The surgical 100

Itrsquos time to celebrate The article you are reading happens to be the 100th in the series of fortnightly medical anecdotes Over the past four years the manymdashor should I be honest enough to say a fewmdashpeople who read this column regularly have been through the entire gamut of human emotions with me with added revelations of truth and untouched horizons of mysteryAt the very beginning of these 100 articles I had written about how I nervously burred my first hole in the skull of an atlcoholic and evacuated a blood clot to see him instantly awaken from a stupendous coma And in one of the last few ones wersquod evolved to extricating tumours from parts of the brain in a way that was once inconceivable a few years agoIn all these stories wersquove honoured the indestructible force of the human spirit but wersquove also learnt that nature has the final word In an attempt to provide the reader with a glimpse into the life of a surgeon Irsquove shared some deeply personal experiencesmdashthe highs the lows the resilience of families the determination of doctors and the dissonance of nature Irsquove laid bare what it means to lose patients you care for with savage tenacity and the exuberance of saving lives that were deemed impossible to survive I believe these narratives have allowed the layperson an honest entry into the world of medicineI write to you today after having gone through the archives reminiscing of patientsrsquo skulls being opened and operated upon while they are fully awake a peasized tumour in the pituitary gland in the brain being the cause of a couplersquos infertility someone who almost died on the operating table and made a complete recovery and someone who had a perfect operation but died soon after There were patients who insisted on admission before sunrise and discharge before sunset and on the surgeon making an incision at an hour approved of by their pandit We learnt how disconnecting a short circuit in the brain can cure intractable epilepsy and how some patients who go to a dentist for a toothache actually need brain surgery There are stories of how little children have battled multiple surgeries and insurmountable odds to lead normal lives and then there are stories of no matter how hard surgeons try they canrsquot always vanquish fate Irsquove met patients whorsquove dealt with their afflictions with such grit and grace it has given me goosebumps Irsquove told you about how a brain tumour was the source of one manrsquos pathological laughter and how an excess accumulation of fluid in the head was the cause of an old ladyrsquos dementia I have written about how we got a paraplegic bride walking two weeks before her destination wedding and I have cautioned against how spinal stenosis is misdiagnosed as Parkinsonrsquos and how a brain tumour can mimic a slip disc I have also counselled that not all back and neck pain are muscular and that all forgetfulness cannot be attributed to old age I have mentioned the influence that mentors nature faith luck and animals have on the work we do I have described in heartbreaking detail what it means for a doctor to be afflicted with the very affliction they have spent a lifetime treating And why closure is often a mythI believe that these vignettes of love laughter sorrow and triumph have also been educational empowering people to take serious charge of their own health and that of their loved ones in a fun way People now know to get an MRI scan of their brain for a headache that does not seem like itrsquos going away and one of their spines if a back or neck ache seems pesty People now know that all visual disturbances are not solely related to the eye and all loss of hearing cannot be attributed solely to a problem within the ear I believe that these articles have helped people look deeper both literally and metaphoricallySuffering from an ailment is a great leveller It makes no distinction between the affluent and the indigent race and religion or the umpteen genders we now know about Each and every one of us has at some point in our life felt pain And just when I thought I had seen everything in my field I came across something Irsquod yet to seeldquoIrsquove had this vague pain in my mid back for the past three monthsrdquo said Neha a highfunctioning executive in her 30s who had come to me with her MRI scans She wore her hair in a bob and sported a fashionable nose ring She gave me directions ldquoA little to the lefthellip slightly higherhelliprdquo as I narrowed onto the spot between her shoulders blades when she finally winced in agony I couldnrsquot feel any swelling but the MRI showed a 4cm chunk of something within the paraspinal muscle at the midthoracic level that was shaped like the eye of a tiger slightly ovoid at the periphery with a perfectly round centreldquoThis is outside the bone of your spine but within the musclerdquo I emphasised on the anatomy to reassure her that there was nothing within the spine and it would not paralyse her which is the worry of most people when they hear the word spine ldquoIt could be a tumour it could be a cystrdquo I added ldquoIrsquom not exactly sure but if itrsquos causing you so much pain just remove itrdquo the surgeon in me proclaimed ldquoI donrsquot want to go under the kniferdquo she admitted reluctantly ldquoWe have other instruments we can cut withrdquo I joked reassuring her that this was a daycare operation and that she would be able to go home a few hours after it After a very detailed discussion she left me with a ldquoIrsquoll think about itrdquoTwo weeks later she called saying she wanted to schedule surgery because the pain was becoming unbearable When I met her the evening before surgery I explained that we would localise the lesion with an ultrasound and get the radiologist to mark the exact spot of the swelling so we could cut right over it the next morning as there was no palpable lump on examination ldquoOn second thought let us do the ultrasound in the operation theatre itself after flipping you pronerdquo I instructed the team as there was no point in duplicating work because we had a machine in the OT So the next day after giving her general anaesthesia and turning her on her tummy we brought in the ultrasound machine to localise the lesionI smeared the skin with jelly and placed the ultrasound probe over it directly over an intricate tattoo of the letter N that she had on her backTo our bewilderment we couldnrsquot see any ldquoeye of the tigerrdquo anymore it wasnrsquot even the eye of a little kitten We adjusted the parameters of the machine but still nothing We called in a senior radiologist to find it for us She said there was nothing there We rechecked if the MRI she had come in with was hers it had her name on it But it had been two months since she had gotten the scan done ldquoLetrsquos just open her up and see what we findrdquo one of my colleagues suggested ldquoIt has to be somewhere thererdquo was his justification ldquoAnd if we donrsquot find anything wersquoll just have ruined her tattoordquo I guffawed Instead we shifted her to the MRI room under anaesthesia to understand what was going on The lesion had completely disappeared We all looked at each otherrsquos faces with foolish grins ensconcing our surprise and confusion ldquoTo live wondersmitten with reality is the gladdest way to liverdquo I had read somewhere in Maria Popovarsquos writingI explained to her mother and sister who came along that there was nothing there to remove anymore ldquoIn hindsight I should have repeated an image before taking her to the OTrdquo I confessed ldquoIt was probably a cyst that has disintegrated or a nodular inflammation of the muscle that went away with the antiinflammatories the pain taking its own time to resolve is my understandingrdquo I explainedWhen she awoke from anaesthesia I told her what had happened ldquoWhy do I still feel painrdquo she asked equally confused as me but happy that she had avoided surgery ldquoItrsquoll passrdquo I reassured her without understanding why but knowing that most pain does A week later her pain was goneThere is a rare entity described in medicine called disappearing lesions They are most often cysts Some of them can be seen and felt to go away on their own But others like Neharsquos do so when you least expect them to Everything that is possible is real even the things that may eventually disappearAs we live and learn Irsquoll see you at a hundred and oneThe writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals