Another Day in the Frontal Lobe (23 page)

I probably annoyed a lawyer who met me in my office regarding one of her clients. She tried to pin me down: “So, did the car accident cause his back problems or not?” I couldn’t say for sure, and had to keep it at that. His back was riddled with arthritis, and that doesn’t develop overnight or from a car accident. And, once you have bad arthritis, almost anything can set it off.

The crazy part about this whole cause-and-effect dilemma is that a surgeon’s reimbursement for an operation is dramatically higher if the herniation is deemed to be “work related” or “accident related” because a different type of insurance kicks in, as opposed to a patient’s regular health insurance. So, for example, if the event occurs at home, the surgeon may be paid less than $2,000 total for the operation and the subsequent three months’ worth of postoperative care, phone calls, prescription refills, employer paperwork, and so on. If the event occurs a couple hours later, while the patient is at work, and can be deemed work related, then the surgeon may get closer to $8,000 for the exact same operation and postoperative follow-up.

There are other curious phenomena as well. Various studies have suggested that a patient’s actual clinical recovery can be partly tied to whether or not they are receiving disability payments, with payments being associated with slower and less complete recovery. Surgeons talk about this phenomenon among themselves and take it to be self-evident. On the other hand, patients who work for themselves, have a job they love, or have no access to disability payments tend to recover more quickly and more fully.

In working with the spine, I have had an interesting window into a certain facet of human variability. I have met people along the way who, for whatever reason, seem particularly prone to trauma. Clumsiness is a highly variable trait. I once saw a young woman with a ruptured disc in her neck and took a detailed history. I asked her about her pain history, lifestyle, recent falls or accidents. “Well, I’ve fallen down the basement stairs a few times.” A few times? Her husband said she’s always been accident-prone. It’s strange: some people who are otherwise perfectly healthy are just more prone than others to slip and fall, twist their ankle, hit their head on something, or get rear-ended. It may be that they are less sure-footed, maybe a little less aware of their surroundings, or simply slow to react. Regardless, I’m sure that a clumsiness rating scale will be invented at some point, and I’m sure that health insurers will have a field day with it.

In my practice I’m strongly in favor of giving patients as much information as possible. I like to direct them to the better Web sites, go over their scan results in detail, clue them in to the current internal controversies of the field, and encourage second opinions if they have the inclination. What I’m a little wary of, though, is sending someone a formal report of their MRI scan before I have a chance to go over everything with them. The words in the report can set off such a flurry of anxiety that the subsequent visit requires twice as long: half the time to explain the results and the other half to manage the anxiety that has built around phrases like “facet hypertrophy,” “thickened ligamentum flavum,” and “incidental note made of a hemangioma of L2.”

Radiologists, in order to cover their own butts in this age of exuberant litigation, need to point out each and every tiny finding, regardless of significance, and may even dictate something like “cannot rule out infection” when infection is really the most remote possibility and they know it. They have to. And, because a spine naturally ages over time, practically any MRI report on a patient over age forty or so will be at least slightly “abnormal” in some way. But, in many cases, certain findings should be no more anxiety provoking than what might be dictated if a physician were to do a detailed report on a patient’s outward appearance: “touch of gray around temples, bilateral crow’s-feet, and incidental note of dry skin on left cheek.” It’s just that the words are less familiar in an MRI report.

You can often tell when a patient has read his own report ahead of time, before the office visit. He may tell you: “My L5 hurts,” in direct reference to the level of his back mentioned in the report as having some sort of finding. In general, it’s best not to do that. Better to just say that you have low back pain and to let the physician try to sort it out. Just because there is a minor abnormality on the scan does not mean that it is definitely the source of the pain. On the flip side, some people with terrible back pain have a completely normal MRI.

As another insider’s piece of advice, it’s best to describe your pain, or any other symptom, as plainly as possible, like “stabbing pain down the back of my right leg,” rather than dramatizing it as “a thousand—maybe ten thousand—little fire ants crawling over my skin, and stabbing me with those little tiny pincers, you know those little pincer things they have.” Doctors can be wary of what they feel may be overdramatization (fair or not) and may even use the dreaded phrase “out of proportion”—as in “pain out of proportion to the relatively minor findings on the MRI.” It’s not that they won’t believe you, it’s just that they might be encouraged to end the visit as quickly as possible.

Similarly, if you have a history of a disc herniation (or disc bulge, disc protrusion) in your back, you don’t get extra sympathy, from a surgeon at least, if you refer to it as a “disc
explosion,
” with wide eyes and dramatic arching arm motions to accompany the term.

I do have tremendous sympathy, though, for any patient trying to make their way through the dizzying array of options when it comes to treating a spine problem. The fact that there are so many options—with new ones always coming on the market and old ones falling out of favor—means that there is really no single best option. You just have to pick one, try it, and move on to the next one if it doesn’t do the trick. Sometimes time is all that is needed, as the body often heals itself, but whatever intervention a patient happened to have tried last will be credited as the miracle cure, with “tincture of time” getting none of the credit.

And another thing: as surgeons, we don’t get any specific training in the fine distinctions between different mattresses, office chairs, or shoes. This falls out of the realm of science and medicine and you’d probably do just as well to ask the same question of your mother or cousin if they’ve experimented with any of the above for their own back. If you want a more professional opinion, though, a chiropractor, physical therapist, or even the salesperson at the local “back store” would probably be able to engage in a more informative and enthusiastic discussion. I once had a patient who asked if I wouldn’t mind accompanying her out to her car to see if the driver’s seat might be contributing to her back problem, and should she get a new car?

