We returned to the trauma room and Gary explained the myelogram test to Billy. As we were leaving to head upstairs to radiology, Billy called out: “Doc…”
Gary returned to the bedside. “Call me Gary.”
“Gary,” the man said quietly, “I can’t move my fingers anymore.”
The adult spinal cord is about two feet long and barely larger than the little finger in girth, passing down the middle of our backs encased in the bony armor of the vertebral column. Through this thin ribbon of fatty nervous tissue courses life. The spinal cord is notoriously intolerant of injury. Like IRS agents and Mafia dons, the cord will tolerate a certain level of insult, but wise men don’t push to that level.
While portrayed as the “main nerve” connecting the brain to the rest of the body, the spinal cord is more than just a nerve. In fact, it is a complex organ possessing an intelligence of its own. Stereotyped movements, like standing and walking, are preprogrammed within the spinal cord’s gray matter. This frees up our cerebrums to do those things which it does best, such as writing sonatas and inventing lite beer ad campaigns.
In lower animals, the cerebrum is so primitive that complicated motor behaviors originate in the spinal cord out of necessity. There just aren’t enough neurons in puny nonprimate brains to accommodate the “software” necessary to power all of the fins, wings, and feet. A headless chicken can run about sans brains. Our neurophysiology department once made a few brainless cats for a vision experiment, later giving them away as pets to unsuspecting cat-lovers who couldn’t tell them from intact animals. (“My Muffin is so smart…she know’s her name, she is just too independent and finicky to come when I call her…”)
As any athlete can verify, thinking too much during competition can hurt performance of repetitive tasks. The higher brain is always trying to embellish movements like a tennis forehand or golf drive, when such actions are best left to the spinal cord alone.
In humans, the “brainlike” behavior of the spinal cord can have macabre consequences. Patients with brains killed by gunshot wounds, hemorrhages, or other injuries can dupe family members, friends, even nurses, into believing that they are awake. An arm reaches up to grab a coat lapel, a hand grasps the hand of a loved one, a leg withdraws in apparent pain after a hospital tray is dropped on it—all preprogrammed spinal reflexes. Called “Lazarus movements” for obvious reasons, these reflexes make it difficult to convince a bereaved family that their loved one is, in fact, legally dead and should be removed from life support.
A spinal cord injury is either “complete” or “incomplete.” A complete injury deprives the patient of all sensation and movement below the level of the injury. If the spinal cord is injured in the upper back, between the shoulder blades, the patient will have no movement in the legs, no bowel or bladder control, and no sensation below the nipples. A complete neck injury will produce paralysis involving the arms as well as the legs. When the injury occurs very high in the neck, near the base of the skull, the muscles of respiration will be paralyzed and the patient usually asphyxiates before help arrives. A successful hanging produces this injury.
If the patient displays any movement or sensation below the level of the injury, even the faint wiggle of a toe or a twoinch patch of feeling on the inner thigh, the injury is said to be incomplete. This is a crucial distinction. Complete spinalcord injuries virtually never improve, while incomplete injuries, even severe ones, can reverse with time and proper treatment.
Gary and I walked up two flight of stairs to the X-ray department in silence. His head was down and his brow furrowed in thought. He was agonizing over what to do for Billy. Suddenly, he stopped and turned to me. “Forget the myelogram. Frank, go downstairs and get that guy to sign a consent for an exploratory laminectomy. I’m going up to the OR and make sure they’re set up and an anesthesia resident is available.”
“Why are we skipping the myelogram?”
“He’s going downhill before our eyes; if we wait much longer he’s going to stop breathing, and the horse will be out of the barn. He can’t have just ruptured a disc in his neck, because that shouldn’t cause the weakness in his legs to ascend into his arms. He may be crazy, but I wouldn’t bank on that, either. I’ve seen a lot of conversion reactions and none of them get worse with time. He must have an epidural clot that’s expanding. At least that’s what I think.” Gary turned and began running up the stairs, calling back to me in a feigned British accent: “Hurry, Watson, the game is afoot! Bring your revolver!”
