03/24/15
back is killing me

9 Reasons Back Surgery Might Help

9 Reasons Your Back Pain Might Improve With Surgery—Or Not

back is killing me

Back pain is a fact of life—if you are a human being (and presumably if you are reading this you are) sooner or later you will have back pain. That’s the bad news.

The good news is that for most of us, it will run its course and we will be none the worse for it. Most of us will have a single bout, perhaps two, lasting a few hours to several days, and that will be it. Some of us will have more, and sometimes that will be recurring pain (every few months or once every few years as an example), or chronic low level discomfort that’s just enough to interfere with life’s enjoyment but not at all incapacitating.

Others will be saddled with incapacitating pain, though even then most folks will find a happy medium and be able to function with certain accommodations, as with any other chronic illness (diabetes, heart disease, kidney failure) or condition (rheumatoid or osteoarthritis, fibromyalgia, emphysema).

But for an unlucky few, and unfortunately the masses of people on this earth mean the numbers work out to hundreds of thousands each year, back pain just might be an indicator for back surgery. This sort of back pain typically doesn’t get better without surgery—or at least doesn’t get better quickly enough for we busy humans. That’s the bad news.

The good news is that for these few, back surgery is overwhelmingly successful.

Here are nine reasons your back pain might need to be treated with surgery.

1. If it’s associated with leg pain.

Back pain that’s associated with leg pain may indicate a pinched nerve. Although even then most of these won’t need surgery, if the pain becomes unrelenting or lasts more than two months, see a physician. This kind of pain generally responds well to surgery, especially if the leg pain is worse than the back pain.

In the overall scheme of things, back pain that is purely and truly back pain is rarely an indication for surgery, though there are always exceptions. There are hundreds of ligaments, bones, and nerves in the back and any one (or group) of them can be a pain generator. This sort of pain might be from a stress fracture, a pulled ligament, a small muscle tear, or any of a thousand other sources—most of little consequence in the long run and most of which will heal and resolve on their own, though it will almost always take longer than you would like or expect.

2. If it’s off the midline to one side or the other.

Back pain that’s off the midline may indicate a pinched nerve or arthritic joint on one side of the back. If it’s always in the same place, it might respond to fusing the joint, deadening the nerve, or decompressing (unpinching) a pinched nerve.

3. If it’s always in the same place and does not roam around.

Pain that will respond to surgery does not roam around. The intensity may vary, and frequently does, but the location of the pain is a constant. Usually it is one sided and off the midline of the spine.

Roaming back pain rarely responds to back surgery and seems more likely related to muscle strain or spasm, or perhaps has no relation to the back at all. 

4. If it’s associated with leg weakness as opposed to pain or numbness.

One of the most frequent back problems is a pinched nerve, and while these don’t always require surgery they certainly can. Leg weakness with back pain is one indication of a pinched nerve and generally indicates that surgery should be strongly considered, especially if it is severe or not getting better with time. In general, if weakness is present, see a physician sooner rather than later.

5. If it’s been present for more than 6-8 weeks and doesn’t seem to be getting better.

Most back pain is self-limited and improves even without therapy, though it takes time since something is wrong and that something takes time to heal. Sometimes pain itself is a diagnostic tool though, and pain that isn’t obviously improving after two months is such a tool and should be thoroughly investigated. 

By the same token, chronic back pain that has been present for more than 2-3 years and is stable is generally unlikely to have a surgically treatable cause, even if severe at times. However, such pain should be thoroughly investigated at some point (at least once) since exceptions do exist.

6. If it’s always present in the morning and does not improve as the day advances.

Back pain that is worse in the morning after just getting out of bed and improves with activity rarely responds to surgical intervention. This is often age related. There’s a reason professional athletes retire around age forty. 

On the other hand, if you have back pain from the time you get up and it consistently does not improve (or even worsens) with activity, you should see a physician if it persists over weeks or months.

7. If the pain increases with walking—until you MUST sit down or else.

Pain that consistently worsens with activity to the point of intolerability, especially if just sitting down for a few minutes improves or alleviates it (sitting for five or ten minutes, not an hour or two), may indicate narrowing in the spinal canal—a condition which responds very well to surgery.

8. If the pain is associated with trouble walking—and you can improve the walking by leaning over a shopping cart.

This is known as a positive shopping cart sign and is so suggestive of a problem that can be fixed that if you have noticed this you should discuss it with your physician. Note that the trouble walking may be pain or weakness or both. Sometimes patients complain of “rubbery legs.”

Typically a person notices these symptoms when grocery shopping—they have to both push the cart and lean forward over it in order to shop. Just hanging on to the cart has no effect, the uncomfortable pain persists. Typically, those with a surgically treatable problem get great relief leaning over the cart as they move around the store. In fact, leaning over the cart becomes a must and is the difference between being able to do their own shopping or not being able to shop at all.

As the severity of the condition progresses, even leaning over the cart becomes ineffective and patients stop doing their own shopping. They become homebound.

9. If the “back pain” is really buttocks and leg pain.

In general, the more leg pain one has, the more likely their problem is to be treatable with surgery. Surgery for back pain alone is, in general, a disappointing experience (except in cases of fracture, tumor, infection, or perhaps scoliosis), but back pain associated with leg pain is a different story.

To understand why, one has to consider the generalized nature of back pain, which makes it difficult to narrow down an exact cause and thus limits what surgery can do. However, the occurrence of leg pain often indicates a pinched nerve and since each nerve has a stereotypic course, the location of the leg pain often marks which nerve is pinched—and hence the location of the back problem—with more or less precision. Surgery can then unpinch, or decompress, the nerve.

Neurosurgery101—TheBlog. About life’s harder or more interesting moments…

Search Edison McDaniels at Amazon for great fiction—Ordinary folks in Extraordinary situations! Intense. Available on Kindle.

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03/5/15
Killing King

Saving King

Saving King

Click the image to go to the Amazon Kindle page to purchase this work.

A seminal work on a moment that changed the world. Stunning.

The Rev. Dr. King was shot at 6:01 pm on April 4th, 1968. He was pronounced dead 64 minutes later, after a struggle that included an emergent tracheostomy and open heart massage. In Saving King, McDaniels dramatically recreates these events in graphic detail, providing an almost minute by minute account of the first responders at the scene, followed by the action as it appears to have taken place in the emergency room. This account is based on a close reading of eyewitness reports, King’s autopsy, and the 1978 House Select Committee on Assassinations’ investigation into the MLK assassination.

