysfunctions lessdirectly.. Figure 2 shows a typical exampleof such a tumour, producing a facio­brachial weakness. A larger tumour maycause a full hemiplegia.

A favourite site of origin with themeningiomata is the superior longitudinalsinus; and meningiomata in this positionmay be in direct relationship with the cellsof origin of the pyramidal fibres to the leg,and also to the sensory representation ofthat limb. There were thirty instances ofthis in the present series. Figure 3 showsa bilateral meningioma in this situation.The extra-pyramidal system is much lessvulnerable to the meningiomata, but thecerebellum is commonly involved by over­lying meningiomata, as in Figure 4, and

ing the course of the cortIcospinal motorpathways; also shown are the cerebellarefferents and (grossly over-simplified) someof the extra-pyramidal pathways. It isevident that the cortical origins of thepyramidal fibres are vulnerable to directcompression by an overlying meningioma..There were in fact some twenty-six tumoursin this series which overlay the convexity

DISABILITY AFTER EXCISION OF BRAIN TUMOURS 1°5

five persons) had unilateral spastic weak­nesses. One had a tetraparesis mainlyaffecting the legs. Six had cerebellarataxies of varying kinds. In addition, therewere several patients with recurrenttumours who ultimately came to haveserious tetrapareses. It is perhaps worthdescribing one of these in brief detatl, as thecase illustrates many of the problems arisingin this field.

",,{,

MENINGIOMA COMPRESSING

CERE BELLUM.

FIGURE 4. DIagrammatIc reconstructionof the effects of a menIngIoma arISIng

from the tentorIum

Case Report.F.D., a housewife, aged forty-one

years, was admitted to the RadcliffeInfirmary in 1948, complaining of epi­lepsy. The character of the attacksindicated a lesion involving the rightmotor cortex, and a carotid arteriogramshowed a tumour in this sIte, arisingfrom the superior longitudinal sinus. Itwas removed, apparently completely.Before operation there was no real motorweakness, but the unavoidable damage ofthe resection left a spastic paresis of theleft leg. This constituted no more than aslight disability, and the lady resumedher former activities. She continued tohave minor epileptic attacks, but thesewere not of great severity. In 195 1, how­ever, she began to complain of right­sided weakness, and a second operation

disclosed a tumour on the left side, theduplicate of that removed from the rightside three years earlier. The conditionwas In fact a bilateral meningioma, muchas in Figure 3. Following the removalof this tumour there was a severeright-sided weakness, with considerableclumsiness of the arm.

She is a persevering person, andalthough now handicapped by bilateralmotor disabilities, especially severe inthe legs, she began to walk betweenparallel bars.. Her husband spared noexpense in reorganizing her life, and, inparticular, he redesigned their house,providing hand-holds everywhere. Un­fortunately, she developed a furtherrecurrence of the tumour; this wasexcised in 1953, but she remains para­plegic-indeed, triplegic, since one armis also profoundly affected. Urinaryincontinence has been added to hertroubles.

This unfortunate woman demonstratescertain very crucial neurological principles.Firstly, a spastic weakness of one leg isnot an insuperable disability. The leg hasbilateral cortical representation, and thehemiplegic can always swing his leg along,albeit with a dragging foot, correctable bya proper toe-raisiNg spring. No hemiplegicin this series was unable to walk. Secondly,a spastic weakness of both legs is just asincapacitating when due to bilateral cor­tical damage as it is when due to spinalinjury, which is the more familiar form ofparaplegia. Thirdly, an upper motorneurone palsy of hand and arm is a pro­found disability, and if it does not recoverwithin a few months it is likely to bepermanent. This is especially so when amotor weakness is combined with sensoryloss. I confess to extreme pessimism overthe function of the hand in any hemiplegiapersisting unchanged for more than two orthree months; Twitchell ( 195I) indeedfound that some voluntary movementusually appears in less than thirty-threedays.

