Tuesday, 6 October 2009

 Everything you never wanted to know about Neurosurgery 
(because you were too well-adjusted to ask)

“The horror! The horror!”
  – Colonel Kurtz, soldier and radical neurosurgeon

This is not going to be easy. This is not going to be nice. We’ll kick off with background stuff and then proceed in ascending order of horror and carnage. If it gets too much feel free to bale out, I won’t be offended. If you know that you or a loved one is going to have a neurosurgical procedure in the future then bale out now. Trust me on this.

As for the rest of you morbid bastards- take a deep breath and we’ll begin.

Your brain weighs about 1.4 kilos if you’re a man, 1.3 if you’re a woman. This is neuroporridge we’re talking about. Mess with it and the effects range from a mild headache to instant death.

Various professional groups mess with neuroporridge:  neurosurgeons, neurologists, psychiatrists, psychologists and neuroradiologists. Get any of these people alone, ply them with excessive drink, and sooner or later they’ll admit they know very little about how it all works.

Originally all we had was Phrenology, which was the ancient medical art of judging stuff like your health and criminal tendencies by feeling the position of lumps on your head. In the great scheme of things it was about as successful as tosis. Tosis, or organ slippage, was a not uncommon medical diagnosis that used to be made from x-rays. In this condition internal organs were found to hang significantly lower in the abdominal cavity that the normal examples taken from textbooks. This was held to be responsible for a variety of presenting symptoms, particularly ‘women’s troubles’. Countless operations were carried out to remedy this by stitching up the cradling connective tissue so that the organs hung higher. Eventually some smartness worked out that the real disease process behind tosis was actually gravity. The x-rays had been taken with the patients standing up, the textbook examples were drawn from cadavers lying down.

Many years after phrenology bit the dust med-cred wise, it was given a new life by World War One and also by a neurosurgeon frigging about with electrodes during an operation. WW 1 because during that time all sorts of high velocity projectiles hit all sorts of heads at all sorts of interesting angles.

Neuroscientists examined survivors to find out exactly which bits of them weren’t working, then patiently waited until the men died so that they could perform post-mortems to find out the corresponding bits of brain that had gone west . This was not exactly an exact science because when a bullet hits a brain it doesn’t take out a nicely isolated bit of brain tissue then politely leave. It causes a massive cone shaped shock wave before exiting very rudely. Nevertheless it allowed them to work out, for example, that the left brain controlled the muscles in the right side of the body and vice-versa.

The neurosurgeon added to our knowledge by sticking electrodes into different parts of the exposed brain during operations and noting which bits of the body twitched. Some of the patients were conscious at the time and reported electrically induced tastes and smells when the right bits were zapped.

In terms of the rude mechanics, this helps today’s neurosurgeon because he has some idea of which bits of the neuroporridge not to disturb if he doesn’t want to paralyze you or stop you breathing (understand that if they go into the brain they have to disturb something).

But the surgeon doesn’t really know where your memories are stored, and he only has the vaguest idea of what bits make you good or responsible or creative or in control. He doesn’t know what bits make you you. But he’s got to make sure he misses them anyway.

A) The case for different
Several clinical conditions give spooky little insights which make you wonder whether the brain is all there is to it. I’m going to get metaphysical now. Neuroscientists never usually do that which is funny because the cutting edge of neuroscience must by definition abut onto metaphysics.

Idiot savants make up a small sub-group of people suffering from autism, a condition caused by brain damage sustained before they were even born. Generally they are of low intelligence and are almost always seriously socially dysfunctional. Yet savants often have one of three bizarre talents. To some you might give a date like 17th March 1907 and, before you’ve had a chance to draw your breath, they will correctly tell you what day of the week that was on. Sure, there are formulae to calculate that sort of thing, but this may be coming from a guy may never string a sentence together in his life. Other types can hear a tune once and reproduce it perfectly on a piano, even though they’ve never had piano lessons. The third type, at an age when their infant peers are playing with crayons for the first time, can draw real life pictures of such complex structures as the Houses of Parliament in high detail and with a full sense of perspective. So in some cases brain damage seems to increase ability.

