Disconnected
Myelomenigocele. It is a neurosurgically treated birth disorder that is largely preventable by Folic acid (vitamin) taken during pregnancy. I had not seen a case in decades until I worked in Saudi Arabia. I lived in a walled compound with guards. The poverty rate? The government hides its data but estimates of 30% unemployment are noted.
Needless to say it was shockingly sad to be treating a condition that was preventable by simple measures taken early in pregnancy.
In this land knowledge mixed with ignorance. I lived in a walled compound separated from the very people I treated in so many ways more than the mere presence of a wall. Yes, it came with a pool. My hospital was no clinic. It was an upscale hospital in busy downtown with a well to do patient population. It meant the general population had poor health care knowledge.
Head scratcher
Speaking of badness… I got to see and treat this guy. Holy!?!!?..shit. Ummm, he walked around with this obvious lump sticking out of his head…for a long time. We took it off/out. He lived happily ever after. You would think I would remember him vividly. I don’t. I took care of so many strange and wondrous things. This was no doubt bad! But it was in a day’s work. Some days you just can’t make this shit up. Better out than in.
Roses
Are you tired of flowers? This set were sent from a florist. There’s a story. Ha! A patient’s family sent them to the office. I had the brilliant notion to invite two families to dinner the previous Saturday. That would be dinner for twelve. I had offered to cook. Yup! I was gonna do it. And then the call came. I had an emergency operation – an acoustic neuroma. They are tricky delicate operations that required the operating microscope and long hours of careful dissection around the nerve and brainstem. Yup, tricky and delicate. I’d draw out this story but long about dinnertime – say about 5PM – I had my operating room nurse call home and inform my wife I’d be a bit longer – say several more hours. Needless to say, my wife had already made Plan B. Everyone went out instead. I finished up around 8PM and could probably have made it to the restaurant. But I chickened out and had dinner nearby with my PA (assistant).
We’re almost at the punchline. After the surgery an anxious family heard the story of the harrowing operation in which we saved their loved one and preserved brain function so that the young man could live on for many more years. I also told them the story of the aborted dinner. The next Tuesday, these enormous roses arrived during my office hours. I would have difficulty explaining how large they were (bigger than my fist – that would be a 7 ½ size surgical glove). I can only say they were the largest blooms I have ever seen. Ok, I’m a guy. What do you do? Take ‘em home to your wife and apologize for messing up dinner the previous weekend. Right! I didn’t tell her the roses were from the family. I told her I’d gotten them (I left out the “how”) and brought them home. The story and apology would’ve worked except that the nurses ratted me out at the Christmas party nine months later. Nurses! They have a long memory. Be nice to them.
Weddings
Signature shot. I shoot weddings. No, not really. I’ve just been there when weddings occurred. Yes. I’ve shot a few. Not as the paid prime photographer. That would be too stressful. After all, wasn’t brain surgery nerve wracking enough? However, I always wanted to do wedding photography. The stress would never equal an aneurysm rupturing right at a critical moment during surgery. You’d never know if it never happened to you. I had some spectacular saves. No, it was not salvage due to incompetence. It was just a few miracle saves. No one ever died on my OR table. For that I thank whatever spirit guided my hand.
I digress. An example? My first is a vivid memory. I was just getting the temporal lobe exposed when the posterior communicating artery aneurysm let loose and ruptured. Blood filled the operating field in an instant. Muscle memory!? I just stuck a clip into the blood and released the clip. The bleeding stopped. Just like that! You have to understand that the bleed is coming up the carotid artery straight from the heart and you die from uncontrolled bleeding pretty fast. Like a bullet in a tire you are flat (dead) pretty fast. I looked around, (changed my underwear), and proceeded to look into the operating field. The clip had been applied perfectly. I mean, as in, we didn’t move that clip again. It was perfectly placed. A third year med student who had been observing me that day, years later at a national meeting: the student, now a fellow neurosurgeon, took me aside. He told me that that operation was the first aneurysm he’d seen and his impression at the time was that operation was how all aneurysm surgery was done. Silly me. I was trying to impress him?
…Friends. They don’t mind that I tote a camera to their weddings. And I shoot without pressure. And afterward, I donate my efforts to the cause. It’s a nice complement to be told that an image I took was treasured as much as any other taken that special day. It’s happened more than once. I’m glad my skill is sometimes appreciated. Oh?! This couple is still married. Happily?
End of the Day
Side view: Mass pressing against the spinal cord
We were on a roll. The same day as the previous case I was introduced to the patient who was weak in both legs and could not walk. She had involvement of her spine with breast carcinoma. The lower mass was about to make her permanently paralyzed.
Side view: cervical thoracic with tumor around spinal cord
There is another large mass in the cervical thoracic junction which was not yet symptomatic. The lower mass at the thoracolumbar junction was the culprit. So instead of going home we took her to the operating room and removed the tumor. It had compressed her spinal cord.
Top down thoracic spinal with tumor distorting spinal cord
Timely decompression gave her a chance to walk again. The next morning she was moving her legs and several days later she stood and walked again. Yes, we were pretty happy for her. And she thanked us too. It was a privilege to be able to save her neurological function and get her to walk again.
Spinal Tumor
Side view: the gray mass below the white column is the tumor
This is a spine tumor. On the day we did this surgery I operated in the neck, in the thoracic spine (chest) and in the lumbosacral spine. We followed that with brain surgery. It’s always interesting. This poor patient was treated for an infection but was not improving. Several biopsies were unsuccessful to establish a diagnosis. Now he was weaker and in more pain. The mass invaded his sacrum – pelvic bone – and surrounded his spinal nerves and was threatening to take his leg strength and bowel and bladder function. It was pretty serious stuff. And previous procedures had everyone guessing what this lesion represented on the MRI scan.
