Frequently Asked Questions

Second Opinions and Coming to LA for Treatment
To get an opinion on treatment options based on a review of your MRI, please email me at dr.lekovic@gregorylekovic.com, and. or send records by email to frontdesk@gregorylekovic.com

Many of my patients come from out of state for treatment in Los Angeles. Please let us know when sending in your images that you are interested in coming to LA for treatment and I will have our surgery counselors reach out to you to explain the logistics in getting you here, having surgery, and getting you home safely.

In general, we always try to use the approach to surgery in teh least invasive means possible to achieve the goals of surgery. Inthe past ten years or so, this has in practice meant an increased use of radiation (radiosurgery) and the surgical endoscope to provide panoramic exposure with a smaller craniotomy and correspondingly smaller incision. I routinely use minimally invasive approaches for some tumors, like pituitary and other anterior skull base surgeries, and selectively in lateral skull base procedures.

Importantly, radiation – in the form of stereotactic radiosurgery – may provide an effective means of treating benign tumors of the brain and spine. Radiosurgery is a critical tool in the comprehensive treatment of tumors such as acoustic neuroma, and plays a role in decision making at all times, even when it is not the appropriate first line of treatment.

The Cyberknife is a linear accelerator mounted on a robotic arm capable of delivering precise radiation without the need of a ‘frame’

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.

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).

Finally, there is reason to be cautious about the use of radiosurgery in patient prone to developing tumors, specifically patients with neurofibromatosis type 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, possibly as high as 4-5%. Hence in ‘otherwise healthy’ patients with NF2, and/or in the young in general, radiation should be used with caution.

The GammaKnife, pictured here, is the original radiosurgery device. Although there is a lot of experience with this machine in many centers across the USA, its use has declined because of the need to immobilize the patient with a frame fixed to the skull with pins.

Recovery can be divided into three stages:

1. Acute recovery (i.e. in the hospital)

• This is generally 2-4 nights, with the first night routinely in the ICU for brain surgery
• At the time of discharge, you should expect to be walking, eating and drinking normally, and able to care for yourself without assistance. You should expect to fatigue easily, however.

2. Immediate post-operative recovery (after discharge from the hospital but before sutures are removed)

• During this time patients should not lift anything heavier than a gallon of milk
• Its OK to wash your hair/ wound with soap or shampoo as soon as you are discharged from the hospital
• don’t scrub or pick at the wound or any scabs
• Non-resistance exercise is encouraged, especially walking

3. At home

• Once sutures have been removed, its OK to gradually increase your activity including lifting heavier objects and doing more resistance exercise or training
• For most procedures, you may return to work around four to six weeks after surgery

If you are not taking narcotics, and you were driving before surgery, then 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 general rule, however, you should exercise caution when driving within two weeks after surgery.

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/ stitches 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 – this 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.

Wound care

The care of your surgical wound is straightforward. There are three simple rules to follow:

1. Keep the wound clean
   • Beginning the day after discharge from the hospital, you should wash the wound with shampoo or soap daily. It is OK to get the wound wet (even let the shower water hit the wound directly). DO NOT SCRUB the wound. By the time you have left the hospital, there is already a water-tight barrier and getting the wound wet will not cause harm. Do not go swimming or submerge the wound, however. Pad the wound with a towel to dry.
2. Keep the wound dry
   • Do not apply antibacterial ointments to the wound after discharge. While in the hospital, you will have an antibiotic ointment placed on the wound. This is not necessary after discharge from the hospital, and in fact may kill normal (healthy) bacteria that colonize the skin, making room for more dangerous bacteria.
3. Keep the wound open to the air
   • Bacteria like dark, moist, oxygen poor environments. Keeping the wound open to the air helps keep your wound clean and healthy. Morevoe, caps and kerchiefs, etc may rub up against the wound and increase the risk of infection.

For insurance and other appointment related issues, please contact my office directly at (213) 929-0419 to verify I am contracted with your insurance and to get an estimate of co-pays, or estimated out of pocket and cash rates.