We're Number One

Did you know that the White Sox have the best record in all of baseball?!? I knew they were in first place in their division, but I didn't realize the extent to which they were winning. Of course, the naysayers out there will say this is the way the Sox usually perform - they're stellar when it don't matter and will just do something tragic like lose 24 games in a row to ensure they miss the playoffs. This would hurt if it weren't true, so it is particularly traumatic since it has some basis in fact. One can only hope the Sox keep up the level of play and that the management doesn't do something outrageous like trade all our pitchers for Barry Bonds.

If you want to keep up on the ChiSox, you can check out their blog which is at:
http://whitesoxpride.mlblogs.com/

Today was a light day for neurosurgery. Saw two cases, one a laminectomy (remove part of the vertebra) and one a foraminotomy (make a hole in the vertebra). The lami was at L4 in a guy with a major disc herniation, looked like a tennis ball was compressing his nerve root while the foraminotomy was at C2 to decompress tension on the nerve root in a lady who was in a motor vehicle accident. Both cases went well and I got to leave relatively early...

Jargonator

My vast readership (which at this point can be counted on one hand) informs me that there is too much medical jargon in my posts, but I'm afraid the jargon will just have to keep piling up because part of this blog is really a selfish exercise designed to help me remember the cases I've seen on rotations. When you're working >10hrs/day, things tend to blur and writing it down is one way for me to remember...anyway, I'll be sure to sneak in some bad movie reviews and inane comments about the ennui of the daily grind, but give up the jargon? Did Pepé Le Pew ever give up on love?

So last Friday we did a spinal angiogram with embolization of a tumor metastasis from a renal cell carcinoma (RCC). The RCC had been treated with a nephrectomy (kidney removal) but the location of the new tumor (near L2) is suspicious for metastasis from the primary RCC. This is the first metastasis in this patient, hopefully her last.

I got Saturday off and Saturday night met up with Vince and Andy, two of my crew from back when I roamed the mean streets of the south side of Chicago (okay, so it was Hyde Park...) We saw a movie, which was an exercise in metrosexuality ("Bewitched") upon which I won't comment other than to say there was one really funny sequence with Will Ferrel. I still feel like I violated some rule of the XY club and plan on making up for it by seeing the next meaningless action thriller that comes out...we had dinner afterwards at Mongolian Barbecue and caught up on things past and plans for the future...

Sunday morning I rounded on patients in the hospital for a few hours and then got the rest of the day to spend with family.

Monday we took out the tumor we embolized from the lady on Friday and the procedure went well and the patient is recovering well, thank God, though she is definitely dealing with postop pain. That case took about 5 hours to do and I spent the rest of the afternoon on the floor, rounding on patients.

Today we did a L3-L5 fusion on an elderly lady with degenerative scoliosis, dural adhesions and lumbar stenosis. Preoperatively she was in a great deal of pain, but the procedure went well and God willing she will improve, as we really freed up a lot of space for her. Also saw a cervical foraminotomy today for a lady who had a history of motor vehicle accident (a drunk driver hit her head on). Quick case and a relatively light day today...

I keep on fallin' in & out...

I am always tempted by the surgical specialties. Neurosurgery just has so many cool procedures, it would be awesome to do it. It's just the training is so rigorous...typically, these guys are working at least 14 hours, if you add 1 hour for commuting that leaves you with 9 hours to fit the rest of your life in. And I haven't even included call (or sleep) into that schedule...

Didn't get a chance to wrap up yesterday's events, lot of stuff went on. The patient that came in for the vertebroplasty, secondary to a compression fracture at L3, also had moyamoya syndrome, which is a situation when you have progressive bilateral stenosis/occlusion of the carotid system, usually quite proximal at the ICAs but it can be further up. In response to the decreased flow, you get tufts of arterial collateralization (usually lenticulostriate vessels off MCA) that look like puffs of smoke (moyamoya is Japanese term for that) on angio.

Here is an example, from Yoon et al that was published in AJR 2000; 174 (195-200) on what moyamoya vessels look like (arrows are pointing to them). Etiology of moyamoya disease is unclear, but it seems to have higher incidence in Asians and is often associated with other conditions. I don't think there is concensus on treatment, but EDAS (encephaloduroarteriosynangiosis) is one option, where you basically take the superficial temporal artery and lay it on the brain tissue to induce collateral formation to feed the brain. EDAM is similar except you lay part of the temporalis muscle on the brain to do the same thing.

We had another patient yesterday who came in for a followup cerebral angio that had EDAS, EDAM and burr holes secondary to severe moyamoya disease. It's amazing to think she is talking and raising children when the major supply to her brain are just collateral vessels...

