Wednesday, January 24, 2007

This is Neurosurgery

I walked into an operating room shortly after 8am this morning, to a case which was already in progress. And when I left the hospital, thirteen and one half hours after arriving, only after the insistent "seriously Nathan, you'll have plenty of long hours later, go home and get some sleep" from my resident, the case was still in progress.

This patient, Mrs. Walker, has an acoustic neuroma, an overgrowth of the protective layer of Schwann cells around her eighth cranial nerve. The nervous system is much like any electrical system, and it needs insulation. So, just as the average copper wire has a coating of plastic around it, our nerves have coatings, made of fat. And around the eighth cranial nerve, CN VIII, the vestibulocochlear nerve, this coating is made of cells called Schwann cells.

Mrs. Walker's Schwann cells have been growing more than they need to for a long time. And as they have grown, since CN VIII is inside the skull, they have run out of room and started to squeeze the nerve, and the rest of the brain. Obviously, this is not good. It also happens to be the job of neurosurgeons to fix.

The initial portion of the case involved starting anesthesia and then laying the patient on her stomach, with her head tilted to one side. Then, through an incision behind the ear, a section of the skull was removed. Then, in one of the best demonstrations I've yet seen of the delicacy and absolutely steady hands necessary to be this kind of surgeon, a microscope was moved into position and the cerebellum was gently retracted out of the way about a centimeter or two. Through the space created, the chief resident and a staff neurosurgeon began gently separating the tumor from its surrounding arteries, nerves, and bone. Though it takes only a paragraph to describe, by this point it was 1PM. The tumor was carefully resected from its surroundings, preserving the nerve running right down its middle.

Then things got complicated. Another surgical team, from otolaryngology, came in to ensure there was no tumor involved with the facial nerve, and to do so, they needed to shift the position of the retractors holding things open. And as they did that, some of the petrosal veins tore. These are tiny, tiny vessels that run from the superior surface of the cerebellum to the superior petrosal sinus. That sinus is labelled at about the 7 o'clock position in the image to the right. There are two problems right away with this. One, veins do not clot off as easily as arteries, so while you bleed faster from an artery, the body will do its best to stop that bleeding. Not so the veins. (at least to some extent) The second is that, with the incision where it was, these veins are behind the edge of the petrous temporal bone from where we were looking. Imagine using tweezers in a hole 3 inches deep, looking through a microscope to see the nerves you are dissecting, and suddenly, a minor emergency occurs around a blind turn at the end of that hole, forcing you to work quickly and accurately on microscopic vessels you can't see around that turn. The next approximately nine hours were consumed with attempting to fix that bleeding. The bleeding was eventually stopped by clotting it with Gelfoam. Then it was time to put everything back, close the incision, and head home. The surgeons were there in the OR until 11PM.

It was thrilling in a way, to see most of this operation and the deliberate haste with which the surgeons worked. At the same time, I realized that, despite how late they were working, all of these guys would be back in the hospital at 5am the next day to start all over again. I could never do this job. I don't mind long hours once in a while, and I defintely signed up to do medicine knowing I would work more hours for less monetary compensation than almost any other educated profession, but I'd like to have a life, someday. And I think, to have a life outside the hospital and be a neurosurgeon, you need to redefine "life."


Alice said...

Way cool surgery. Thanks for the comment on my blog. I'm enjoying discovering your site.

Steve said...

Fascinating description. Thanks. I assume, of course, that Mrs. Walker is a pseudonym.

Nathan said...

Alice - I'm glad to hear it

Steve - Yes, it is. All names on this site are changed, to protect innocent and guilty alike.

Joel said...

Wow. That's amazing. You're not kidding about the steady hands...

Joel said...
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