The incredible journey to the center of the body and back.
The patient was bed ridden. He had lost all power in his left lower limb. He was barely moving his right hip, knee and ankle. He had a forlorn look in his eyes as he recounted the gradual deterioration in the power of his lower limbs. He had severe bowel and bladder complaints, which further compounded his suffering.
An MRI of the thoracic spine revealed severe compression of the spinal cord at the fifth thoracic vertebral level. The cause could have been tuberculosis, malignancy, or then an osteoporotic compression fracture. Irrespective of the etiology, the only remedy was to decompress the severely compromised spinal cord at the earliest. Prolonged compression could result in irreversible damage to the cord leaving him paralysed for life.
He was worked up and scheduled for surgery. Decompression of the cord in his case had to be done by an approach that involved opening the thoracic cage, gently retracting the lung on that side and then drilling away through the offending diseased vertebral body to relieve the compression on the cord.
The patient was positioned and strapped to the table and after painting and draping the right side, I embark on an incredible journey that will take me to the centre, or the core of the body.
As I take the incision, I utter a silent prayer to the Lord to bless my journey and give me the fortitude to deal with all the odds that I know are stacked up against me in my endeavor.
I soon expose the 5th rib, and shave off the soft tissues. This rib will have to be sacrificed to permit access to the pathology. As the rib is cut, I catch a glimpse of the delicate and thin pleura,a membrane that houses the lungs. I incise the pleura and I'm greeted by the pink, mottled, soft compressible lung that's expanding with each breath inflated by the ventilating anesthesia Boyles machine.
The lung, that's an incredibly intricate architecture of miles of tubes ( bronchioles) and small bubble like balloons ( alveoli). This soft, spongy organ provides the body with oxygen and also removes carbon dioxide by a very complex interchange system. I stare at it, my mind filled with awe as I imagine, what might be happening at the microscopic level. The impure hemoglobin that's saturated with carbon dioxide transfers it's cargo to the alveoli and gets recharged with molecules of oxygen, which it will distribute to the ever hungry tissues. The mechanism is effected by a protocol and intelligence that's mind numbing. I cannot afford the luxury of deliberating too much as I still have a long was to go. I gently cover the lower part of the lung and retract it. It's almost like coaxing the organ to relent and yield to the gradually increasing pressure of the retractor. The anesthetist has been kind enough to use a double lumen endotracheal tube, that can selectively ventilate the left lung only. This makes my job easier as retracting a lung that's expanding with each breath can be really very frustrating.
Once I've got the lung out of my way, i take a deep breath as I encounter the master. The throbbing, pulsating, undulating heart wrapped in a membranous pericardium beating relentlessly in the anterior part of the chest cavity. This organ, beats ceaselessly for 70 odd years, without a moments rest. What a stupendous bit of engineering, and design. I offer my respect to this pulsating perfection and focus on reaching my target. With all the retractors in place, i locate the body of the diseased 5th vertebra.
Now begins the job of isolating and sculpting away the diseased bone beneath which lies the trapped cord. I mark the area by defining the intervertebral discs above and below the fifth vertebra. I coagulate and seal the traversing segmental blood vessels and take the drilling burr. I get on with grinding away the diseased vertebral body. I continuously need to refer to a 3 dimensional reconstructed mental image of the distorted anatomy using the 2 dimensional MRI images. The diseased vertebra has to be decored and thinned out to a just a thin cortex, immediately beneath which lies the cord. The cord is extremely delicate and extreme care must be taken to avoid the smallest of insult.
I walk up to the x ray viewer, and review the MRI to confirm the depth that I will have to go to decompress the cord.
I get back and carefully drill away till I sense the bone getting thinner. I guess there are just a few millimeters of bone between the tip of my instrument and the cord. A shudder goes through my body, as I confirm this. The Lord of restraint blessed me in time and made me release the pedal that operated the drill. A few seconds more and I might have easily gone through and entered the cord.
Once the remaining thin shell of bone is removed, I encounter some strange soft tissue which I remove and save for biopsy. This is what was really squeezing the cord. I have to work across the midline and ensure that I've decompressed the cord through 180 degrees. With baited breaths, and in a silence that's broken by the thudding of my own heartbeats, I gently separate the overlying tissues all around.