On top of all that we had a bunch of traumas come in yesterday. One of them was a UIC religion professor who had blunt trauma to the head and was brought to Loyola where he was pronounced dead leaving behind a wife and 1.5 year-old daughter. Tragic story that made the local news: http://www.chicagotribune.com/news/local/chi-050623professor,1,1122218.story?coll=chi-news-hed

Today we removed a tumor, most likely a hemangioblastoma, in the posterior fossa roughly between the SCA and PCA on the right. I got to watch the neurointerventional radiologist embolize the tumor's blood supply yesterday, so it was neat to see it get taken out today by the neurosurgeon. The patient looked good after the surgery, we'll see how he is in the morning...

Who's lovin' it?

On the way home today, I saw a billboard for McDonald's, showing a big picture of an Egg McMuffin and a caption reading something like, "Don't you wish you looked this good in the morning?"

I found this to be a rather strange ad, I mean how many of us really compare how we look to food? I'm not in the habit, for instance, of saying, "Dude, my hair is so mostaccioli today" or "She looks so tiramisu". I mean, even if I did compare how I, or anyone else looks, to food, I doubt the Egg McMuffin would be the benchmark by which I would establish my metaphorical scale. I mean really, I would rather look like chicken tikka in the morning, I think that has a much more pleasant hue to it than the Egg McMuffin. Come to think of it, there really isn't anything that I wish would look more like an Egg McMuffin. Nothing at all...I'm guessing the intern at the advertising company came up with this one...what future jingles will we have to look forward to on I55?

As far as rotation news, observed a vertebroplasty, cerebral angio and embolization of a cerebellar hemangioblastoma. The cerebral angio was a cool case, a patient who previously had an EDAS done. Will write more later, gotta get up early...

Of medicine and machines

Some important legislation has been introduced that will make it easier for medical students to repay their educational loans. You can support this effort by going to:
http://capwiz.com/aoa-aoia/mail/oneclick_compose/?alertid=7742211
Although the form letter is written for osteopathic medical residents, you can easily modify it to your own situation. The website will then send an email on your behalf.

Today, I saw an interesting case - coiling of a left MCA aneurysm. First we shot an angio of the anterior circulation by selective catheterization of the involved MCA side branch. We then performed intracarotid sodium amobarbital test, or Wada test, in order to lateralize speech and assess memory function. We also had a neurologist come in and administer an exam to test the patient's language skills. After all that, a balloon was inflated to temporarily occlude the artery and determine the area supplied by it (the "wedge"). It looked like there were sufficient collaterals supplying the wedge from the anterior circulation, but it was decided to see whether or not the wedge was also supplied by the posterior circulation (i.e. branches of the PCA). The angio confirmed this and the decision was made to treat the aneurysm by coiling it. Before doing that, however, we also delivered a dose of radiotracer for the SPECT scan which we would obtain two hours later, after the procedure. Anyway, the branch of the MCA was again accessed, and first a "mesh" was delivered into the aneurysm followed by the coils. I think we used 5 sets of the coils in order to fill it properly. Afterwards, we shot another angio which showed obliteration of the aneurysm (good thing) and good filling of the wedge from surrounding collaterals (a very good thing). Clinically, the patient did real well w/no neurological deficits after the procedure. We are still waiting for the nuc study to get read but, thank God, it looks like it all went really well for the patient. Cool procedure, done by the neuroradiologist...

In totally unrelated news, Lexus has put up a preview site for the 2006 IS which looks tight, may replace the Acura TL as my current favorite. You can check it out here:
http://lexus.com/2006is_preview/?s_ocid=20117
I don't know what the Germans are doing to their cars, but I really think Audi and VW are going in the wrong direction and I can't say I like any of the new BMW designs except for the 3 series. Mercedes has some saving grace with the redesign of its SUV (2005 M-class) and the 4-door CLS500 coupe, but all that is almost cancelled out by its plan to introduce the R-class, a strange looking cross between a mini-van and station wagon...

NSx updates

Week 2 of neurosx of Loyola and am continuing to see some great cases. Saw a repair of a Chiari malformation (suboccipital craniotomy with duraplasty). All I can say is it is so cool to see the arachnoid after dissection of the dura - the CSF pushes it up, so it is like glistening saran wrap...and I'm still not quite used to the practice of using drills, which seem to be the tool of choice whenever a neurosurgeon needs to go through bone. I also saw an embolization of a dural fistula (between a small branch of the left PCA and a vein that dumped into the transverse sinus), which was embolized with that space-age substance called...you guessed it...glue. Yep, no matter how advanced medicine gets, there's still nothing like a little crazy glue in the brain...