 Another interesting disease is hydrocephalus, a condition in which excess fluid is produced in the ventricles of the brain. These swell so much they compress the brain tissue so that all that’s left is a patina on the inside of the skull. Death or severe brain damage often results, but sometimes it produces no symptoms at all and people  go on to live normal lives,  graduate from university etc. Yet they hardly have any brain at all.

Tumours can also destroy very large amounts of brain tissue before any symptoms are manifested. Intelligence and personality are not usually changed, even though perhaps half the brain has been replaced by tumour.

Stuff like this makes you wonder what part of the brain actually plays in making us the people we are. Is it perhaps just a filter between reality and the collective unconscious, that all-seeing, all-knowing metaphysical entity of which we are all a part, according to Jung? Are brains like blinkers, there to reduce our otherwise all-encompassing perception?

As for you: do you believe all your finer feelings, your love for people and music and landscapes, are all down to a lump of neuroporridge?

The argument here is pretty good too. This comes down to whacks on the head. A common,  and heartbreakingly plaintive, cry from the relatives of badly head injured patients is that even after they have apparently recovered, ‘they’re not the same person.’ Many divorces occur. Calm, placid people can become violent and irrational. Prudish, reserved people can become totally sexually uninhibited. Intelligence, memory and attention levels can become radically diminished. A whack on the head can completely change your personality, can apparently change the essential you.

Where does that leave free will and the immortal soul?

The bottom line is that though a neurosurgical procedure is far more controlled than a whack on the head, the surgeon risks not only altering your body and your brain but perhaps something even more profound.

And now, one more point before we get into the gore:


I reckon that private detective series in the TV have indirectly caused countless deaths and severe disabilities. When I was a kid, the big one was the Rockford files but the pattern can be found in the Professionals, the A-Team  etc. Several times in a series, sometimes even a couple of times in  single episode, our doughty hero will be whacked on the back of the head by the dastardly bad guy and will fall to the floor (cue fade to black). Time passes, our hero ‘comes to’, rubs the back of his head to signify ‘ooh, that smarts’, then solves the case, shoots the bad guy and beds the heroine.

It’s all dangerously misleading shit.

Loss of consciousness is a bad thing. If it lasts only seconds or minutes you can get away with it. Longer and your chances of emerging without neurological damage diminish. And by damage we’re talking things like personality changes, memory disorders, reduction in reasoning powers, epilepsy, blindness, paralysis and dementia. Some temporary,  some not. Even if you ‘come to’ you may not be out of the woods. One third of people who will eventually die from their head injury will at some point recover consciousness enough to talk.

That’s why if you do come to, the first thing the doctor will ask you, or any witnesses, is how long you were unconscious for. He’s not just doing this to make polite conversation. He’s using it to work out your chances.

I wonder how many night watchmen, policemen and, yes, private detectives have been whacked on the head by people who were under the impression, gained from countless hours of television, that this was a relatively benign way to keep someone out of your hair for a while.

And I’ll bet you a pound to a penny that none of the victims got round to bedding heroines for quite a while afterwards.

By now you’re probably asking why anyone in their right mind would operate on someone’s brain when the consequences can be so dire. Trouble is, so many conditions can get a lot worse very quickly all by themselves. If no one does anything the patient can die. Worse still, they could wind up in a vegetative state (cabbage or asparagus, depending on their socio-economic group).

And, by God, it works! Even the Incas did it and with roaring success!

Of course, it’s all dressed up in medico-scientific jargon nowadays. They reckon it’s not devils you’re letting out, you’re releasing increased pressure in the brain caused by an intracranial bleed and swelling (resulting, say, from a benign whack on the head).

