If you act like you know what you’re doing, you can do anything you want – except neurosurgery.
Sharon Stone
This is a bit of a welcome back post after disappearing of the face of the planet for a few years. It was a good few years. Work was busy and I spent 2 years working in another country, where I gained perspective and a license to dive to to 60m or 200ft, on mixed gases that included helium, nitrogen and oxygen. But that isn’t what this article is about.
I remember a time, soon after I had finished my training when I was asked what I did for a living. My response was, “I’m a neurosurgeon.” And this was met with a little confusion as supplemental questions were on if I treated tumors (which I do), strokes (which I sometimes have to), and migraines (which I don’t). But also calling myself a brain surgeon seemed incomplete since I perform an equal number of spine surgeries and have had specific training to be able to do those surgeries through smaller and smaller incisions.
So I decided to write this as a sort of resurrection of this blog/website and the need of the hour which is a wider online presence. Which explains a new instagram handle, if you came here from there, perfect! If not like and follow drsavitrsastri for more!
So what do neurosurgeons do? For that we need to head back to the basics.
This here is the central nervous system. It consists, as wiki has been kind enough to demonstrate, the brain AND the spinal cord. That’s the anatomy, the hardware, so to speak. The brain does pretty much everything. It is who we are, what we think, what we say, do, believe in. It’s what made Shakespeare exclaim, “what a piece of work is a man…”
And possibly what made Mr Smith behave inappropriately at the Oscars.
The complexity of brain function is a few books, even to just outline, and here is a good place to start. But to sum it up, the brain is in charge of everything. At it’s lowest level of functioning it controls breathing and other such things that keep us alive. The next layer in the pecking order is likely the one that protects us from falls, the elements, occasionally even ourselves. As layers get added on, the complexity increases. There is an emotional layer (the Will layer), for example, and right on top is what makes us human – judgement, reason, memory and speech. And consciousness. There are specific parts of the brain that control and form the substrate for these entities. And yet behavior may not have a single part of the brain responsible for it.
And the brain speaks to the rest of the body and pays attention to what the body is saying via the spinal cord. It’s the thick set of cables that go in and out of the CPU of humans, gathering data from sensory organs and responding to stimuli and causing movements in milliseconds.
So the Brain and the Spinal Cord work closely enough to be considered one functional unit and three branches of medicine have set about trying to figure it all out.
Psychiatry
Neurology
Neurosurgery
In order of increasing tangibility and blood loss.
Psychiatry deals with diseases of the mind. How is that different from diseases of the brain? One may argue that psychiatric illnesses are a subset of diseases of the brain. But there’s a difference. Diseases of the mind and behavior often have no anatomical abnormality in the brain. At a cellular and chemical level, yes, they do but rarely does a part of the brain change its shape or what it looks like. Psychiatry very simply put is a UI/UX problem.
Neurology is software and sometimes just lousy RAM, a broken hardisk and outdated processors, with a cooling fan that will run at unpredictable speeds and often never at all.
Neurology deals with neurological diseases. Tautology apart, these range from epilepsy and seizures, migraines and headaches, movement disorders such as Parkinson’s disease and chorea, strokes and what have you.
And just to complicate things there are enough overlaps between these two fields, to make studying the brain incredibly fascinating.
Oliver Sacks – The man who mistook his wife for a hat, and Susan O,Sullivan – It’s all in your head, are fantastic books that beautifully describe this grey zone.
That leaves me and my professional brethren and sistren, and the confusion of who really is a spine surgeon.
Modern Neurosurgery is the child of Harvey Cushing. Today, the 8th of April is his birth anniversary and considered World Neurosurgery Day. I had the good fortune to gaze at his tombstone in Cleveland a few years ago and give thanks. Prior to Cushing, there have been many reports of trephination or drilling holes in the skull to let evil spirits out. Peruvians, Egyptians, Ancient Greeks, all had waxed eloquent about ailments of the head.
To jump right in,
Head injuries. Of all kinds. Bumps and lacerations, to the stupidity of falling off a 2 wheeler without a helmet. Neurosurgery handles the acute care of these patients. They sometimes need surgery to reduce the pressure in the skull due to blood clots or brain swelling after the injury. We also work closely with intensive care since many of these patients may not be conscious and would need supportive care till they recover.
Strokes. This is a bit of a cooperative team effort. Strokes as I’ve outlined earlier (not much has changed since then) maybe ischemic where there is lack of blood supply to the brain. Neurosurgeons may rarely be called in if there’s brain swelling that needs decompression.
Strokes that the result of bleeding in to the brain may also similarly need surgical intervention, to reduce pressure and remove the blood clot.
Tumors. This is our domain. Interestingly depending on where the tumors are in the brain and how fast they grow, they often present themselves to neurologists and psychiatrists. In the days before CTs and MRIs may patients with tumors were diagnosed incorrectly and treated for their symptoms that were identical to other psychiatric and neurological disorders. Not all tumors need surgery, though, and there are newer modalities of treatment that may offer as good a result for specific tumors.
Epilepsy (certain types) and Parkinson’s Disease. Very specific types of epilepsy are surgically curable. And Deep Brain Stimulation for Parkinson’s has been proven in the holy altar of Randomized Controlled Trials to have a better outcome. It’s a brain pacemaker. Whodathunk?!?
Pediatric Neurosurgery involves the treatment of children with congential deformities of the brain, skull and spine. Hydrocephalus (water in the brain), meningocele (arrested development of parts of the spine), craniosynostosis (deformed heads due to early fusion of skull bones) are some of the common disorders that require surgical correction.
Aneurysms and other malformations of the blood vessels are again now a team effort with interventional radiologists and neurointervention specialists who work to treat these disorders from within the blood vessels or endovascular-ly.
That leaves Spine.
This is an area of moderate controversy since both orthopedic surgeons and neurosurgeons can be spine surgeons. And it’s true. Both neurosurgeons and orthopedic spine surgeons are qualified to treat spine and spinal cord disease.
These include trauma, tumors, degenerative diseases like disc bulges and herniated discs, spondylolisthesis or slipping of a vertebra. congenital issues of the spine since birth or childhood, deformity correction, to pretty much sum it up.
Some of us also do pain management, some do peripheral nerve surgery (like that for carpal tunnel or nerve injury), some work with radiation therapy machines like the x-knife and gamma knife, and some work in the frontiers of neuroscience marrying brain to machine to create what every sci-fi dystopian future movie has warned about.
I do hope to write more about disorders of the brain that need neurosurgical treatment, and maybe even those that don’t – because let’s face it the brain is fascinating, and it is the final frontier of medical science.