The epidural space lies between the cardboardlike covering of the brain and spinal cord, called dura, and the skull and vertebrae. It is a space densely packed with veins which can be torn during trauma. While epidural blood clots are common in the head, where they compress the brain and cause coma, they are distinctly uncommon in the spine. Gary was guessing. I bet he had never even seen a traumatic epidural in the spine before. If he was wrong, we could be subjecting a man suffering from transient hysteria to a risky and painful operation. If he was right, and we waited to get the myelogram to prove it, the spinal cord might be hopelessly damaged. Gary had decided that a hysteric with an incision was better than a quadriplegic with pretty myelogram films.
I returned to the ER. Billy’s wife was sitting by the stretcher, holding his now limp hand and crying. I stopped short of entering the room.
“Where are the kids?” I overheard him ask.
“With my mom,” she replied, “they’re going to spend the night there.”
“Good, good…I don’t know how long I’ll be here. My bank card isn’t in my wallet, it’s on the ‘fridge…”
Life goes on. Honey, call the plumber and, by the way, I’m paralyzed. I broke in and introduced myself. I examined Billy again. He could no longer grasp with either hand and his biceps were weaker. He still had a few areas of sensation in his legs, although they remained paralyzed. Excellent, I thought, he’s still incomplete.
I explained that the myelogram would take an hour or two to set up and complete and so we had decided to go ahead and take Billy to the OR and explore his spine. If we didn’t do something soon, he might die from the advancing paralysis. After I was through talking, there was a pause. Billy took a deep breath and then spoke. “Let’s do it. But give me a minute with my wife, alone.”
I left the room and closed the door. I found Walter stretched across a tattered vinyl sofa in the ER lounge. “Give them five minutes,” I instructed the intern, “and get him upstairs to the OR. Call Fred back and tell him where we are.” There would be the expected spousal grief when it came time to take Billy upstairs, and I didn’t want to be there. These pathetic scenes, like exposure to X rays, are occupational hazards that take a cumulative toll on a physician’s health. I avoided them whenever I could. I wasn’t a complete psychopath just yet.
I changed back into surgical scrubs and met Gary in operating room eight. Chun, a senior anesthesia resident, was setting up his machines and Lisa, our scrub tech, was opening a package of sterile instruments.
“We’re on our own, buddy,” Gary said through his mask. “Two other rooms are still running and there isn’t any circulating nurse. Do-it-yourself neurosurgery. Help me with this.” Gary yanked a large metal-and-Styrofoam contraption from the bottom of the OR cupboard. It was the laminectomy frame, used to hold patients prone on the operating table.
The circulating nurse assists with setting up the room. During an operation, the “circulator” serves as an all-purpose gofer, answering phones, opening suture material, checking pagers, and so on. When the OR was understaffed, as it usually was in the evenings and on weekends, circulating nurses were pressed into duty as scrub nurses.
Walter arrived minutes later, pushing Billy on his stretcher. Just then the OR phone rang. Chun answered it, then handed the receiver to Gary. “It’s for you.” Gary thrust the frame at me and took the phone.
“Yeah…Oh, hello, Fred…yeah, he must have a clot…No, I didn’t get any studies, but he’s ascending…
What? Uh-huh…of course I gave him steroids…I’m going to start at about T3 and work up…OK, we’ll be here. See you later.”
Gary hung up, his eyes narrowing above his mask. “A dickwith-ears, that’s what he is. He’s pissed because we have no myelogram, but he’s going to have to stay pissed. He only wants a myelogram because he’s at the symphony and it would have delayed the case until after he’s heard his fucking Beethoven. He’ll show up two hours late, anyway. Let’s get started.” He then called out to Walter, who was standing in his street clothes outside the OR, baby-sitting Billy. “Get dressed, amigo, we need you to circulate in here.”
Gary and I wheeled the stretcher into the small OR, parking it parallel to the OR table. The patient would be anesthetized on the stretcher and then flipped onto his stomach on the OR table after he was asleep. Gary examined him again. Billy’s large biceps muscles were now both totally flaccid. “Relax, ace, Dr. Chun here is going to put you to sleep. See you soon.” We then sat on stools in the corner and let Chun do his work.
