THALAMOTOMY

I have just had one of the strangest experiences of my life.  I am writing this from the ICU in the neurosurgery wing of OHSU.  Eight hours ago I was in the OR with a very thin five-inch metal probe inserted in my brain.  I was fully conscious. 

Over the past few years I have had a tremor in my right hand and arm that was gradually getting worse.   There is a treatment that can fix this: thalamotomy.  In this procedure a tiny portion of the thalamus is damaged.   When this is done correctly the tremor abruptly stops.  And doesn't come back.

Before I went to the OR there were two preliminary steps.  First, a rigid non-magnetic frame was attached firmly to my skull.  This was done with four sharp pins that were screwed down until they pierced the scalp and  imbedded themselves in the skull.  I had a local anesthetic at these attachment points.  This frame was marked with reference  coordinates that allow the surgeon to position the probe at a specific point in the brain.  Once the frame is in place the brain/frame assemblage is imaged  with MRI to complete the picture of the brain relative to the frame coordinates.  The MRI bed has a mating outer support structure rigidly fixed to it that holds your head in place.  Everything bolts solidly together, producing loud, resonating clanks and bangs which you hear directly through your skull.   

Then on to the OR. My surgeon, Kim Burchiel,  typically does two of these procedures each week. There were seven people in the room.  It was apparent  that my operation was also a teaching  session for one of the other physicians.  There was a great deal of technical chatter.  "You see here, this is set at 91.6, and 90.3 on the other side." And, "Now put that down and hold this with your left hand."

And so on.

"You have a  doctor in training here,"  I said to Burchiel.  "Yes," he replied, "but my hand is on the steering wheel at every moment."  Which is what I needed to hear.

There was a fifteen minute delay -- someone dropped a key piece of gear which had to be resterilized before the action could resume.  I knew things were getting serious when Burchiel said, "We want to go in right here," touching the front of my head above my hairline, " give me some local here."

The sting of the injection.  "Sometimes the painkiller hurts worse than the pain," I said.  Then I felt the unmistakable feeling of a drill boring into my skull.  "Is that a hand-crank drill?"  I asked.  "Yeah," Burchiel responded, "with the hand drill I can feel what the bit is doing -- feel when I break through." 

"How thick is the skull?"

"Well, a woman's skull is thicker."  A couple of the nurses tittered.

"Hey, come on," I said, "you can't let him get away with this sexist comment."

"No, that's literally true," Burchiel insisted. "This is well documented."  He cited the relevant studies.  

The drilling continued. Then it stopped.  More training comments:  "Get this lined up. Now tighten it down. No, that's loosening it -- the other way -- righty-tighty."

"I can't believe I heard my brain surgeon say righty-tighty."  

Burchiel responded, "And I can't tell you how many times I've had to explain that in this room."

More chatter about positioning -- coordinates, numbers, etc.  I knew the preliminaries were about over.  Somewhere about now the probe was going to be inserted in my brain.  I didn't know what to expect.  

It happened and I felt nothing.  

"'Hold this paper cup in your hand," Burchiel said.  "Now bring it to your mouth as though taking a drink."  I did as he asked.  Tremor was strong as ever.  "OK, put the cup down."  

"Hold the hand up again. Now tell me when you feel anything in that hand -- anything at all."  I focused on that hand.

At one point, late in the procedure, I began to think it wasn't going to work. He had tried (it seemed to 

me) repeatedly. "Tell me when you feel something in that hand.  Anything. Some people say it's a tingle."  Nothing.  I was getting  exhausted.  Finally I said, "At what point do you give up and declare defeat?"  "What? he responded,  "that's not an option!" 

Concentrating, I thought I felt a faint warmth. "OK, hold this cup again.  Move it to your mouth." Tremor still there.  "OK, we're not there. How about now -- feel anything?" This time I felt a warm glow suffuse

my  entire hand.  "OK -- we're close.  Give me your hand."  He placed my hand flat on my chest and pressed the other surgeon's hand on top it.  "You should feel a slow bup-bup-bup.  Feel that?"  I felt it.  The other surgeon said, "I can feel that."  "OK, hold the cup again.  Drink from it."  I made the gesture smoothly.

"Well, the tremor is clearly better," I said.

"Better? It's gone." 

"I meant to say gone," I corrected myself hastily. That drew chuckles.  

"Don't be underselling us here," Burchiel said. And it   was true.  I looked at my hand, turned it this way and that.  No tremor at all!

I couldn't see him, but I imagined him stripping off his gloves.  "And that," he said with a tone of finality, "is how you do it."

He started instructing the others in final details.  Disconnect this, take that off, etc.  “Does this all come out in one piece?” someone asked. [Jesus!]

A  moment later I saw Kim’s back as he was leaving the  room,  I called out to him but he was out of earshot.  “I wanted to thank him,” I said.

[On Thursday, three days after the surgery, I wrote the   following.]

I have put in a regular day of activities, I'm feeling good, and there is no sign of that tremor.  At all.  

Some side effects.  Balance is slightly off -- I probably couldn't pass the "walk a straight line" test. I felt a little trippy Tuesday and Wednesday -- almost gone today.  My typing is sloppy -- mostly right-hand errors.  The doc says the hand will take some retraining.  A patch of my scalp about three inches in diameter below the incision is numb.  I haven't asked the doc about that -- my assumption is a nerve was severed that serves that region.   BUT all body functions are normal and I feel vastly relieved.  I think we pulled off a bold trick successfully!

Audacity.  That's the term that keeps coming to mind.  On the part of the doctor mainly. There are levels.  Just to be a doctor, that's bold to start with.  Then, to be a surgeon -- oh my! That is serious indeed! But, to be a  brain surgeon -- operating on the brain.  Now that is audacious!

Jerry Shifman

28  June 2014