I've been impressed with the neurosx attendings at Loyola, they are quite nice and answer questions readily. The residents, while busy, are about as laid back as you can be when 12-hour shifts are considered "short" days...they are also willing to teach and are remarkable, well-adjusted people. I've also been impressed with the scope of neurosx, never considered, for example, that they do PNS procedures (like decompression of left common peroneal nerve which I saw last Friday). Whether it's the head, spine or down in your legs, there's nowhere these physicians can't go...

Also nice to see some fellow Midwestern medical students out at Loyola - I've spotted at least two colleagues (both doing anesthesia). I don't get out on the floor much, so if they aren't in the OR or Specials, I won't see them (morning rounds start at 5:30 AM and finish around 7:15 AM, when others are just getting started). There are a decent number of residents who also have "D.O." emblazoned on their lab jackets, which is nice to see...

One thing that is weird - Loyola medical students get white coats that are as long as attending coats...what's up with that? They do have really nice facilities for their medical school, which is right next door to the main hospital.

And so it begins

Christopher Nolan may not be a household name yet, but if his latest movie "Batman: Begins" is any indication, he is well on his way. The 35-year-old Nolan first received widespread attention with his film "Memento" which earned him rave reviews from critics, two Academy Award nominations and around $24 million from the box office. He followed that effort with the Al Pacino thriller "Insomnia" which made $26 million in its opening weekend but didn't quite have the same critical impact as "Memento".

I never sat through all of "Memento" but I had seen "Insomnia" and thought it was good enough. Certainly not memorable enough that I could tell you much about the plot other than a couple of scenes where Al Pacino took an inordinately long amount of time to close some blinds in his Alaskan hotel room. And so it was that June 18th found me standing in line for the 3pm IMAX showing of "Batman: Begins" with some apprehension. After all, Batman is one of my favorite comic book characters and I still have not been able to sit through "Batman and Robin" the last film starring the caped crusader, a disastrous work by Joel Schumacher who seemed bent on running the series firmly into the ground.

Thankfully, there were other avenues through which one could get a Batman fix, the original animated series, which explored the complexities of Batman's character with the noir atmosphere that Bob Kane probably intended. That may sound like high praise for a cartoon, but it is not undeserved. Apparently, Mr. Nolan watched at least a few of those episodes, because "Batman: Begins" is a fantastic hit, better than any Batman movie before it. While the original "Batman" by Tim Burton is a great film, it does not capture the transformation of Bruce Wayne into Batman in the way Nolan's film does and Burton's film had a less imaginative script and plot. While both Burton and Nolan created a dark atmosphere for Gotham, there is something more compelling in Nolan's version of it, perhaps driven by his extensive use of the Chicago cityscape in creating Gotham. Of course, that may come from having a $150 million budget, but the money was well spent.

Christian Bale's portrayal of Bruce Wayne/Batman is also convincing, and his physical presence is also more compelling than Michael Keaton's ever was. And who can argue with the choice of Michael Caine as Alfred or Morgan Freeman as Lucius Fox? Liam Neeson was excellent as Ducard and even Gary Oldman surprised me as Gordon (I almost didn't recognize Oldman). The only disappointing choice in casting was Katie Holmes whose crooked smile is almost as annoying as her total lack of talent...oh well, at least she has Tom...

The dynamic between the Bruce Wayne and Ducard characters gives a lot of energy to the plot and the special effects were great (I even grew to like the Batmobile, which is a little too SUV in its styling for my taste).

An interesting question the movie seems to raise for me is the question of vigilantism. Batman works outside the law to bring justice while the archvillain in the movie works outside the law to bring about his own evil and disturbing conception of justice. Which seems to me to be the big problem with vigilantism in the first place, it opens the door for anyone to mete out their own version of "justice". As Rachel Dawes (Katie Holmes' character) suggests, it's wrong to work outside the law in the first place though by the end of the movie, she seems resigned to accepting Batman's role as a necessary contingency for the city of Gotham, though, motivated in part for personal reasons, she waits for the day that the city won't need him.

Of course, that day won't be anytime soon in coming, otherwise we wouldn't have any sequels to look forward to. Whatever one's issue with vigilantism, it's hard to not enjoy Batman's style of it, as he does what only he can do to save Gotham. And given the opening week success of Batman (over $70 milllion in five days) we can expect to see Mr. Nolan bringing us more of the Dark Knight's quests in the years to come...

NSx at Loyola

Started neurosurgery at Loyola this week and it's off to a great start. I've always wanted to see neurosurgery and it's amazing to see what these physicians get to do on a regular basis. So far, I've seen skull biopsies for possible mets from prostate CA, ommaya-reservoir placed for CNS prophylaxis of ALL and clipping of SCA aneurysm. Today, spent the whole day on removal of an acoustic schwannoma, which looked like the size of a grapefruit, and did not come out easy...

Welcome!

Well, I've crashed the blogging party. Let's see how it goes...