As I gently excise this tissue I'm greeted by the welcoming dural tube. I think it's analogous to the emotion that rescue parties experience after surmounting untold obstacles and finally reach the trapped victims. I comfort the tormented cord by covering it with a Cotton Pattie. I've reached the centre of the body.
I then get to removing all the thin bone and soft tissue till the cord is bulging with its restored pride and glory. Watching the dural tube pulsating is the moment of ecstasy. Through this tube traverse those delicate cables, that animate the lower body. I gently caress the expanded tube, with an admiration that is more worship. Neural tissue has a sanctity, that's hard to explain. I can perceive "Handle with care" vibes the moment I am anywhere in the vicinity of this ivory white structure that will never reveal the mystery behind it's functioning.
Thereafter, i measure the required length of titanium cage, fill it with bone chips and gently impact it between the 4th and 6th vertebra. I take a quick glance to ensure there's no bleeder that could cause problems. I confirm the perfect placement of the implant using a C arm.
All looks well.
I then begin the exit. Akin to a careful descent after summiting a challenging peak. Descent is adulterated with euphoria which can compromise caution. I galvanise the teams spirit, specially my second assistant, who's hand that held the retractor must be weary. I start covering my tracks, suturing the separated tissues begging pardon of the almighty for this violation, this trespass of his creation.
After an hour, i get a call from my houseman. The patient post operatively is not moving both lower limbs. My heart sinks. But, such deterioration is expected after even minor handling of the cord. I explain this to the relatives and ask my junior to keep a close vigil, whilst I keep my fingers crossed. These moments are the hardest to deal with. I seek solace from the fact that I did my best.
Next day morning he has in fact recovered power completely in the right lower limb and is partially recovering power in the left lower limb. I'm relieved and then even more thrilled as I see the X-rays, which reveal the perfect placement of the implant, but not a trace of the painstaking 5 hour journey to the center of the Body and back.
Dr. Deepak Ranade.
The patient was bed ridden. He had lost all power in his left lower limb. He was barely moving his right hip, knee and ankle. He had a forlorn look in his eyes as he recounted the gradual deterioration in the power of his lower limbs. He had severe bowel and bladder complaints, which further compounded his suffering.
An MRI of the thoracic spine revealed severe compression of the spinal cord at the fifth thoracic vertebral level. The cause could have been tuberculosis, malignancy, or then an osteoporotic compression fracture. Irrespective of the etiology, the only remedy was to decompress the severely compromised spinal cord at the earliest. Prolonged compression could result in irreversible damage to the cord leaving him paralysed for life.
He was worked up and scheduled for surgery. Decompression of the cord in his case had to be done by an approach that involved opening the thoracic cage, gently retracting the lung on that side and then drilling away through the offending diseased vertebral body to relieve the compression on the cord.
The patient was positioned and strapped to the table and after painting and draping the right side, I embark on an incredible journey that will take me to the centre, or the core of the body.
As I take the incision, I utter a silent prayer to the Lord to bless my journey and give me the fortitude to deal with all the odds that I know are stacked up against me in my endeavor.
I soon expose the 5th rib, and shave off the soft tissues. This rib will have to be sacrificed to permit access to the pathology. As the rib is cut, I catch a glimpse of the delicate and thin pleura,a membrane that houses the lungs. I incise the pleura and I'm greeted by the pink, mottled, soft compressible lung that's expanding with each breath inflated by the ventilating anesthesia Boyles machine.
The lung, that's an incredibly intricate architecture of miles of tubes ( bronchioles) and small bubble like balloons ( alveoli). This soft, spongy organ provides the body with oxygen and also removes carbon dioxide by a very complex interchange system. I stare at it, my mind filled with awe as I imagine, what might be happening at the microscopic level. The impure hemoglobin that's saturated with carbon dioxide transfers it's cargo to the alveoli and gets recharged with molecules of oxygen, which it will distribute to the ever hungry tissues. The mechanism is effected by a protocol and intelligence that's mind numbing. I cannot afford the luxury of deliberating too much as I still have a long was to go. I gently cover the lower part of the lung and retract it. It's almost like coaxing the organ to relent and yield to the gradually increasing pressure of the retractor. The anesthetist has been kind enough to use a double lumen endotracheal tube, that can selectively ventilate the left lung only. This makes my job easier as retracting a lung that's expanding with each breath can be really very frustrating.