Saving King is a clever work of creative nonfiction which not only dramatizes the action in heartbreaking detail, it showcases the US trauma system at work in 1968—and in 2013. One of the most interesting portions of the monograph (which runs about 8,000 words and is an intense read by any measure) comes near the end, when McDaniels goes the extra mile and shows how such a grievous injury might be handled today.

In fact, one of the things Saving King does so well is to inform the lay public about the US trauma system. In this regard it is informative and educational without seeming to be. It reads more like a novella than a monograph, and very definitely has a story to tell.

The story opens with King on the balcony of the Lorraine Motel one minute before he is shot, and doesn’t end until he is pronounced dead 65 minutes later. Along the way, we watch as the first responders (a modern term) are overwhelmed by the bleeding and essentially just scoop and run. It is a tense 15-20 minutes later before King’s airway is finally established via an emergent tracheostomy—and his breathing finally restored to something reasonable. We learn too about the incredible coincidence that led to a delay in calling an ambulance—it turns out King wasn’t the only fatal casualty that day.

The author is himself an accomplished writer, and more than qualified to write such an authoritative work. Edison McDaniels is a board certified neurosurgeon with an extensive surgical experience, including more than a little bit of trauma. He is the author of several novels, including the acclaimed Not One Among Them Whole: A Novel of Gettysburg, which  has been described as a magnificently harrowing trip into the bloody horrors of the Battle of Gettysburg. It’s about surgery in a time when every wound was potentially fatal and every operation was a minor miracle, according to the author himself.

McDaniels’ strength in writing, which comes across loud and clear in Saving King, is his unusual ability to make the intricacies of medicine and surgery understandable to the masses. This is at least in part owing to his unique combination as an experienced surgeon, a talented writer, and a passion for both. And, in his case at least, the parts sum to more than the whole. Indeed, Taylor Polites, author of The Rebel Wife, has called him “An amazingly talented writer…”

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03/4/15
SixWordStoryEPM

Six Word Stories

 

—Other stories from the mind of Edison McDaniels—

The American Civil War Series

Not One Among Them Whole — A magnificently harrowing trip into the bloody horrors of battlefield surgery at Gettysburg in 1863. A vivid, steep descent into insanity.
An award winning novel available in trade paperback and eBook (Kindle, Kobo, Nook).

The Matriarch of Ruins (coming soon) — A widow woman struggles to keep her family together amid the onslaught of battle in 1863.
The sequel to Not One Among Them Whole. A novel.

An Endless Array of Broken Men — A surgeon struggles to save his son’s life at a battlefield hospital.
An award winning, vivid & engrossing FREE story available right here at surgeonwriter.com.

 

Thrillers Well Calculated to Keep You in Suspense

The Touched — Dr. Isaac Weed had it all, until his daughter died. Then he discovers a door to the afterlife, one never meant to be opened. Sometimes, healing can go too far.
A far surpassing supernatural medical thriller, a novel available on Kindle.

Juicing Out — Think you know how a surgeon’s thinks? Think again.
A tale of suspense, a novella available on Kindle.

Blade Man — A chilling tale of life on the road.
A twisted thrill ride, a novella available on Kindle.

The Weight of Potter’s Field (coming soon) — When an operation goes horribly wrong, a patient returns from the grave to haunt his surgeon. But it isn’t revenge he’s seeking…
A terrifying tale of things that go bump in the night at an old county hospital. A soon to be published novel.

 

Others Stories of Note

The Bottom of the Fifth — The miracles surrounding a little boy on opening day of the little league baseball season.
A short story available on Kindle.

Saving King — Dr. King struggled for 64 minutes after being shot. This is the story of that struggle.
Creative nonfiction, available on Kindle. Not for the faint of heart.

The Crucible — A brain surgeon works to save the life of a little boy on his operating table in 1951.
A gripping & empathetic short story. FREE. Available HERE.

Send to Kindle
03/4/15
Gutenberg Review

gutenburg

Gutenberg Review

—Other stories from the mind of Edison McDaniels—

The American Civil War Series

Not One Among Them Whole — A magnificently harrowing trip into the bloody horrors of battlefield surgery at Gettysburg in 1863. A vivid, steep descent into insanity.
An award winning novel available in trade paperback and eBook (Kindle, Kobo, Nook).

The Matriarch of Ruins (coming soon) — A widow woman struggles to keep her family together amid the onslaught of battle in 1863.
The sequel to Not One Among Them Whole. A novel.

An Endless Array of Broken Men — A surgeon struggles to save his son’s life at a battlefield hospital.
An award winning, vivid & engrossing FREE story available right here at surgeonwriter.com.

 

Thrillers Well Calculated to Keep You in Suspense

The Touched — Dr. Isaac Weed had it all, until his daughter died. Then he discovers a door to the afterlife, one never meant to be opened. Sometimes, healing can go too far.
A far surpassing supernatural medical thriller, a novel available on Kindle.

Juicing Out — Think you know how a surgeon’s thinks? Think again.
A tale of suspense, a novella available on Kindle.

Blade Man — A chilling tale of life on the road.
A twisted thrill ride, a novella available on Kindle.

The Weight of Potter’s Field (coming soon) — When an operation goes horribly wrong, a patient returns from the grave to haunt his surgeon. But it isn’t revenge he’s seeking…
A terrifying tale of things that go bump in the night at an old county hospital. A soon to be published novel.

 

Others Stories of Note

The Bottom of the Fifth — The miracles surrounding a little boy on opening day of the little league baseball season.
A short story available on Kindle.

Saving King — Dr. King struggled for 64 minutes after being shot. This is the story of that struggle.
Creative nonfiction, available on Kindle. Not for the faint of heart.

The Crucible — A brain surgeon works to save the life of a little boy on his operating table in 1951.
A gripping & empathetic short story. FREE. Available HERE.

Send to Kindle
03/4/15
Writers World

Writers World Passage

Writers World

—Other stories from the mind of Edison McDaniels—

The American Civil War Series

Not One Among Them Whole — A magnificently harrowing trip into the bloody horrors of battlefield surgery at Gettysburg in 1863. A vivid, steep descent into insanity.
An award winning novel available in trade paperback and eBook (Kindle, Kobo, Nook).

The Matriarch of Ruins (coming soon) — A widow woman struggles to keep her family together amid the onslaught of battle in 1863.
The sequel to Not One Among Them Whole. A novel.

An Endless Array of Broken Men — A surgeon struggles to save his son’s life at a battlefield hospital.
An award winning, vivid & engrossing FREE story available right here at surgeonwriter.com.