And nowadays they don’t use sharp stones. Instead it’s high tech Black and Deckers with a stop .  The stop is very important as anyone who has drilled into a plaster wall will know. You have to put pressure on the drill to overcome the resistance of the plaster. But then when the drill clears the plaster there’s suddenly no resistance, and before you know it you’ve pushed the drill several inches into the cavity beyond. Surgically speaking this would be considered uncool operating technique.

Best not try this one at home, Kids!

Starting to get grisly now. In fac , although it may sound awful, this is about as non-invasive as you can get. The rationale is this: the patient has a terrible intractable tremor which is so bad it’s ruining their life. Let’s go in, but really try to disturb the oatmeal as little as possible.

So the surgeon literally screws a cube-shaped frame into the bone of the patient’s skull so that the head is enclosed by it. The cube is effectively a more macabre 3D  version of the graphs you frigged about with in school. It forms a frame of reference like the axes of your graph did.

The patient gets imaged on a super-duper machine and the bit of the brain causing the problem is localised with respect to the frame (x, y and z marks the spot). Up to theatre now and the surgeon takes a drill bit (half inch Whitworth) and drills into the skull. The drill is very sharp and the bone is fully of sticky fatty marrow but it’s still surprising to see it come away in  continuous white spiral swathes, like you’d get if you drilled into a bar of soap.

A probe is then pushed into the brain until it gets to the malfunctioning bit at x, y and z. Power is put into the tip which heats up and destroys that neural pathway in the brain at that point.

And now (gulp), the patient has to be brought round, to check that the man-made lesion has stopped the tremor. The patient comes too in an operating theatre with a frame bolted to their skull and they can get quite a start and rear up from the table, Frankenstein like. Some force in sometimes required to keep them down.

Some patients go through the whole thing fully conscious from start to finish. Respect.

This ‘stereotaxic neurosurgery’, as it’s actually called, may sound like it’s straight from Edgar Allen Poe, but  the alternative is to go in in earnest, as we will see.

Enough of the kid’s stuff. Let’s get serious.

When the wall of a blood vessel weakens it balloons out to form an aneurysm. Like all good balloons, your aneurysm can only get so big before it bursts and you get an intracranial bleed which is a Bad Thing. 

-----Public Health Message-----

If you very suddenly develop a headache, a ‘thunderclap headache’ as it’s called, this is nature’s way of telling you to seek medical attention and fast. This may be your only symptom that:

i) you have an aneurysm

ii) it’s starting to bleed

If you suddenly wake up with a headache after 10 pints the night before, or you bang your head on a shelf, please do not mistake this for a thunderclap headache and run to your doctor as the ‘Fuck off’ response you’ll get may cause offense.

-----Message ends-----

Assuming you’ve made it to surgery in time, the surgeon cuts across the scalp and peels it back from the face and skull like the rubber mask it resembles. Now he saws a palm sized hole in the skull, and cuts through the three slithery slimy membranes that encase the brain. Without skull bone to contain it, the brain pulses out at you like a cheap Hammer horror effect.

That’s the easy bit.

The surgeon now has to cut and separate the brain down to the depth of the aneurysm, which can be pretty deep. He then places clips on either side of the vessel to isolate it from the cerebral circulation. Obviously they’ve got to make the incisions as small as possible to avoid all the horrible consequences of messing with the neural tissue that I’ve already mentioned. And as they make their tiny incremental cuts down into the brain with their sharp instruments, they know that hidden perhaps only a millimetre or so deeper is the paper-thin wall of a blood filled balloon about to burst. And if it does burst, and blood pours out into the cavity and fills it so they can’t see what they’re doing or the bits they’re supposed to clip to stop the blood.... well, let’s just say that would constitute a bad day at the office for the surgeon.

I think it fair to say there’s some pressure in that job. And some skill, because operative mortality is actually less than 3%.

More latterly aneurysms are being treated by feeding a metre long tube up through an artery in your groin and squeezing glue into the aneurysm.  Sounds weird and icky but it’s much less invasive than full on neurosurgery.