I wish that I could conclude with someintelligent comments on the amelioration ofall these disabilities.. Their prevention, bywell-planned and well-executed surgery, isof course the ideal. But in many instances

106 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

FIGURE SA PerIarticular calcIfication In the shoulder jOintof hemiplegIc arm

FIGURE 5B Osteophytic formation in the elba"\\' Joint of hemIplegic arm

DISABILITY AFTER EXCISION OF BRAIN TUMOURS 1°7

they are unavoidable. Disabilities frompoor vision, epilepsy, or mental deteriora­tion are not primarily the concern of thephysiotherapist; but I make no apology foremphasizing their frequency because theyprofoundly aggravate any motor disabilities.You will know much better than I thetechnical problems of re-abling the hemi­plegic, the paraplegic, and the ataxic. Iwould like only to make certain not veryoriginal observations on three importantobstacles to success in this field: arthritis,obesity, and demoralization.

The first is sometimes forgotten. Whena joint is immobilized there is a very strongtendency to capsular adhesions and ulti­mately even ligamentous calcification - inshort, to a painful, frozen joint. Arthritisis perhaps a poor term for this pathologicalstate; one might describe it better as rustingup. This is especially to be feared in theshoulder, but it may occur in the elbow, thefingers, and elsewhere. The patients aremiddle-aged or elderly, and, therefore,prone to arthritis. Their paralysed limbsare usually spastic, and the spastic armassumes a posture (flexion and adduction)of very little biological utility. If such aposture is maintained by painful arthritis,function will remain poor even thoughvoluntary muscular contraction is restored.Figure 5 shows the periarticular calcifica­tion which developed in a man with a sub­frontal meningioma in this series: he didnot receive physiotherapy in the immediatepostoperative period-he was exceedinglyill-and although the left hemiparesis hasvirtually recovered, his arm is still of verylittle service. In most cases, frequentpassive movements through a ful1 range willavert this. Sometimes, however, thearthritis seems to develop despite the mostassiduous physiotherapy. One sometimeswonders whether the joint is not sUfferingfrom the withdrawal of a trophic nervoussystem, but there is very little evidence forthis belief and, probably, simple disuse willexplain the phenomenon.

The second, obesity, is also at times over­looked. Any bedridden patient tends to eatmore than he needs; it is one of the fewpleasures open to neurosurgical convales-

cents. Moreover, persons with frontaltumours commonly have a pathologicalappetite~ One must watch against aninordinate gain in weight in a hemiplegic:it will greatly hamper his return to properwalking.

The third, the question of morale, is toocomplex for full discussion. The per­sonality of the medical attendant and thephysiotherapist with, of course, the inherentcourage of the patient are perhaps thegreatest factors in the first weeks. Butwhen the period of recovery is over andthe patient is faced with some permanentdisability it is necessary to invoke morespecialized help. Rehabilitation and physio­therapy must then be directed to somespecific aim comprehensible to the patient;it is, at least in the younger patients, farmore important to provide a trade oroccupation than to labour over exerciseswhich are meaningless to the patient andtedious to the physiotherapist It is at thisstage that rehabilitation centres have mostto offer. These centres not only give thepatient some potentially lucrative skillappropriate to his disability, but they alsoplace him beside competition from otherssimilarly placed. In the elderly, one mayperhaps accept a disability and aim ratherat the patient's comfort. In the young andIniddle aged, however, the goal is economicindependence; and in the series I have pre­sented some notable successes wereachieved. They were obtained by the teamwork of many people - the neurosurgicalstaff, the department of physical medicine,the rehabilitation services, and the hospitalalmoner service.

Acknowledgements.I alTI obliged to Mr. J. Pennybacker for

assistance throughout the survey reportedhere and for permission to present the casesmentioned in this paper.

References.FINCHER, E F (1954), Surg Chn N Amer J

1037GRANT) F C (1954), ] Neurosurg) II, 479HaeSSLY) G F, and OLlVECRONA, H (1955), J.

Neurosurg ~ 12, 614TVvITCHELL, T E. (I95 I ), Brain, 74, 443