Neurosurgeon Robert Spetzler MD is a pioneer of an operating technique that induces hypothermia and cardiac arrest so that lesions can be reached. He spoke to us about the highs and lows of a life spent at the edge of the possible.
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For me, neurosurgery has absolutely been a dream come true. It was a passion, and it was a mistress who required a great deal!
You couldn't say no when you were called at two o’clock in the morning, as somebody’s life depended on you intervening. You couldn't say no if you had other plans. In this way it wasn’t just something that affected you personally, it was hard on all the people around you, too. Everything could suddenly be turned upside down.
When you’re facing a patient with a very significant problem, then you put a loved one’s face on that patient.
Handling the stress of neurosurgery takes many different forms. If I knew I was going to do a big case the next day, I would be awake at night and virtually any complication one could conceive of during an operation would go through my mind.
Let’s say you have a patient with a problem that there is no good solution for. This turns in your mind, and suddenly at two or three o’clock in the morning you have an “a-ha!” moment. You realize a safer way to do something that looked like it couldn't be done.
When you’re facing a patient with a very significant problem, then you put a loved one’s face on that patient. You think that if you would do this for yourself or your loved ones, then you have every right to do it for that patient, too. Compassion is absolutely critical in recognizing what the patient is facing.
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In neurosurgery we have tire problems just like cars on the road do! In the old days, when you had a weak tire, it would get a bulge that would grow bigger from the pressure inside. Eventually the tire would fail, and it would burst.
You also have wear and tear in your blood vessels, which are under constant threat from your heart as it pushes blood through your entire system. You get these little weak points that bulge out. These are what we call aneurisms. I’ve had the opportunity to operate on more aneurisms than anybody else in the world!
The real challenge was the giant aneurisms very deep in the brain. At the time, we didn’t really have any good way to treat them. But the bigger an aneurism becomes, the more likely it is to burst and cause mayhem. When an aneurism bursts, more than half the patients die. Of those who survive, more than half never fully recover. In this way an aneurism can be a devastating event.
To reach giant blood vessels that you can’t easily get to, one of the solutions we utilized was something called cardiac standstill. This is when a patient is put to sleep, catheters are put into the arteries and veins, and a heart-and-lung machine takes over the circulation of the body.
Then you start to cool the patient down. The heart stops beating when the body temperature is around 30 degrees centigrade, so at that point the heart-and-lung machine takes over to circulate the blood through the body. When the patient gets to the target temperature – 14 or 15 degrees centigrade – you can actually turn off the machine and drain blood out of the body.
Now you’ve got this big, distended sack under high pressure that will suddenly be deflated. This gives you room to work so that you can fix these truly incurable lesions that we just had no other options for. Even with this technique there is significant risk to the patient, but it was so much better than the natural course of the disease.
I’ve done this so many times, but each time was absolutely incredible. To see a patient without any brain waves, pulse or respiration – by all accounts dead except for the fact that they’re cold and can be revived.
Robotics can turn a huge operation into a very safe smaller one.
The technological disruption in our field has been absolutely momentous.
It wasn’t so long ago that to diagnose lesions in the brain you injected air into the spinal fluid. Then you put a patient in a chair that could be moved in all directions. This brought the air up into the head so you could take X-rays to see if anything was deformed. It was medieval in its torture and patients routinely vomited all over the place. But it was a way to find things.
Then CT scans came along, followed by MRI scans. These tools allowed us to look into the finest recesses of the brain. We could see blood vessels without causing injury, and we could do exams repeatedly over time.
All of these places in the brain become apparent the closer we look – and we’re not anywhere near done looking.
Just like in industry, I think robotics will revolutionize this field. Robots don’t get tired, they don’t care whether the instrument they’re holding is heavy or light, they don’t care how long an operation takes. Robotics can turn a huge operation into a very safe smaller one. These robotic attributes and advantages are just going to mushroom in the coming years.
Anybody who thinks we really understand the functioning of the brain is being very simplistic!
It used to be that we thought 80% of our brain was redundant; that you could even take the frontal lobes off and still have a person who sort of functions. But when you look closely, you see that all the regions of the brain have important subtle roles: the appreciation of music, the ability to dream, the cause of depression, and so on. All of these places in the brain become apparent the closer we look – and we’re not anywhere near done looking.
Think about the fact that we can now put electrodes on the brain. If you are paralyzed – for example, you want to be able to move an arm – that signal can be captured through an array of electrodes. Then a computer can stimulate the paralyzed region with an electrical connection that will induce actual motion.
This is being done already. It’s rudimentary right now, but as you get to increase from having 16 electrodes to a billion, you can imagine how exact that sort of movement can be.
Cells are programmed to have a certain life expectancy. When we’re at the point where we can change that program – which will certainly happen – you will then have the “problem” that people are not going to die. This will bring enormous challenges that will be very difficult to face.
Just think of something as controversial as abortion today in society, where you have strong views on both sides. Then think of how you have Uncle Mark, who is 180 years old and still CEO of the family company! If we can biologically keep him alive, then is it time for him to go and who makes that decision?
Life expectancy has changed and results in surgery have changed. But there will always be complications, and that’s what keeps you humble.
Neurosurgery has incredible highs, but it doesn’t keep you there for very long. Without a doubt you’re going to get a 2:00 am call that a patient you operated on had a bleed, so you have to rush there in the middle of the night. Then you have to come out and tell a family or a loved one what happened despite all your efforts.
I would like to say that as time goes on, you get used to having patients who did poorly. But that is absolutely not the case. The pain you feel when you haven’t helped somebody – or have hurt somebody – was just as acute for me at 70 years old as it was at 30. I think in many ways the fact that there is such pain in failure is what drives you to find solutions and success.
Robert Spetzler MD is a renowned neurosurgeon who specializes in treating cerebrovascular disease and skull-base tumors. He has worked on pioneering the technique of hypothermia and cardiac arrest so that lesions can be operated on.
Dr. Spetzler has received many accolades from professional societies, including being chosen as the youngest ever Honored Guest of the Congress of Neurological Surgeons when he was 49. He has published more than 300 neuroscience articles and 180 chapters in neuroscience books.