This, as I hope you realise by now, is potentially very hazardous. Paradoxically however, quite large (but specific) bits of the brain can be cut out with, on balance, beneficial effects. Intractable epilepsies and depression may radically benefit (the accent here is on intractable, people who just get pissed off now and again need not apply).

Cutting these specific bits out is actually pretty safe for the patient and relatively easy for the neurosurgeon because the bits have well defined boundaries he can identify. Tumour boundaries, however, generally aren’t well defined because they have varying degrees of infiltration into surrounding neural tissue. The surgeon has to decide intra-operatively and ‘on the fly’ which bits to cut out (or more likely suck out) and which bits to leave. Take out too little and the tumour recurs, take out too much and the damage to the patient can be profound (and you probably dither about how much money to take out of the cash machine).

And while we’re on the subject of depression, consider Electro-Convulsive Therapy or ‘jump starting loonies’ as some cynical medics describe it. Zapping depressed brains with high electrical charges often works where drug therapies and counselling fail. This week’s competition: how does ECT actually work.  Answers on a postcard to Territories. The winner will receive a Nobel Prize and free jump-starts for life.

 Dear Clare,

I have a real poser of a problem that’s got me stumped. I’d be grateful for any advice you might offer.

One of my patients has a desperately deep-seated tumour. It’s in his pituitary, in fact. Whatever approach I take it’s going to damage a lot of other neural tissue and he’ll probably never play the piano again,


Worried of Glasgow. 

Dear Worried of Glasgow,

The answer is staring you right in the face. Literally. The secret is to go in through the nose. I hope you’re right handed because you’ll find it easier to work down the right side of the nasal septum. That way the effects will be less because the right frontal lobes are usually non-dominant. You could even consider approaching through the eye socket (just pop the patient’s  eye out and rest it on their cheek).

And remember, the operative mortality rate is less than 10% so Happy Hunting,


Neurosurgeons can get to consultant level in their early thirties, starting on £75K but rising over the years to £100K, plus private work and merit wards which can double that. Losing your sympathy?

Consider this: you’re woken up at 3am to perform life and death work of such intricacy that you have to look down a microscope to see what those sharp little instruments are doing,

Speaking personally, I can’t even tie my shoelaces  at three in the morning.

And of course 3am is when it all happens, especially at the weekend. A large proportion of head injuries happen to drunks. Drunks being hit by other drunks, drunks being hit by cars and drunks just falling over in their own loveable spontaneous way. So remember the neurosurgeon the next time you have a skinfull and stagger out of a late-night club spoiling for a fight.

Neurosurgeons are very much in the ‘Gung Ho’ mould. You’d be amazed how many of them, in the limited spare time they have, take evening classes in plumbing. Most fix their own cars though they could well afford to pay someone else to do it. If something’s wrong, they sometimes have to be physically restrained from ‘going in’ and tinkering with it until it works.

And try for a minute to imagine the confidence they need. Operating ‘theatres’ aren’t called that for nothing. There you are, two knuckles deep inside some poor guy’s brain, and you’ve got a matinee audience of anaesthetists, nurses and other surgeons. All intelligent professionals who have a pretty clear idea of what you should be doing and when you should be doing it. So when the neurosurgeon fucks up, and let’s face it gentle readers, we all fuck up sometime, everyone else in the theatre is going to know it. Fucking up here isn’t like forgetting the mustard if you’re a burger slinger. It means death or disability and sometimes expensive litigation.

Even worse, in a fair proportion of cases, the patient is going to die anyway no matter how good you are. Imaging how galling that can be to these ‘can-do’ personalities.

Would I do it for £100K per annum?  In the words of the well known Biblical innkeeper: ‘No fucking way, Jose.”
So that’s the 10 things you didn’t want to know about neurosurgery. It sounds barbaric and little understood but in the face of such terrible injuries and diseases, do you have any better ideas? And please, any New-Agers out there with their pyramids and reflexology and aromatherapy, just gimme a break, OK!

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