The Philosophy of Pathology.
The young lady was just 28 years old. She presented with complaints of severe backache and then gradual loss of power in both her lower limbs. She had become weak, and was a shade cachexic when I saw her in my outpatient. An MRI revealed severe compression of her thoracic spinal cord by an ominous looking mass, that was most certainly a tubercular abscess. The disease process had destroyed the normal vertebra and adjacent disc spaces into a gooey pulp of pus, granulation tissue, necrotic material and fragments and shards of residual bone. This heterogenous mass of disintegrating tissues had severely compressed the underlying spinal cord. The lady had started developing spasticity ( stiffness) of both her lower limbs and had to walk with support.
Tuberculosis is a very complex disease, a dynamic interaction between the virulence of the bacteria and the immunity of the host. It can vary from a small highly localised 1cm scar in the lung ( Ghons Complex) to a full blown, multi organ involvement ( miliary tuberculosis).
She was taken up for surgery to decompress the spinal cord. All the dead bone, granulation tissue, pus, and necrotic material had to be excised, followed by reconstruction of the vertebral column by interposing a titanium cage. The integrity of the vertebral column is critical to lead a normal, active life.
Since the compression was from the front (anteriorly) and the body of the vertebra that was diseased also had to be reconstructed, the approach is through the rib cage, by spreading the ribs.
After I open the chest wall, I immediately notice this knotty lump, that's distorted the curvature of the vertebral column. I get about my task carefully sealing the segmental veins and arteries, the source of blood supply to the vertebrae.
As students of surgery, we are trained to identify tissue planes, and dissect in these potential spaces between tissues to reach the target. Tissue planes are potential spaces that need to be skillfully opened to minimise blood loss, and ensure protection of the various organs that we encounter enroute.
Infections like Tuberculosis result in gumming of the tissues and their junctions ( planes). This makes it truly difficult to identify any landmarks. Its like finding one's way in a town destroyed by a tsunami. I have to keep a close track of where I might encounter the spinal cord, as I separate the necrotic tissues with sharp and blunt dissection.
These moments are tense. I have to keep battling and titrating three images in my mind. The normal anatomy, what I expect to find on interpreting the MR scans, and what I actually find. Dealing with a distorted anatomy ravaged by a virulent infective pathology can throw up surprises. Experience is minimising the chasm between what I have envisage on seeing the MR scan images and what I actually encounter. I have to undertake a retrograde time travel, to fathom how this pathology unfolded to effect this lump of distortion, this incomprehensible mass, which has to be untangled with precision. As I'm gently tugging at a whitish looking strip of tissue, I shudder. I hope I'm not anywhere near the cord. I release the tissue and take a deep breath. I readjust the microscope to get another perspective of the same contentious looking tissue. When I look at the same tissue from another angle, it provides greater details, to my discriminatory powers.
I realise again, the importance of readjusting the focus of our viewpoint when dealing with any problem, to help get another perspective of looking at the same problem. Neurosurgery teaches and reveals some very profound philosophies of life too. It reveals, the large, yawning gap, between my understanding of the problem and the actual nature of the problem. I have to keep alert, be my own devil's advocate, and take the necessary measures to correct the course of my approach.
As I take the micro-drill in my hand to burr away the residual bone, I say a silent prayer, to keep my hand and my focus steady. I can't afford to be myopic, and whilst one eye is on the target tissue, the other eye is occupied in passive surveillance of the surrounding structures. One small slip and I could well cause irreparable damage to the cord. It's a risk I have to undertake, if I want to get rid of the hard, unyielding bone fragments. Some problems in life, require very tough remedies. They need tough measures, like high torque drills, but have to be used with caution, and nerves of steel.
I'm well on my way, and there is a sudden gush of cherry red blood. I have to place a piece of cotton patty to suck away the blood. I can't do it directly for fear of injuring the sensitive and delicate cord which is in the vicinity. Some problems need to be addressed indirectly, covering them with a cottonoid of patience. Direct confrontations don't work in all situations.
I manage to locate the spurting blood vessel and seal it with my forceps.
After about an hour of gentle dissection, i can start delineating the outline of the underlying cord. Seeing it decompressed fills me with a sense of relief. I then get the appropriate sized implant. I have to do a lot of gardening of the bed, to ensure a snug fit of the titanium cage. I manage to get the implant in the desired position, that's verified by x rays.
As another case is over, it also ensures a quick revision of strategies that I need to employ to deal with the pathologies of Life too. Pathology is a distorting force, an intrinsic nature of creation where entropy always increases. Pathology contorts and breeds disorder, chaos. By deploying our power of discretion, and the vast array of tools at our disposal, we certainly have the wherwithal to usher in order and normalcy. Surgery, is largely an attempt at decreasing the entropy perpetrated by this demon called pathology.