 

Thrillers Well Calculated to Keep You in Suspense

The Touched — Dr. Isaac Weed had it all, until his daughter died. Then he discovers a door to the afterlife, one never meant to be opened. Sometimes, healing can go too far.
A far surpassing supernatural medical thriller, a novel available on Kindle.

Juicing Out — Think you know how a surgeon’s thinks? Think again.
A tale of suspense, a novella available on Kindle.

Blade Man — A chilling tale of life on the road.
A twisted thrill ride, a novella available on Kindle.

The Weight of Potter’s Field (coming soon) — When an operation goes horribly wrong, a patient returns from the grave to haunt his surgeon. But it isn’t revenge he’s seeking…
A terrifying tale of things that go bump in the night at an old county hospital. A soon to be published novel.

 

Others Stories of Note

The Bottom of the Fifth — The miracles surrounding a little boy on opening day of the little league baseball season.
A short story available on Kindle.

Saving King — Dr. King struggled for 64 minutes after being shot. This is the story of that struggle.
Creative nonfiction, available on Kindle. Not for the faint of heart.

The Crucible — A brain surgeon works to save the life of a little boy on his operating table in 1951.
A gripping & empathetic short story. FREE. Available HERE.

Send to Kindle
03/3/15
Cervical Fracture Cartoon

Cervical Fracture Explained

Cervical Fracture Cartoon

Cervical Fracture Explained

This graphic details a lateral x-ray showing a C4/5 fracture/subluxation, but there’s no bony fracture! How is that possible?

The injury here is through the disk space between the fourth and fifth cervical vertebrae (C4/5). The force of the injury ripped through the soft tissue disk and tore the ligaments front and back at this level. This is a devastating injury for two reasons.

First, with such great disruption of the ligaments, surgery is absolutely necessary to stabilize the bones. Ligaments hold bone to bone and when they tear, there is nothing to check the movement of the bones. In contradistinction, with a bony fracture, the bones will generally knit back together if immobilized in place (with a cast or pins).

Second, and perhaps more important, with such severe disruption and unstable movement of the bones, the spinal cord has been injured. The spinal cord does not heal well; such an injury is likely to result in permanent paralysis.

Think of the spinal cord as a vast cable with millions of wires. The wires carry messages between the brain and body. Compare it to the transatlantic cable, with all its wires. Imagine the cable is damaged, cut in half for instance, midway between the US and England. Imagine all of the wires are the same color and you are tasked with splicing them back together. Ten thousand feet underwater. While holding your breath.

This is the task of the neurosurgeon in repairing a damaged spinal cord (though the cord is rarely transected; it is usually bruised beyond repair). We can’t see the individual nerve fibers in the operating room (we actually don’t even expose the spinal cord in such as injury as experience has proven the cord recovers better if we don’t disturb it), and even if we could we wouldn’t be able to tell which fiber connects to which other fiber—it all looks the same and though we might use a microscope, that’s more for illumination than magnification. No way we could magnify things enough to see the individual cells, or even bundles of cells.

Fortunately, as noted above the cord is rarely transected. What this means is that it is still anatomically intact (though physiologically disrupted). Because it is anatomically intact, in at least some cases there may be potential to regenerate the appropriate connections between damaged fibers. There is much research directed to this end, though success is still many years away. But as long as the cord is anatomically in one piece, the less we manipulate it the better. It might heal—emphasis on MIGHT—but not if we disrupt it still further. Hands off is the order of the day.

In the mean time, the best we can do is realign the bones and replace the ligaments with screws and rods to stabilize everything. This decreases the amount of pain, minimizes any chance of ongoing spinal cord injury, and gets the patient up and about earlier—which minimizes peri-operative complications. Mobilizing a patient as soon as possible after such an injury is key to returning them to a viable lifestyle, both mentally and physically. It also helps to prevent DVT, pneumonia, muscle wasting, nutritional depletion, infection, etc. In short, surgery to stabilize and realign the bones is crucial to optimize the environment around a damaged spinal cord in hopes of getting some eventual healing, or at least in preventing further injury.

Bottom line. The best treatment for a spinal cord injury is not to injure the cord in the first place. NEVER DIVE HEAD FIRST INTO A BODY OF WATER. NEVER.

 

 

 

 

 

 

 

 

 

 

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07/10/14
BrainVeins

Veins of the Brain

BrainVeins

A Neurosurgeon’s Perspective on the Veins of the Brain

The most curious thing about the veins of the brain is how seemingly innocuous they are, until you mess with them. They can get you in trouble in a hurry. Thin walled, they can be very stubborn and persistent in their oozing (and oozing is what they do, this is largely a low pressure system). They don’t hold stitches well, so often if damaged they have to be sacrificed. That may or may not turn out well. In general, if a vein has a name (vein of Labbe, vein of Trolard), it was named for a reason. Probably somebody in the past messed with it, usually with poor consequences.

For instance, the vein of Labbe is the largest vein draining the temporal lobe into the transverse or sigmoid sinus. Sacrificing it often results in a stoke of the temporal lobe—so much so that one rarely violated rule is ‘don’t fuck with Labbe!’ The vein is Trolard is a less constant vein, usually draining the parietal lobe up to the superior sagittal sinus.

Sinuses differ from veins in that they are designed not to collapse. They carry great volumes of blood under low pressure, but they don’t like to be occluded (stopped up). They bleed copiously and when stoppered, even for a few seconds, the brain behind them swells dangerously. Not good.

Click to see JUICING OUT on Amazon.

Click to see JUICING OUT on Amazon.

In my stories, I have written several fictional scenes of a neurosurgeon dealing with venous bleeding. Here’s one, from my novella JUICING OUT, which is just 99¢ for the Amazon Kindle (though the price is going up soon):

He looked pale. Like instead of a bullet to the brain he’d taken a vampire to the neck. His blood pressure was ninety over thirty one moment and sixty over fuck the next. If he had been awake and not anesthetized, he’d have passed out. He would have fainted and never awakened. Yes sir, he looked like a forty percenter to me.

Bobby, he drinks some but he ain’t no bad guy you know. He hardly ever do me when I don’t want it. I thought Bobby’s days of doing her were just about over.

I stole a glance at the scrub tech. She was frantically trying to get the instruments laid out and ready. I glanced at the table, saw a scalpel and a mess of hemostats, scissors, clamps, and sponges. I thought it probably wouldn’t be enough. I thought it had to be enough. Jesus Mother Mary. You wait any longer, I told myself, you’ll be operating on a cadaver.

“I can’t wait,” I said. “Help me with this, Joe.”

Together we unwrapped the diaper and the crown of his head came into view. He was mostly bald, middle-aged or better I thought. I hadn’t asked his age in the confusion, not that it mattered much now. His age would be on his tombstone after all. No confusion about that.