The room was quiet. Contrary to popular belief, operating rooms are not always crowded, dramatic, and noisy. Nor are there choirs of seraphim basking in the glow of a larger-than-life surgeon. The OR can be an insufferably intimate place, an arena where an intensely personal transaction occurs: the bartering of one person’s skill for another’s quality of life. There we gathered, two men from a pizza shop, one man from a softball diamond, and an anesthesiologist, spending a tragic Friday evening together.
Chun glided an endotracheal tube into Billy’s throat and began taping it to the sleeping man’s face. I swiftly placed a bladder catheter into Billy and then the three of us, Gary, Chun, and I, grunted and heaved Billy over onto the Wilson frame and positioned him to our satisfaction. “Shit,” said Gary as he stared down at Billy’s broad, tanned back, now faceup on the OR table, “this guy’s built like a rock. What a waste if we don’t get his cord back.”
After we had scrubbed and draped the operative area, Gary and I took our positions on opposite sides of the table. “Knife,” Gary said softly. Lisa suspended the Bard-Parker blade between us, but Gary didn’t move to take it. He just stood and looked at me. “Well, are you going to take it or not? I didn’t tear you away from the Skipper and his little buddy just to watch me do a case, did I?”
“Me?”
“You’ll be a senior resident before you know it. C’mon, bring this guy’s legs back to life for him.”
I took the knife. Gary placed his right index finger on the nape of Billy’s neck and his left index finger in the middle of the his back, just below the rib cage. “Between here and here…let’s go, don’t be shy.” I slid the knife on a line between Gary’s hands and took the incision deep through the skin and fatty tissues. The incision was over a foot and a half in length. “Now get your hot knife,” Gary continued to instruct me. I grabbed the electrocautery pen and began carving the thick meat of Billy’s back from the spinal bones below. Gary swept away the tissue with large silver scoops as I detached it with the heat. This allows access to the spine, but does no permanent damage since muscle can heal.
About ninety minutes later, we had exposed the laminae of the spine from the neck down to the midback. The laminae are bony shingles which extend along the length of the spine and protect the back of the spinal cord. “OK,” said Gary as he probed under the edge of one of the laminar shingles with a small curette, “get a Kerrison punch under here and get to work.” The Kerrison is a long-handled metal tool with a small biting cup at the tip. It’s used to chip small pieces of bone away, bit by bit. Removing the thick protective bone in this manner is tedious, but it is the only safe way given the delicate organ below. Removing the laminae, a procedure known as laminectomy, is like chiseling through a cinder block to reach an egg encased within—without cracking the shell.
We removed one lamina, at the fourth thoracic level, and found nothing but pristine dura. No clot. I could almost feel Gary’s stomach churning with a mixture of doubt and pepperoni. “Keep going,” he barked, “it’s got to be here. Look, the dura isn’t pulsating.” The lack of pulsations was evidence, albeit weak, that some compression of the cord existed above our laminectomy.
I kept chipping away. Piece by piece, the third thoracic lamina ended up in the silver pan on Lisa’s Mayo stand. Still no clot. “I think the dura is pulsating here,” I observed, trying to be scholarly. Gary was unimpressed. “Keep going, tiger. Higher.”
In and out of the cavernous wound I went, dipping my tiring hand down to the spinal canal, grasping a bite of bone, and then releasing it into a specimen pan. Grasping and releasing, grasping and releasing, in and out, in and out. A widening expanse of translucent dura, the spinal cord visible just below, grew at the depths of the red wound. I had never worked around the spinal cord before and my arms were tense as I painstakingly guided the metal rongeur repeatedly under the laminae. My fatigue was growing, but I could not show weakness. If it was easy, anybody could do it.
Suddenly, just below the cut edge of the second thoracic lamina, a small piece of clot, resembling fresh liver, peeked out around the left side of the spinal dura. “There!” Gary shouted with the enthusiasm of a prospector seeing the glint of gold in his pan. He grasped the Kerrison from my hand and began making swift, sure strokes, slicing through the lamina like a rower slicing through a river. The clot grew larger and larger as the spinal opening proceeded higher. “Oh, sorry,” he apologized, handing the instrument back to me, “you’re doing fine.”