Top down: the bone and spinal canal are all filled with tumor
Head is toward left: this is the spinal sac – the tubular structure.
Surgery was difficult as expected. The mass was completely in front of the spinal sac. It’s partly why the diagnosis was so difficult to establish with a extensive surgery. You can see the nerve sac. This turned out to be a tumor lying stuck tightly among the nerve roots. It had been growing slowly. About six hours later and the nerves and spinal sac were decompressed. We worked slowly under the operating microscope to get the pressure off the nerves. It was most rewarding to hear the patient tell me the next day that his severe debilitating pain was much improved. Some days end up pretty nice.
Slow Growing
Side view: nose and mouth to the lower front left
This is a brain tumor. And if it is in your head this is big trouble. It is benign and grew slowly. The only noticeable symptom was that the patient lost his sense of smell. It did not act like a stroke so the symptom was ignored until now. And there is swelling around this tumor so it is actively growing. Now it can no longer be ignored. Surgeons like fisherman like to exaggerate about size so here are the images and you can make your own guess. This one Is on the extra large side of the equation. It is not the largest tumor I have removed. My assistant shook his head in amazement because it was the largest he has seen me remove while he worked with me. But hey! I’m older. The task at hand is to get this tumor out without causing any disturbance to the surrounding brain.
Face on view: the back of the eye nerves are the dots – nose in the middle
Oh? Yes it is benign. And the sense of smell is gone because the tumor origin is right from that area. There are a lot of serious neurological structures to worry about like the nerves for vision and major arteries into the brain. Of course it requires a complex approach to just expose the mass. As large as the tumor grew, it is still a matter of millimeters between trouble and success. We spent some hours taking this out. In fact it was close to six. And… the end result was that the patient was fine! That is the only thing that matters in the end. I just wish I had met this tumor when it was a lot smaller. But since I’ve been here there are lots of people who have refused surgery in favor of just waiting. Gee!
Top down view: things are turned around left and right. Lots of swelling around the tumor
And the patient – he will make a good recovery except for the sense of smell which was taken by the tumor growing.
Meningomyelocele
This is a birth defect. Once in a while you have a run of cases that are interesting. In Jeddah everyone is wary of surgery. The reasons are myriad but mostly people are just plain afraid. I had some recent successes so for a few days I’ll post up some medical things.
This child was born with a failure of the spine to close over into a proper canal. So the lump is a combination of nerves and skin exposed to the air. The spinal cord begins as a plate which rolls into a tube which is surrounded by the muscle bone and skin. Failure of the tube to roll up results in this defect. It is largely unseen in the US for many years. Prenatal vitamins has pretty much made this so rare that I have not cared for such a patient in many years.
You can see that the nerve sac is incomplete and sticking out through the spine at its lower end.
Fortunately the defect may be low enough that the child will walk. His bowel bladder function may be incomplete. The repair is shown.
The wound is several days after surgery so there is a lot of swelling and bruising but the defect is covered and repaired now. Many more problems will face this child as he grows. This is the first step. The biggest challenge now was to make a proper closure and to prevent infection.
Spine Surgery
Blood attracts attention. This is basic carpentry. There is not too much finesse in play here. The spinal canal was decompressed. Large screws, rods and a cross link were inserted to stabilize the spine. The problem with photographing spine surgery is that all the field is red and the anatomy does not show well at all. You cannot appreciate the screws; just their tops are in view. It all looks intimidating. It is. This system was inserted about ten years ago. The technology is old already. We have moved on to variable head screws. Just like the anatomy, the picture tells me much more than it can the casual viewer.
And this is cable. One professor of mine exclaimed he would never use it. For some problems this is the way to go. Braided cable is softer to work with and is less dangerous to use for certain conditions. So I did. It is much akin to the right tool for the right job. Knowing what is available helps in finding the best solution.
Cranial Trephine
The serrated T-handled instrument at the top is a trephine. These are battlefield surgical instruments. They are replicas which can be purchased for the historical demonstration here. Trephines were used in ancient Egypt for access to the brain. They were described by Kocher in a 1914 book in which he published techniques on how to use the device. The trephine is basically a circular drill bit the one could get at Home Depot today. We don’t use such devices in present day neurosurgery.
The center point is to drive through the skull to position the bit before you proceed to drill. If you look closely you will see the point is too long. It will pierce the brain long before the drill has made a hole in the skull. Crude and dangerous, but then again if you have to use this on a battlefield casualty, it’s probably not going to end well.
Another thought came to me as the demonstrator described how the other instruments were used to probe for and remove the lead balls in the wounded soldiers. Why? You don’t remove the lead. That’s not what is going to kill you. It’s damage to vital organs and the uncontrolled bleeding that will kill you. General anesthesia is not until the 1900’s, so bite the rawhide!
To this day though some things don’t change. It’s been a while since I had to remove a bullet. But I still ask for a metal kidney shaped basin. In today’s OR’s it’s all plastic. The nurses scramble around to get one from some back closet shelf. Then carefully holding the bullet fragment 12 inches above the basin, I release it to hear the satisfying clunk of bullet in the metal basin. For those of you who watched ‘Gunsmoke’ on television as a kid, you will understand.
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