The skin at the back of his head was torn and bruised. I saw that much. Then Joe pulled the diaper off the hole in Bobby’s skull and the damn burst wide. A sea of dark blue, almost black, blood. For an  instant, it poured out like somebody had diverted Niagara freakin’ Falls into that broken head. Acting with twenty years of experience behind me and without really thinking, I stuffed a wad of cotton into that opening. It might make things worse, might even kill him on the spot if there was a clot inside half as big as the wad of cotton outside. That clot would press the brainstem and then, in the words of Josie’s grammie, he’d go to ground quick. But I didn’t think that would happen. Blood finds it’s own level, and, like water, is always looking for a way out, any way out. I hadn’t seen a clot on the scan (which at twenty minutes old was, admittedly, now ancient history) but the man had looked too good right up until a minute before. So I pressed that wad of cotton against the hole in his skull, against his brain, and bought us a few more precious minutes. “Get that blood, goddammit.” I hadn’t even had time to wash my hands or put on a gown.

“Getting frequent PVC’s over here.” Back flips again. The beeps filled the room, going up and down like a radio signal you couldn’t quite tune in. Bobby’s heart was losing the race. “We need blood for christ’s sake.”

The door opened just then and a pimply faced kid came in carrying a picnic cooler. If he had a clue he was carrying the man’s life in his hands, he didn’t show it. “Hey who do I give this to?”

The blood was hanging within one minute. One of the anesthesia folks (I couldn’t keep straight who was doing what and didn’t try) was squeezing the blood bag between his hands. When the first was finished, he squeezed in a second. He was on his third bag before I pulled away the cotton.

A large piece of lead floated out of Bobby head, followed by dark chunks of what could only be pieces of Bobby’s brain.

The torrent started up again. It flowed steady rather than pulsed with his heart. I knew from that, and from the amount of blood, that it was that mofo vein bleeding. And probably more than a small tear if the amount of blood was telling. I thought there had to be a hole the size of Montana in that thing. “Jesus Mother Mary” I said, then “Stitch!”

The scrub tech slapped a needle holder into my palm, a curved needle and silk stitch clamped into the end of it. I might have closed my eyes—I’ve been told I do that sometimes in surgery when I’m trying to visualize something—though if so I don’t remember doing it. I took that needle and aimed it into the pool of blood. “Suck here Joe, right here,” I said, and when I thought I could see something, something gray and not black red, I plunged the pointy end of the needle through whatever the visible tissue was and looped it out again. I cinched it down and tied it quick, then repeated the maneuver again after adjusting slightly for lighting, sweating, my own bounding heartbeat, and the regret I wasn’t wearing my own diaper. We’re losing.

An image of Josie came to me then. Josie in her Howard Johnson’s maid’s outfit, her weight in the upper limits of the couch potato zone, her unhealthy ruddy complexion. She sucked a cigarette and smelled of pinesol from the toilets she cleaned. The blue beneath her eye had coalesced somehow and now she had a decidedly black eye. Bobby, he drinks some but he ain’t no bad guy you know. He hardly ever do me when I don’t want it. I know he love me.

I fished out another piece of lead. Either the blood was slowing or whatever was left in his veins was thinning, I couldn’t say which at that moment. But I thought maybe I could see better, that Joe was doing a pretty damn good job moving that sucker here and there, sucking away the blood and oozing brain so I could work. Looking at that broken mess, looking through that thinning blood, I suddenly saw what needed doing, how there was not but one thing to do.

I saw that if I oversewed that mofo vein, it would probably kill him within a few minutes. That’d be like plugging a hose at its business end while water still flowed in from the faucet. In a few seconds that hose would rupture at its weakest point. Bobby’s weakest point was somewhere deep inside his skull, somewhere I hadn’t a prayer of getting to, and when it burst—game freaking over.

But I had no other choice. He was like a pig on a stick otherwise. I could watch him bleed out right now, or I could oversew that mofo vein and wait a few minutes for his head to explode.

He hardly ever do me when I don’t want it. I know he love me.

I thought, So that’s true love then This is for you, Josie. It’s all I got left to save your ain’t no bad guy. And I began to oversew that mother-fucker. When I was nearly done, I looked up to see Bobby’s color was better and, more important, his heart sounded a steady beep throughout the room. More important still, the puddle of blood at my feet had stopped growing and the flow out of his head had thickened and trickled. A few final throws and it stopped altogether.

“Damn fine job, Sam,” Joe said. “You can cut on me anytime.”

Want more? JUICING OUT, a kindle novella for just 99¢ over at Amazon. Give it a read today. Thanks.

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06/28/14
FirstGSWSpineLogo

The First Clinical Xray

FirstGSWSpineLogo

 

This is an historic image.

On January 1st, 1896, Wilhelm Rontgen presented the first ever xray, an image of his wife Anna’s left hand. Later that year, a young doctor by the name of Harvey Cushing—who would go on to become one of the most prolific surgeons in history and the father of modern neurosurgery, produced this image, the first clinical x-ray (they called them rontgenograms back then)—a gunshot wound to the neck and spine.

There are actually two images here, one from the front (on top) and one from the side (on bottom). Each image took an incredible thirty-five minutes to expose.

The xrays show the bullet frgament (the dark blob) either within or overlying the C6 vertebra. So which is it—within the bone or in front of it?

It’s worth recalling that x-rays are 2-D representations of 3-D space. Consider a regular photograph. Everything visible in the frame of a regular photo will be condensed to a single plane, with only the items in the forefront visible. Everything behind will be hidden. With an x-ray however, everything in the frame will be condensed to a single plane including the items in the background. What?

If I take a picture of my hand over my face, my face is hidden by my hand. You can’t see how big my nose is or how many teeth are missing, because they are in hidden by my hand. But if I take an xray of my hand over my face, you’ll see not only my hand bones, but all the bones, teeth, and various soft tissues of my both my hand and face. In fact, that’s the hallmark of an xray—it looks through what’s on top to show what’s behind.

Put another way, in a photo only the visible foreground information is used to generate the image. By contrast, in an x-ray, all of the information in the frame (hidden or not to the naked eye) is used to generate the image. 

So how do we know if the bullet is in the bone or in front of it? The answer, of course, is we have to have two images in different orientations. Fortunately, Harvey Cushing intuited this even back in 1896. The image on top is an AP image—an exposure taken from the front. The dark spot overlying the C6 vertebra is the bullet. C is the skull and D is the ribs and lungs. The image is severely underexposed, so the soft tissue does not show well (including the lungs). Of course, since it was the first x-ray of its kind, we can forgive the underexposure.

