Twelve years have passed since I wrote this book, the chronicle of a neurosurgical residency that took place nearly a quarter of a century ago. Not surprisingly, many aspects of neurosurgery have changed over the years, in both how the specialty is taught and how it is practiced. The biggest change in residency programs has been the recent legislativelymandated restrictions on how many hours a resident trainee can work in a week (eighty hours); when I trained, we worked until everything was done, sometimes days in a row, often over one hundred hours a week. Needless to say, we “gray hairs” look upon today’s trainees as—I grope for the right word—wimps!
As for the surgeries, the procedures depicted here are still done in pretty much the same way as I have described them, but the trend over the last two decades has been toward less invasive ways of dealing with neurological disease. Indeed, the goal has been to avoid surgery altogether. As one of my colleagues used to say, “The person who dies with the least scars wins.” He was an internist, of course. A surgical practice with no scars is not victorious. Bankrupt is a more accurate description.
Most cerebral aneurysms are now treated nonsurgically by filling them with tiny platinum coils. The coils are threaded into the defective blood vessel through a long catheter inserted into the patient’s femoral artery, in the groin. The metallic fibers induce clotting and scar formation in the aneurysm without the risk of an open operation. Surgery is now used only in the rare instances when this approach fails. Likewise, pituitary tumors are still removed through the nose, but many more now receive nonsurgical radiation treatments using sophisticated computer-guided cobalt machines, a procedure known as stereotactic radiosurgery. Radiosurgery has also reduced the need for surgical treatment of brain tumors, both benign and malignant. Unfortunately, patients with malignant brain tumors fare no better now than they did in the 1990s, or the 1980s, or the 1970s. In fact, the last significant improvement in the prognosis of brain cancer came in the 1950s, with the advent of more powerful radiotherapy machines. There has been little or no progress since.
These changes do not spell doom for the working neurosurgeon, however. Spine surgery, always the bulk of any neurosurgical practice, still thrives. As the population ages, and as older patients deservedly seek a higher level of activity despite their deteriorating joints and discs, the number and complexity of spinal operations are rising exponentially. Likewise, the neurosurgical treatment of pain disorders, including the implantation of spinal cord stimulators and morphine pumps, remains a growth industry.
Brain surgery is still done, of course, for traumatic blood clots, life-threatening brain tumors, abscesses, bullet wounds, and the like, but the operations are getting smaller and “more intelligent” all the time. Thanks to technologies like “frameless stereotaxis” (a kind of GPS system for navigating the brain), surgeons now have an unprecedented ability to know where they are going and see what they are doing inside the “threepound universe” of the mind. A few operating rooms in the United States now have MRI scanners installed at the head of the operating table, enabling the surgeon to see inside the brain in real time as the surgery progresses.
Presently, the most rapidly growing sector of our field is socalled “functional” neurosurgery, the treatment of neurological dysfunction by destroying tiny bits of brain or by installing electrical stimulating devices akin to brain pacemakers. These approaches were around for years even prior to my residency in the 1980s, but recent advances in computer hardware, coupled with an ever-increasing knowledge of the brain, have allowed functional neurosurgery to achieve unparalleled successes. Deep-brain stimulation for Parkinson’s disease has become so effective that it may soon become the preferred initial treatment. Currently, initial therapy consists of drugs like L-dopa or other dopamine-like oral medications; surgery traditionally has been reserved for patients in whom the beneficial effect of drugs has begun to wane (typically between five and fifteen years into the course of the disease), or for those patients who develop intolerable side effects. The call for an earlier use of stimulators, instead of drugs, represents an unusual reversal of the modern trend against invasive surgery.
Brain stimulation may have wider application. Recently, the journal Nature reported a case of semi-coma reversed by the use of brain stimulation. Thus, as in many aspects of life, as one door closes for the surgeon (no more aneurysm surgery), another opens (many more functional surgeries). I doubt the surgeon will ever be out of business entirely.
The recent progress in brain stimulation, as it turns out, is particularly relevant for me. In 2001, I developed a mild tremor of my left hand. This didn’t hinder me in the operating room, at least not at first, but my unsteadiness soon became obvious to my patients and colleagues alike. A brain surgeon with unsteady hands is, well, pick whatever analogy you like, it’s not good. I began limiting myself to operations like simple disc procedures and carpal tunnel releases, but the situation steadily declined. By late 2002, I had to quit surgery and do office consultations only.
By 2004, it became clear that I had early Parkinson’s disease. So far, my condition has not progressed much beyond hand tremors and I can still play tennis and golf, and even scuba dive. In fact, I can do most anything—everything except surgery. I found it difficult at first; in fact, even years later, I have occasionally dreamed that I am doing a meningioma removal (my favorite operation). But now, I rarely think of my past life as a surgeon.
Despite the passage of time and the numerous changes in the field, I still believe this book is relevant today. When the Air Hits Your Brain is not about the technology, it isn’t even really about the medicine. It’s about the human aspect of disease, the human dimension of those who suffer from it, and the human dimension of those neophytes, like me, who learn to treat it. And that dimension is timeless.
As for me, I sense the cycle may soon become complete as I gradually transform from healer to patient. One day, medications will fail and I will need a brain stimulator. So, when the air hits my own brain as the electrodes go in, will I be the same? I hope not. I hope to be better.
Isn’t that what it’s all about?
Frank T. Vertosick, Jr., M.D.
August 4, 2007