Once I've got the lung out of my way, i take a deep breath as I encounter the master. The throbbing, pulsating, undulating heart wrapped in a membranous pericardium beating relentlessly in the anterior part of the chest cavity. This organ, beats ceaselessly for 70 odd years, without a moments rest. What a stupendous bit of engineering, and design. I offer my respect to this pulsating perfection and focus on reaching my target. With all the retractors in place, i locate the body of the diseased 5th vertebra.
Now begins the job of isolating and sculpting away the diseased bone beneath which lies the trapped cord. I mark the area by defining the intervertebral discs above and below the fifth vertebra. I coagulate and seal the traversing segmental blood vessels and take the drilling burr. I get on with grinding away the diseased vertebral body. I continuously need to refer to a 3 dimensional reconstructed mental image of the distorted anatomy using the 2 dimensional MRI images. The diseased vertebra has to be decored and thinned out to a just a thin cortex, immediately beneath which lies the cord. The cord is extremely delicate and extreme care must be taken to avoid the smallest of insult.
I walk up to the x ray viewer, and review the MRI to confirm the depth that I will have to go to decompress the cord.
I get back and carefully drill away till I sense the bone getting thinner. I guess there are just a few millimeters of bone between the tip of my instrument and the cord. A shudder goes through my body, as I confirm this. The Lord of restraint blessed me in time and made me release the pedal that operated the drill. A few seconds more and I might have easily gone through and entered the cord.
Once the remaining thin shell of bone is removed, I encounter some strange soft tissue which I remove and save for biopsy. This is what was really squeezing the cord. I have to work across the midline and ensure that I've decompressed the cord through 180 degrees. With baited breaths, and in a silence that's broken by the thudding of my own heartbeats, I gently separate the overlying tissues all around.
As I gently excise this tissue I'm greeted by the welcoming dural tube. I think it's analogous to the emotion that rescue parties experience after surmounting untold obstacles and finally reach the trapped victims. I comfort the tormented cord by covering it with a Cotton Pattie. I've reached the centre of the body.
I then get to removing all the thin bone and soft tissue till the cord is bulging with its restored pride and glory. Watching the dural tube pulsating is the moment of ecstasy. Through this tube traverse those delicate cables, that animate the lower body. I gently caress the expanded tube, with an admiration that is more worship. Neural tissue has a sanctity, that's hard to explain. I can perceive "Handle with care" vibes the moment I am anywhere in the vicinity of this ivory white structure that will never reveal the mystery behind it's functioning.
Thereafter, i measure the required length of titanium cage, fill it with bone chips and gently impact it between the 4th and 6th vertebra. I take a quick glance to ensure there's no bleeder that could cause problems. I confirm the perfect placement of the implant using a C arm.
All looks well.
I then begin the exit. Akin to a careful descent after summiting a challenging peak. Descent is adulterated with euphoria which can compromise caution. I galvanise the teams spirit, specially my second assistant, who's hand that held the retractor must be weary. I start covering my tracks, suturing the separated tissues begging pardon of the almighty for this violation, this trespass of his creation.
After an hour, i get a call from my houseman. The patient post operatively is not moving both lower limbs. My heart sinks. But, such deterioration is expected after even minor handling of the cord. I explain this to the relatives and ask my junior to keep a close vigil, whilst I keep my fingers crossed. These moments are the hardest to deal with. I seek solace from the fact that I did my best.
Next day morning he has in fact recovered power completely in the right lower limb and is partially recovering power in the left lower limb. I'm relieved and then even more thrilled as I see the X-rays, which reveal the perfect placement of the implant, but not a trace of the painstaking 5 hour journey to the center of the Body and back.
Dr. Deepak Ranade.
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