The lower image is a side view. It shows the bullet overlying the C6 vertebral body as well. Since both the AP and side (lateral) xrays show the bullet overlying the bone, it must in fact be within the C6 vertebral bone itself—and not just in the soft tissue in front of or alongside the bone.

FirstGSWSpineDetail

On the lateral image, A is the spinal canal (where the spinal cord itself lives, here it has been colored in for clarity). B is the so-called pre-vertebral space, the soft tissue in front of the spinal column. There isn’t much detail here compared to today’s imaging, but there’s enough for us to say there is no fracture of the bones despite the presence of the bullet in the body of the C6 vertebra. The body of any vertebrae lies in front of the spinal cord, and very often a bullet may be lodged there without damage to the cord itself (especially if it is a low velocity missile image, as it likely was here). 

At other times, severe spinal cord injury (paralysis) may result from a gunshot wound to the spine, even one that completely missed the spinal cord itself. This is caused by blast effect, a sort of shock wave that goes through the tissue as a result of the kinetic energy of the gunshot wound as it passes through and disrupts the anatomy. Think of it as the ripples emanating from a pebble thrown into a quiet pond of water.

Of course, it’s possible the bullet passed through the spinal cord before it came to rest in the C6 body. That’s doubtful here though, since there’s no apparent bony fracture and such a path would very likely have disrupted bone. More likely, this bullet entered the front or side of the neck and came to rest just in front of the spinal cord, within the C6 vertebral body. From a stability standpoint, such an injury is very stable (that is, it does not compromise the spine’s ability to hold the head up—the patient would not need to be externally braced). We would not operate to remove such a bullet today, unless CT showed a blood clot compressing the spinal cord. Even then, the primary goal would be to remove the blood clot; retrieving the bullet would be secondary. Of course, there might be a non-neurosurgical reason to operate, such as damage to the trachea, etc.

Occasionally, serial imaging will show the bullet’s position is not stable, that is, that the bullet is migrating around. In such a case, removal may become necessary. There is a famous case in the neurosurgical literature of a very heavy bullet migrating through brain tissue. Imagine the damage that could cause!

Was this patient paralyzed? No way to tell from the images and his or her clincial fate is lost to us.

What about Harvey Cushing, the enterprising young doctor who made the x-rays? As noted, he went on to become the father of modern brain surgery. Almost single handedly he reduced mortality in brain surgery from a wopping 70-90% to much more tolerable though still astounding 10% (today it’s well below 1%).

Harvey Cushing operated on over 2,000 brain tumors. After he lost a patient in surgery as a medical student (he was responsible for anesthetizing the patient while the professor repaired a hernia during a lecture—when the patient died, the operation proceeded anyway!), he developed the anesthetic record, being the first to use serial recordings of heart rate and breathing. Blood pressure was added later after he discovered the BP cuff on a trip to Italy and brought it back to the United States with him (standard of care is to record all of these vitals and much more in modern day surgical anesthesia).

He made numerous advances in our understanding of the pituitary gland (Cushing’s disease, a dysfunction of the pituitary gland, is named after him).

Along with William Bovie, he developed electrocautery, which is used in 99% of operations today to minimize bleeding. Without it, modern surgery would not be possible.

He also won the 1926 Pulitzer Prize for his biography of Sir William Osler (considered by many the father of modern medicine, and one of the founders of Johns Hopkins Hospital). By the way, Cushing, who manned a military hospital in France during the last year of WWI and made many contributions to military medicine and surgery as well, was present when Osler’s son Revere died of his war wounds in France.

Cushing, a chain smoker, died of heart disease in 1939 at age 70. An autopsy showed he had a benign form of brain growth called a colloid cyst—which might well have been operated on using today’s standards.

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06/19/14
NOATW Sketch

Not One Among Them Whole—Intense & Engaging

For these men & their charges, laudable pus will be the least of their worries.

An intense and audacious tale of battlefield surgery, distressed surgeons,
and the insanity of life & death in the Civil War.

“Engaging, heart-breaking, & absolutely fantastic. A terrific book.”
—D. Buxman, a top 1000 reviewer & Vine Voice at Amazon

NOATW Sketch

It is the summer of 1863, and the greatest battle ever fought on American soil is in full tilt. Southern Pennsylvania has become one great grinding stone and thousands of dead or dying are its grist. In this tilted landscape, reputations are made, careers are ruined, and men and women are driven to the brink in the wake of two armies intent on killing one another. Yet opportunity is everywhere…

For the privates and officers who fight the battle, it’s a kill or be killed world, with salvation or damnation just a bullet away…

For one undertaker in particular, the dead are a canvas, and his ability to make a body reflect the living individual is nothing short of uncanny. For Jupiter Jones, the burgeoning dead themselves are the opportunity…

And finally, for one teenage former slave, alive only because his father had the courage to bury him, opportunity comes in the form of a ten-year-old boy with a creel and only one shoe, who may or may not be a ghost…

In the summer of 1863, humanity itself is under siege. What happens amid the carnage and human flotsam of Gettysburg, Pennsylvania, will be unholy, unnerving, and all but unbearable, with only this certain: not one among them will escape unscathed.

Here, hell is in session.

And it’s the devil’s own day.

 

“McDaniels’ fine Civil War novel is not the world of Robert E. Lee or Ulysses S. Grant or even Abraham Lincoln. McDaniels’ Gettysburg is a microcosm, a seething world of its own from which no player escapes.”
— P.B. Sharp, an Amazon Top 500 Reviewer

 

~ THE CHARACTERS ~

Ezra Coffin, a severely wounded Union soldier, has never seen his infant son, and perhaps never will…

Major Tom Jersey, a Confederate officer, awakens terribly mangled in the aftermath of combat, his only companions: the wounded enemy, without whom he can’t survive, and the ghost of his son—who may be his only means of escape…

Major Solomon Hardy, chief surgeon, who stands at the tables until his health fails—then watches over his own dying son…

Major Josiah Boyd, a gifted surgeon but a flawed man. His time behind the knife may cost him everything—and his patients even more…

Captain Tobias Ellis, his courage under fire makes him a hero, but he may just be the most flawed of all—and the most dangerous…

Liza Coffin, who isn’t eighteen, but already has been a homeless orphan, a mother, and perhaps now a widow too…

Jupiter Jones, showman extraordinaire, itinerant undertaker, and reader of the dead. His healing Oil, acquired from the equatorial coast of West Africa, may be the real thing…

And finally Cuuda Monk, a teenage boy and former slave, alive today only because his father had the courage to bury him when the end came. His visions of the boy with the creel may make him the sanest man in the land—and just may be the means to all their salvation…

It is the summer of 1863 and humanity is under siege. What happens next amid the carnage and human flotsam will be unholy, unnerving, and all but unbearable.