The lady is doing well by Gods grace and her post op X rays fill my heart with satisfaction and joy
The young lady was just 28 years old. She presented with complaints of severe backache and then gradual loss of power in both her lower limbs. She had become weak, and was a shade cachexic when I saw her in my outpatient. An MRI revealed severe compression of her thoracic spinal cord by an ominous looking mass, that was most certainly a tubercular abscess. The disease process had destroyed the normal vertebra and adjacent disc spaces into a gooey pulp of pus, granulation tissue, necrotic material and fragments and shards of residual bone. This heterogenous mass of disintegrating tissues had severely compressed the underlying spinal cord. The lady had started developing spasticity ( stiffness) of both her lower limbs and had to walk with support.
Tuberculosis is a very complex disease, a dynamic interaction between the virulence of the bacteria and the immunity of the host. It can vary from a small highly localised 1cm scar in the lung ( Ghons Complex) to a full blown, multi organ involvement ( miliary tuberculosis).
She was taken up for surgery to decompress the spinal cord. All the dead bone, granulation tissue, pus, and necrotic material had to be excised, followed by reconstruction of the vertebral column by interposing a titanium cage. The integrity of the vertebral column is critical to lead a normal, active life.
Since the compression was from the front (anteriorly) and the body of the vertebra that was diseased also had to be reconstructed, the approach is through the rib cage, by spreading the ribs.
After I open the chest wall, I immediately notice this knotty lump, that's distorted the curvature of the vertebral column. I get about my task carefully sealing the segmental veins and arteries, the source of blood supply to the vertebrae.
As students of surgery, we are trained to identify tissue planes, and dissect in these potential spaces between tissues to reach the target. Tissue planes are potential spaces that need to be skillfully opened to minimise blood loss, and ensure protection of the various organs that we encounter enroute.
Infections like Tuberculosis result in gumming of the tissues and their junctions ( planes). This makes it truly difficult to identify any landmarks. Its like finding one's way in a town destroyed by a tsunami. I have to keep a close track of where I might encounter the spinal cord, as I separate the necrotic tissues with sharp and blunt dissection.
These moments are tense. I have to keep battling and titrating three images in my mind. The normal anatomy, what I expect to find on interpreting the MR scans, and what I actually find. Dealing with a distorted anatomy ravaged by a virulent infective pathology can throw up surprises. Experience is minimising the chasm between what I have envisage on seeing the MR scan images and what I actually encounter. I have to undertake a retrograde time travel, to fathom how this pathology unfolded to effect this lump of distortion, this incomprehensible mass, which has to be untangled with precision. As I'm gently tugging at a whitish looking strip of tissue, I shudder. I hope I'm not anywhere near the cord. I release the tissue and take a deep breath. I readjust the microscope to get another perspective of the same contentious looking tissue. When I look at the same tissue from another angle, it provides greater details, to my discriminatory powers.
I realise again, the importance of readjusting the focus of our viewpoint when dealing with any problem, to help get another perspective of looking at the same problem. Neurosurgery teaches and reveals some very profound philosophies of life too. It reveals, the large, yawning gap, between my understanding of the problem and the actual nature of the problem. I have to keep alert, be my own devil's advocate, and take the necessary measures to correct the course of my approach.
As I take the micro-drill in my hand to burr away the residual bone, I say a silent prayer, to keep my hand and my focus steady. I can't afford to be myopic, and whilst one eye is on the target tissue, the other eye is occupied in passive surveillance of the surrounding structures. One small slip and I could well cause irreparable damage to the cord. It's a risk I have to undertake, if I want to get rid of the hard, unyielding bone fragments. Some problems in life, require very tough remedies. They need tough measures, like high torque drills, but have to be used with caution, and nerves of steel.
I'm well on my way, and there is a sudden gush of cherry red blood. I have to place a piece of cotton patty to suck away the blood. I can't do it directly for fear of injuring the sensitive and delicate cord which is in the vicinity. Some problems need to be addressed indirectly, covering them with a cottonoid of patience. Direct confrontations don't work in all situations.
I manage to locate the spurting blood vessel and seal it with my forceps.
After about an hour of gentle dissection, i can start delineating the outline of the underlying cord. Seeing it decompressed fills me with a sense of relief. I then get the appropriate sized implant. I have to do a lot of gardening of the bed, to ensure a snug fit of the titanium cage. I manage to get the implant in the desired position, that's verified by x rays.
As another case is over, it also ensures a quick revision of strategies that I need to employ to deal with the pathologies of Life too. Pathology is a distorting force, an intrinsic nature of creation where entropy always increases. Pathology contorts and breeds disorder, chaos. By deploying our power of discretion, and the vast array of tools at our disposal, we certainly have the wherwithal to usher in order and normalcy. Surgery, is largely an attempt at decreasing the entropy perpetrated by this demon called pathology.
The lady is doing well by Gods grace and her post op X rays fill my heart with satisfaction and joy
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