New surgical spine procedures are being developed more rapidly than ever before, and each area of the country is covered by a roving team of industry representatives who know all the facts about their particular instrumentation, their brand of screws and rods, and whatever revolutionary device their company has just rolled out. And they’re more than happy to take a surgeon out to dinner. The rapid pace of new developments is amazing to see and, in general, I’m very enthusiastic about innovation and the American way, as long as new devices are approached with at least some skepticism at first. (But not too much skepticism. That can be just as bad as none at all.)

What impresses me is the number of patients willing to be guinea pigs: to consider becoming early recipients of a new technology—not just buying the latest version of an iPod, but going through the latest operation or having the latest implant placed in their spine. A current trend, for example, is the idea of disc replacement. There are many ways to handle a worn-out disc: live with it; take pain medication as needed; manage it with continued conservative care like physical therapy, chiropractic manipulation, acupuncture, et cetera; have surgery to remove the disc and fuse the disc space; or try the new disc replacement procedure (which requires surgery through, or just to the side of, the abdomen).

The replacement option makes a heck of a lot of intuitive sense. After all, a disc is a type of joint. When a hip goes bad we don’t fuse it, we replace it! This logic, so clear and simple, is certainly alluring to patients. Furthermore, there are data from the enlightened continent of Europe and the procedure is now approved in the United States. So why not? Well, what about the slowly developing information that perhaps 10 percent of disc replacement patients may require repeat surgery at some point, and that repeat surgery can be risky because of scarring around major blood vessels? And how do these mechanical discs look in ten, twenty years?

The bottom line, from my point of view, is that disc replacement technology is probably here to stay, but it may be overused in the heady early years until we figure out which patients are really the most appropriate candidates. So, the earliest patients are performing a valuable service, not only potentially for themselves, but equally for future patients who may either accept or shy away from this option based on their longer-term data. For the time being, I remain an intrigued observer.

An aging mind is even more mysterious than an aging back. Dementia, especially, can be a tough problem to tease apart, especially when the patient himself denies the problem and is dragged in by a spouse. When memory starts to fail, most people will jump to one of two conclusions: old age or Alzheimer’s disease. In general, it’s best not to assume either one at first. If you assume old age, you may decide not to seek help. If you assume Alzheimer’s disease, you may be overwhelmed by a sense of futility. A good dementia workup by a neurologist is the way to go, before jumping to any conclusions.

Most forms of dementia, unfortunately, are irreversible. True, there are a couple drugs on the market that can slow down the process, but none can really halt or reverse the deterioration and they never seem to work the miracles that we all hope they will. The problem is too complex to be treated by a single drug. The diagnosis and treatment of dementia is still in its infancy, but I do remain optimistic about the future.

Neurosurgeons are not typically involved in the diagnosis and treatment of dementia, except in the less common
reversible
forms in which surgery is an option. We’re not on the front lines of the dementia war, and I don’t claim to be the world’s expert. What I can say, though, is that helping one of the lucky patients with a reversible form of dementia can be quite satisfying.

Very rarely, a tumor such as a large one pressing on both frontal lobes may be responsible for the cognitive changes. Surgery to remove the tumor can improve the deficits. More commonly, an elderly patient will be diagnosed with an even more mysterious entity: normal pressure hydrocephalus, or NPH. Some small percentage of patients (there are no exact numbers) who are thought to have Alzheimer’s disease actually have NPH, and it takes a savvy internist, neurologist, or television-watching family member to consider the diagnosis in the first place.

I’m serious about the television-watching family member. A layperson, for example, will often ask for certain drugs by trade name or description (like the “purple pill”) because of television and magazine ads. Doctors are used to that. What’s new is that a patient or family member may ask about a particular device, one used to treat NPH, because of a television ad. I have seen elderly patients coming out of the woodwork recently—usually accompanied by an Internet-savvy daughter or son—with the potential diagnosis of NPH. They see the ad on television, look up the disorder on the Internet, discover that a programmable shunt is the answer, type in their zip code on the device company’s Web site, and find out that I’m in their area.

Normal pressure hydrocephalus is an unusual condition. It occurs almost exclusively in the elderly brain. At its core, there is an underlying problem with absorption of cerebrospinal fluid, which not only surrounds the brain, but fills the ventricles, the fluid spaces deep within the brain. There are four ventricles: the two lateral ventricles, the third ventricle, and the fourth ventricle. Normally, cerebrospinal fluid is produced and absorbed at a rate of about 450 cc per day (almost half a liter). At any given time, about 150 cc of cerebrospinal fluid surrounds the nervous system—the typical soda can holds 355 cc—which means that the entire volume is produced and absorbed three times over a twenty-four-hour period. If not absorbed properly, it tends to build up, causing enlargement of the ventricles.

Although the ventricles of an elderly person are naturally larger than a younger person’s, due to atrophy, in NPH we say that the ventricular enlargement is “out of proportion to the atrophy.” The ventricles are larger than expected for the patient’s age. The “normal” in the name of the disease sets it apart from the better-known hydrocephalus of childhood, which causes elevated pressure. So, unlike the typical hydrocephalus, it does not cause headaches and has no potential to be acutely life threatening. Nobody knows why it happens or even exactly why it causes that particular triad of symptoms. It still falls into the “bad luck” category of disease etiology.