It is the summer of 1863 and everything is about to change.

Everything.

Forever.

Not One Among Them Whole, A Novel of Gettysburg, by Edison McDaniels

Click the book cover to buy the Kindle version from Amazon for just $6.99!

 ~An Excerpt~

Surgeon Josiah Boyd leaned toward the corner, pressed his tongue against his lips, and spat. Reflex mostly, something he did without thinking whenever the need presented, which was often. The gob splattered against the wall, joining the smear of juice already there. Assistant Surgeon Tobias Ellis gave little thought to the smear of tobacco, keeping his mind on the task at hand. Like Boyd, his hands and forearms were streaked with the blood of scores of men. They looked raw, almost skinned.

“Artery clamp.” Boyd stretched a palm out in waiting. 

Tiny, the surgeon’s helper, was a heavyset kid in his early twenties, though he looked younger. His experience put the lie to his appearance. He’d spent the better part of two years—the worst part of a lifetime—with the field hospital. He rummaged in the dirty water of the basin even as he held a chloroformed mask over the patient’s face. His fingers made quick work in the cool, blood pink water, finding the instrument by feel. He slammed the clamp into Boyd’s hand with a sharp smack and Boyd squeezed the clamp around the femoral artery as Ellis lifted the great vessel out of its bed, the thrum of the pulse fighting back from within. The clamp clicked as it locked, and the artery beyond the obstruction went limp. “Ligature,” Boyd said with a practiced calm.

Major Josiah Boyd was old for his thirty-eight years. His hair had thinned up top and he hadn’t shaved in days. He was of lanky build and sallow complexion, possessed of a long drawn-out face almost ghoulish in its particulars, with prominent cheekbones high under his eyes. His lower jaw had been twice broken (once by a horse, once by a man) and poorly set. It jutted obtrusively and his teeth came together at an angle somewhat off the expected, so that the whole of his face looked skewed. His hands were large and his fingers long and spindly like the legs of a great spider. They were economical in their wanderings across the surgical field however, with no waste of motion. 

The soldier on the table lay on his back. He was insensible to the workings both around and upon him, heavy under the influence of a chloroform-soaked towel. Boyd and Ellis worked quickly at their labors, their movements looking somewhat frantic at times. They had about them a look of resigned experience, showing both intolerable exhaustion and inordinate energy at the same time. They’d been working feverishly at one task or another since first light a dozen hours before. Their efforts had made not a dent in the line of men awaiting their services. At times, they worked so fast and the wounded spent so little time before them, it seemed they were cutting the same man over and over again.

Tiny passed the silk ligature and Ellis encircled the artery twice with it, just above the clamp. His fingers blurred with movement as he tied the thread and occluded the artery. He repeated the exercise on the thinner-walled vein beside it. Tiny retrieved a pair of scissors from the basin and slapped them into Ellis’s hand even before the man could ask for them. The assistant surgeon divided the vessels—artery and vein—below the ligatures and removed the clamp.

They had cut away the soldier’s trousers and filleted his thigh to the bone midway between hip and knee ten minutes before. Now, with the last of the muscle and flesh parted and only the bare thigh bone joining the lower leg to the upper, the amputation was complete in all but fact. Only the saw cut remained.

“Capital saw,” Ellis said, and out of his side vision he caught Boyd turning to spit again. This time he had time to consider the action, something he’d seen Boyd do a thousand times in a dozen hovels just like this one. In the instant before the handle of the bone saw struck his palm, Ellis wondered at the incongruities of the man who was his direct senior. He had ‘good hands’. Goddammit that ain’t true, Ellis thought, he’s more than that, a genuine honest-to-God born surgeon. Ellis had seen a lot of men work the tables in his almost two years as an assistant surgeon and Boyd was, hands down, the best cutter out there. But it was also true the man had odd ways. Like his want to chew during surgery, which perhaps wasn’t all that bad, except it meant he was always spitting. And there was his habit of spacing out in the middle of an operation. He’d suddenly walk away from the table, turn his back to the room or go behind a wall, then reappear before too long as if nothing had happened. Except something had happened, Ellis would always think. At such times Boyd looked different. Certainly not better, and not worse (or probably not worse, he’d had occasion to think a few times—and how curious was that?). Just different. It showed most in his hands, which looked somehow, he tried to think of the correct word, revitalized? Was that it? Upon returning to the table, those hands, which had seemed worn and tired, would now be spirited and quick to perform. But it was Boyd’s eyes that bothered. Once the surgeon reappeared, Ellis always found those eyes…unsettling. As if Boyd’s eyes had developed an unpleasant ‘lag,’ a sort of disparity with his hands. As if the one had given to the other, Ellis suddenly thought. He swallowed hard then, tried to put that absurd notion out of his head. A fevered product of his own exhausted mind, he decided. After all, once a battle was joined and the bloodletting began, there was never enough rest.

Tiny put the saw in Ellis’s palm and he came back to the moment. He curled his fingers around it—they seemed to have conformed to it over the endless months of the war—and went to task on the soldier’s femur. Boyd held the meat of the leg out of the way as Ellis laid the business side of the saw against the lower end of the bare thighbone and began to run it back and forth. The blade’s teeth bit at the glistening bone with a gritty feel and flecks of ivory dust and crimson blood peppered the air as he worked. The sawing took more force than Ellis supposed it should and he made a mental note to have Tiny replace the blade before the next patient. When he’d about sawn through the whole of the femur, the remnant snapped with the pop of a dry twig and the leg fell away. Tiny stuffed a wad of lint against the bleeding stump as Boyd removed the now useless limb.

“Bone file.”

Tiny anticipated the request and passed it without hesitation. Ellis grasped the narrow, five-inch flat metal file and worked the roughened side against the sharp edges of the bony stump. When he was satisfied with its appearance and feel, no sharp edges to work through the skin later, he nodded at Boyd, who took a quick feel as well. “That’ll do,” the senior man said. Ellis handed the file back to Tiny and Boyd took up an amputation knife—its long, sharp edge might easily slice a ham—and carved away a bit of remaining muscle and flesh on the back of the thigh, until he was satisfied with the look and feel of the flap to lay over the stub of bone.