Hour after hour, I pulled bone away as Gary suctioned the thick epidural clot. Fred showed up, peered into the wound, and retreated to the lounge to sleep. At 5 A.M., over six hours into surgery, we reached the top of the clot at the fourth cervical vertebra. To me, scaling Everest couldn’t have felt better. I gave my aching forearm a rest while Gary probed the side of the spinal canal for further bleeding. “Look, Frank”—he gently tugged the spinal cord to one side, showing a tangle of thick, oozing veins—“I think this is where the clot originated. He must have flexed his neck badly when the truck rolled over and tore one of these veins. The slow ooze gave him the progressive paralysis.” He coagulated the veins with the bipolar cautery and packed the area with a small piece of Billy’s back muscle.
Fred came in again at the end of the case and Gary described the findings. “Very good,” said the attending surgeon, who had retreated to the far end of the room and was rummaging in an equipment drawer. Fred came over to the scrub nurses’ table and opened a sterile marking pen onto the field. “What’s that for?” Gary gave the staff man a quizzical stare.
“Well,” observed Fred dryly, “you have such a large area of dura exposed, I thought you might want to personalize it by writing ‘Fuck you, Fred,’ or something like that.” Both men laughed. They looked like colleagues now. I felt more like a surgeon and less like a medical student. In the glow of this male bonding, however, a question remained: How would Billy feel?
As for Walter, he wasn’t feeling anything. He had been sleeping on the OR floor for the past three hours.
Billy was no better the next day, or the day after that. He was transferred to a rotating bed, designed to keep the quadriplegic patient in constant motion and prevent the formation of phlebitis and bedsores. He had regained a little motion in his biceps muscles, but his hands and legs remained paralyzed. He did retain some sensation in his stomach and feet, but not much, and he had lost bladder and bowel control.
He spent his days listening to the radio and talking with his family and friends, all the while turning about like a rack of ribs on a spit. His mood was defiant and upbeat. He talked with his son about the fishing trips they would take. His wife brought in the family finances for his approval and read the newspaper to him daily. He treated his disability as purely temporary and was determined not to let his marriage or his mind wither like his nerveless muscles.
Making rounds on patients like Billy is a difficult task. People complain about the little time their
surgeons spend with them, but they should try it from our perspective. What could I say to this man—How are you feeling today? (Paralyzed from the chin down, thank you, same as yesterday.) Small talk begins to look truly small: How about that win by the Pirates? Do you think it’s going to rain this weekend? Hey, time to get those tomato plants in! Eventually, however, doctor and patient find some neutral ground, some subject they can discuss that does not draw attention to the reality at hand. With Billy it was tennis.
Billy’s wife told me that he was an avid tennis fan. One day in June, after Billy had been hospitalized about three weeks, I found him sitting in a stretch chair watching the French Open on TV. His neck was still wrapped in a rigid plastic collar, and his hands and feet were bound in braces to slow the formation of contractures in his lifeless limbs. He was shouting “Just keep it in, just keep it in!” at the screen.
“What are you watching?” I asked.
“Oh, Jimmy Connors playing some kid at Roland Garros. The kid is trying to play serve-and-volley against Connors on clay. Connors isn’t consistent today, and if the kid would just stay back and play some longer rallies, he might do better. Right now he’s getting his ass kicked. You can’t play serve-and-volley on the brick dust unless you’re McEnroe.”
We sat and talked for an hour about pro tennis and our own philosophies about playing the game. I told him I preferred the baseline game, which surprised him. He thought my height favored a net game. He was being kind. In reality, my body habitus favors sitting in the stands with a Sno-Cone.
He grew quiet. “When do you think I’ll hit a serve again?” I told him I didn’t know. It was the truth: I didn’t. From that day on he called me Pancho, a reference to Pancho Gonzales, the tennis great. I called him Bjorn.
When the Air Hits Your Brain: Tales from Neurosurgery Page 14