Brain Verse

There are a few things I never thought I would see in this lifetime. 

For example, I don't expect to see conjoined twins, a 9-foot tall person, or a human being live to be 130 years old. But, up until very recently, there were two other things I never thought I would see: The first was a heart beating calmly and strongly inside a man's chest. But that is old news now, as that happened during my first clerkship in general surgery. Second, I never thought I would see a brain. I  mean, a clear and clean brain, still inside of someone's head, and prepped for examination. 

But, just this past week, I saw not one, not two, but three patients prepped in such a manner. With nearly ten professionals--nurses, doctors, PAs, anesthesiologists--standing around the room in great expectation. Three brains! Two of them undergoing a treatment for Parkinson's Disease called DBS, or Deep Brain Stimulation. 

I first heard of DBS through Michael J. Fox. Many of us know him as the famous actor who developed early Parkinson's Disease (PD) and subsequently began a foundation dedicated to treatment, education, advice and research for further treatments for PD. 

I'm going to go on a bit of a tangent about DBS because there is yet a third thing I never thought I'd see in this lifetime. In fact, it's not even something I ever "heard" of. And that is something I'm going to call brain verse. 

To begin with, DBS works for those with PD and dystonia--dystonia depicts movement disorders, in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures. DBS has also recently been used for obsessive compulsive disorder and it is currently being researched for use in those with Tourettes Syndrome, depression and even obesity. For Parkinson's, DBS works by inserting a micro-electrode, as thin as a hair, into a part of the brain called the subthalamic nucleus (STN). When this electrode is stimulated, it essentially confuses all the neurons in the STN and for those with Parkinson's, that means the relief of the majority of their symptoms, which may include dystonia, tremor, bradykinesia (slow movement), inability to talk, shuffling gait and cognitive decline, and possible psychosis due to the medications used to treat PD. 

Before surgery is done the brain is mapped--using MRI and CT scans of the head--to pinpoint exact measurements in the brain so that the electrode can be inserted, a half a millimeter at a time, until it reaches its target--in the STN. As the microelectrode is inserted, slowly, by a neurologist, this electrode records brain cell activity. What I learned from my first DBS procedure, is that different parts of the brain actually sound, well, different. Different parts have different neuronal activity and the neurons fire quicker or slower, depending on where they are in the brain. A set of speakers in the surgical suite pick up this activity, and, through them, we can hear the brain verse. The neurons of the thalamus, for example, kind of sound like an idling tractor. The entire surgical team listens to the speakers waiting for the distinctive sound of the target area, the STN. The STN, I heard, is much quieter in amplitude, but the neurons here are almost continually firing. The STN sounds like a purring kitten, with hiccups. 

Whats even stranger, is that the patient is awake--and hopefully calm and cooperative--through this mapping. And their head is placed in an archaic looking cage so that they aren't able to move, which is, of course, a good thing. 

A patient undergoing DBS placement. 

Once the electrode is in place, the neurologist turns it on, and tests it on the patient in the operating room. We all watch to see if the tremor goes away, which is why the patient must be awake. 

The first time I met a patient with PD she had a tremor so bad I could not shake her hand and she was unable to walk into the exam room. During her surgery, when the electrode was placed and stimulated, I watched her ten-year old tremor disappear. Just like that. It was as if a light switch had been thrown. I stuck my head under the surgical drape settling down over her forehead, grabbed her hand in a firm handshake, and smiled. I couldn't help it. 

I can't wait to see her walk into the office next week. 

My neurosurgical rotation is, surprisingly, already halfway done. In the past two weeks I have seen things I never thought possible. I've been present for difficult conversations about new onset Alzheimers disease, scrubbed in on multiple surgeries, helped heal chronic back pain, held many hands, shook my head a few times right along with the patients, tried to convince several neurosurgeons to hire me, worked with a world-renowned neurologist, meditated with a patient, and pretty much ran the gamut of human emotion. Needless to say, neurosurgery is captivating on all levels and I can't wait to see what the next two weeks will bring.  

Oh, and next time I need to tell you about the man with the fused backbone...