They continued to work largely in silence, with no idle chit-chat. Ellis removed the lint from the end of the sawn bone. Satisfied the wound was not oozing too much blood, the surgeons flapped the skin up and approximated the edges with several silk stitches placed an inch apart. Ellis dressed the incision with a plaster cap and Tiny fanned the man to purge the chloroform from his system. A quick whiff of liquor of ammonia served finally to bring him back to consciousness, where upon he began to groan. Judging the man was safely over the effects of the chloroform, Boyd dribbled a few drops of laudanum, a sweet concoction of opium and alcohol, on the soldier’s tongue to dull him to the agony of the hours to come. Ellis had seen its effect on men time and again. Some the laudanum slept, others it simply relaxed. Ellis himself had taken it once or twice to kill a headache. Its effect had felt something akin to salvation—removing him from the horrors of the field hospital and the tussle of war, albeit transiently. Good stuff, he thought, and dangerous. Too much of that could turn a man out.

A pair of stretcher bearers stepped forward and lifted the patient with only a bare afterthought of gentleness, grabbing him under his butt and armpits. The man’s grunts as they carried him outside to be deposited alongside the other unfortunates were lost in the chaos of the battlefield hospital. Boyd stood off to one side of the room, several men interposed between he and Ellis. Ellis watched as the surgeon put his hands out, looking at the trembling, blood soaked palms as if they might suddenly fall off. Another of Boyd’s odd behaviors. There followed a curious moment in which Boyd looked about, spotted Ellis, and slipped awkwardly out the back of the building. 

Another soldier was placed on the table. As Tiny pressed a cloth over the man’s nose and mouth and chloroformed him, Ellis probed the wound in his calf with a stiff finger, feeling for splinters of bone and the ball that had done the damage. The soldier winced, not quite under yet. As Ellis pulled his finger from the man’s innards, Boyd appeared at the side of the assistant surgeon and chuckled in an odd, not at all funny way. “The truth of the flesh,” he said, or something very much like it. Ellis couldn’t be sure. It was a small thing, but as Boyd called for a scalpel, it disturbed Ellis nonetheless and he had no idea why.

 

If you liked the excerpt, you aren’t alone… 

NOT ONE AMONG THEM WHOLE is available for the Amazon Kindle & in trade paperback. Also available in other eBook formats. Now featured at the National Park Service bookstore at Gettysburg itself.

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06/7/14
BrainSqueeze

Brain Squeeze

 

Brain Squeeze: The Intracranial Pressure Monster
by Edison McDaniels, MD

The skull is a closed box. Think about it. They don’t call it the cranial vault for nothing. Once past the age of a toddler, the skull is fused—it continues to grow towards the normal adult size, but the bones of the skull are knitted together and there is no mechanism whereby they can open again (short of the surgeon’s knife, or a terrible fracture) to rapidly expand the volume of the vault.

The box is closed and the volume within is, for all intents and purposes, fixed.

This, of course, presents a curious problem. There’s only so much room inside a closed box. What happens when that room is exhausted, that is, over subscribed? What happens when there’s more stuff filling the space than it was designed for?

Huh? What?

To understand this further, imagine a shoe box with an expanding balloon inside. With the lid off the box, the balloon simply expands outward, eventually expanding out of the box entirely. But with the lid on, the expanding balloon eventually destroys the box. Now imagine the box is not empty to begin with, that when the balloon is placed inside it, the box is already 90% full. What happens then? In that case, it’s the stuff filling the box that gets damaged first as the ballon expands to squeeze the contents of the box.

Now, imagine that box is the skull, already filled to near capacity by the brain. Picture the expanding balloon to be a tumor, or perhaps trapped spinal fluid (hydrocephalus), or maybe even a brain swelling out of control after a head injury.

Ouch. Not a pretty picture. Let’s look at this box and its contents more closely.

For starters, it turns out that for all practical purposes there are only three things inside this skull box: blood, brain, and spinal fluid (CSF).

CSF is a non-compressible, usually straw colored fluid that is largely water. It contains no cells under normal circumstances. It bathes the brain and spinal cord, providing a cushion in which these elements float.

Yes, the brain floats.

This is good and bad. It’s good in that under normal circumstances there is nothing pushing against the brain. It’s bad in that with a rapid acceleration or deceleration, like a fall or a blow to the head (think of a baseball bat, or a fist), the skull stops moving before the floating brain does. Or the skull starts moving while the brain is still standing still. Either way, the brain slams into the skull. As they say, it’s not the fall that gets you, nor even the sudden stop. It’s that you don’t stop all at once. Ouch again. 

Back to the CSF. The liquor cerebri, as it has been called, is produced at a constant rate of about 500 cc per day come hell or high water. Under normal circumstances it is reabsorbed into the venous system through the large vein at the top of the brain. The production and reabsorption of CSF are independent of each other however, and uncoupling of this fine balance can lead to life threatening problems within a matter of hours. This buildup of CSF is called hydrocephalus.

You might think the brain itself is a fixed volume, but you’d be wrong. The substance of the brain is composed of cells interspersed in a watery milieu, the so-called interstitial fluid that exists between the tightly packed cells. Both the cells themselves and the interstitial space they sit in are capable of changes in volume relative to a given physiological stress.

What kind of stresses? Simple breathing for one. The volume of the brain is reduced slightly with hyperventilation, i.e., rapid breathing. As a caveat, hypoventilation (very slow breathing) can cause an increase in the volume of the brain. This happens every night when we sleep (sleeping produces a relative hypoventilation—shallow breathing—leading to a slight increase in brain volume. Not enough to cause a problem in the normal circumstance, but if there is something else taking up space inside the head (hydrocephalus, a tumor, or even a slowly expanding hemorrhage—the chronic subdural of the aged), this slight change in brain volume while sleeping can cause symptoms (this is partly why patients with brain tumors tend to have a headache in the morning when they first get up—later in the process they often vomit in the mornings as well, after which they feel better because the act of vomiting has pushed a good deal of CSF out of the head and into the spine, relieving pressure within the skull).

Gravity is another stress. The volume of the brain (as well as the amount of CSF within the head itself) tends to be lower during the day when we are upright. Most of us sleep lying flat, however, and lying flat takes gravity out of the picture and fluid tends to flow back into the head during the sleeping hours. Patients with untreated brain tumors or chronic hydrocephalus learn that sleeping upright feels better and causes less trouble. Neurosurgeons often elevate the head of their patients after surgery for the same reason.

A much more significant stress is head injury. Physicians often refer to closed head injury, CHI. CHI is generally a blunt force trauma, like a fall or striking the head in an auto accident. Being hit by a thrown ball is another example. Gunshot wounds and stabbings are examples of penetrating head injuries. All of these cause swelling in various degrees, i.e., an increase in the amount of water in the brain tissue (not to mention hemorrhage—this is the definition of contusion, which is bruising).

Uncontrolled brain swelling can cause shifts of brain tissue within the skull. It turns out the intracranial space is not a simple box with a brain within. Rather, it is a complicated 3-D space with various shelves, nooks, and crannies. These divide the space into various compartments, each called a fossa (anterior, middle, and posterior—front, middle, and back), as well a right and left half with a large shelf of tissue between. Neurosurgeons spend years learning how to get in and out of these various fossas with as little injury as possible.

Swelling represents an increase in the local pressure within the brain. Simple physics dictates that material moves from an area of higher pressure to an area of lower pressure. The brain is no different. With brain swelling, injured tissue has a higher pressure than surrounding normal brain. These gradients are generally gradual and so the shift is small at first. But when the gradient increases (the swelling rises), shifts of significant magnitude can occur between and across the various shelves and compartments. This not only squeezes and distorts good brain, it also squeezes blood vessels, which may lead to stroke. All of these things can potentially turn good brain into bad brain. Bad brain swells, and the situation is potentiated until either the surgeon intervenes successfully or the patient dies. This is malignant cerebral edema (AKA malignant brain swelling).

So that’s CSF and brain. What about the third substance normally present within the skull, blood? Does the volume of blood change? Yes. In fact, the hyperventilation/hypoventilation discussed above also affects the amount of blood in the cerebral vessels. Hyperventilation reduces any pooling of blood, which is a very quick and effective way of reducing increased pressure in the head related either to brain swelling or tumors. This effect is short lived, hours to a day or so, but is quite potent and is used often in emergencies to temporize on the way to the operating room. It is one of the reasons that head injured patients are intubated so quickly.

The caveat of the above paragraph is that hypoventilation (under ventilation or shallow breathing) can kill. Hypoventilation allows pooling of blood in the head and, in the setting of brain swelling, that is very dangerous. One place this can occur is in the CT scanner in the first moments evaluating a head injured patient. This is another reason such patients are intubated early in their care, not so much because hyperventilation is necessary, but because hypoventilation is so bad.

So, the three most frequent occasions when there is a problem with the volume of brain tissue itself are tumors, brain swelling from head injury, and aging.

A brain tumor may be thought of in terms of an expansion of brain volume or brain tissue. As the tumor enlarges, it takes up valuable space inside the so-called cranial vault, space normally occupied by the normal brain. As the tumor grows, it displaces normal brain (and spinal fluid). If the tumor gets large enough, this displacement leads to shifts in brain matter (for the same reasons as above). These shifts are known as herniation. Herniation is a situation in which brain tissue is displaced out of it’s normal position. Sometimes this herniation is relatively benign and serves as a marker that there is a problem. Though the herniation itself might be relatively benign, if allowed to continue it may lead to either stroke or death—so not so benign afterall. Other types of herniation are even more significant, leading to pressure on the centers of the brain controlling heart rate, blood pressure, and breathing. Obviously, such herniations are immediately life threatening. These are sometimes irreversible.

Another situation in which blood becomes a problem inside the head is with hemorrhage (intracranial bleeding). An expanding intracranial hematoma can rapidly become lethal. This may take the form of a post-traumatic hemorrhage (epidural or sudural hematoma, hemorrhages outside the brain proper) or a spontaneous hemorrhage, which is usually within the substance of the brain itself. This latter is a form of stroke and is caused by the rupture of a small vessel within the brain substance. Sometimes such a hematoma will be amenable to removal, sometimes it occurs in an area where it cannot be reached without leaving a person devastated from a brain function perspective (in such a case, surgery is usually deferred).

Not only is the size of an expanding mass inside the skull important, but the rate of expansion of the mass is equally important. I have seen a slow growing benign tumor the size of a softball cause little in the way of problems (the young woman presented with a lump on her head she was curious about, no headaches or other symptoms!). Benign tumors can grow very, very slowly, taking many years to achieve a clinically significant size. For this reason, when such a tumor is discovered in an elderly person (whose brains have lost volume due to aging and so have extra room already), neurosurgeons often chose not to remove the tumor unless it shows evidence of significant growth over time. Depending on a person’s age, a slow growing tumor may not grow fast enough to become a problem during a person’s life.

On the other hand, an expanding epidural hematoma after a fall or other head injury may cause life-threatening problems at a relatively small size of just 25-30 cc. Sometimes a lucid interval occurs after a head injury, often seemingly minor, during which blood is accumulating in the skull until it reaches a symptomatic size, by which time it may be too late. The classic case is an epidural hematoma (bleeding outside the brain and just under the skull). Natasha Richardson, the actress, was in a lucid interval when she declined medical aid after suffering what was thought to be a minor head injury while skiing. Somewhat later, perhaps an hour or two, she collapsed when the hematoma finally reached a size where it caused one of the above noted herniations.

So, to recap. First, the skull is a closed box. Second, there are only three things inside the box: blood, brain, and CSF. Third, an increase in the volume of any one of these three substances (blood, brain, CSF) leads to a compensatory decrease in the volume of the other two. And finally, once these compensatory decreases are exhausted, the intracranial pressure rises and shift and herniation is the result. If this badness cycle isn’t interrupted at some point, death or stroke is the result.

The last paragraph is a statement of the most fundamental doctrine in all of neurosurgery, the Munroe-Kellie Doctrine. This is learned by every neurosurgery resident during the first week of training and never forgotten. In fact, there is nothing a neurosurgeon does inside the head where he or she does not have to take the Monroe-Kellie Doctrine into account.

Stated another way, as a neurosurgeon, with every intervention I make involving the brain, I have to consider the effect on intracranial pressure. Not to do so invites catastrophe, and preventing catastrophe is what treating brain squeeze is all about.

Oh, one more thing. I am often asked what happens after we lose CSF in surgery. The short answer is, nothing. As I noted above, CSF is produced at a constant rate of about 500 cc a day, which is about the volume of CSF in the head. Thus, anything lost at surgery is replenished in a matter of hours. Until then, the brain sort of sits like a lump inside the head. This might well cause a headache, though it doesn’t seem to be too bad in most patients. Sometimes nausea as well, though it’s difficult to say if this comes from the anesthesia meds, the removal of the tumor itself, or the loss of spinal fluid. Either way, the situation resolves itself before the patient goes home. This is one reason most patients don’t go dancing the night of surgery, though many are able to walk the halls of the hospital by the morning after surgery.

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