#42. Do No Harm: A Neurosurgeon's views - Dr. Dilnavaz Bhiladvala

Dr. Dilnavaz Bhiladvala is a neurosurgeon with over 30 years of experience working in various hospitals across India and the UAE. She is the Head of Department of Neurosurgery at Al Dhaid Hospital, Sharjah, UAE before which she was the Head of Department and Professor Neurosurgery at Kamineni Institute of Medical Sciences, India. She takes us through how the field of neurosurgery has changed across her career. We discuss the steps involved in deciding whether surgery is required and when not to operate. Dr. Bhiladvala also shares information the public should know about neurosurgery and signs to look out for. We cover a few interesting cases across her career, her research and how technology has changed the field of neurosurgery for the better.

Chapters

• 0:00 Introductions
• 1:42 A Background into Neurosurgery
• 6:39 Neurosurgery Has Evolved since the 1980s
• 13:51 Informing Patients and When do you operate?
• 23:57 Signs people should be watchful of
• 26:15 Types of patients and recovery times
• 32:10 How do Brain Clots form?
• 39:57 Neurosurgery and Robotics
• 42:55 Research and interesting cases in Neurosurgery
• 51:12 Slipping into Comas
• 53:28 Brain Plasticity
• 56:50 Advice to the public from a Neurosurgeon
• 1:02:26 Approach to a surgery

Transcript

0:03

Okay, welcome everybody to the Smooth Brain Society. I am Sahir and today we have Dr. Dilnawaz Biladwala with us who has been a neurosurgeon for the past 30 years. She is the head of neurosurgery department at Al-Daid Hospital, Shahjah UAE, just retired. And before that, she was a professor of neurosurgery at Kamdini Hospitals and Kamdini. Kamanini Institute of Medical Sciences, Hyderabad. So she's on to talk about neurosurgery with us. And as you guys know, the premise of the podcast is we get someone on who has no real clue about the subject and we try to get our experts to kind of explain the subject to us and our guinea pig. For this episode, our guinea pig is Farheen Khan. I will let her introduce herself. Okay, hello everyone. I'm Farine as Sahil said. I've done my graduation in psychology, literature, and political science, after which I went on to take up the interiors degree from Montreal, Canada. And presently I'm into manufacturing of furniture and that's what my field is. I'm very happy to be here today. Thank you so much. Awesome. Just for people watching on the video, if you see us look left and right, it's because we're all recording in the same room. But yeah, on different screens. So it's first time this happening. We'll see what's on the same table. Yeah. Moving up in the world. Okay. So shall we start with a little bit of a background into neurosurgery itself? If you could tell us a little bit about the course of neurosurgery and your experiences in getting into the field. Okay. Yeah. See neurosurgery. is counted as one of the super specialties. It is a course that you do after having done your masters in general surgery most of the time, earlier and in some institutes, it is still possible to do your neurosurgery course directly after finishing your basic MBBS degree. But those are getting far and few between majority of the places required to have a degree in general surgery prior to appearing for a. entrance into the neurosurgery course. A neurosurgery degree is MCH. It is called Magistro Chirujuva. That's a Latin term which means master of the art. Now you have MCH in very many fields of superspecialization but all on the surgical side, not on the medical. Medical means on the physician side. So you have MCH in cardiothoracic surgery, MCH in plastic surgery. and you have MCH in neurology and so on. Corresponding degrees are DM in cardiology, a DM, that is similar, but there is no surgery involved, that is all medical or physician's management. So having said that, after you do your MBBS, then you do your general surgery for three years, and then you do a three-year course or sometimes a four-year course to do your MCH in neurosurgery. At the end of all that, we are officially proclaimed a neurosurgeon. So that is how the course runs. And of course, you have fields from the side, you can do your DNB in neurosurgery and still be recognized on par with NMCH. So those are different courses depending on the country, depending on the region from which you are coming. Now what is neurosurgery per se? Neurosurgery is the science to study. the ailments which are affecting the brain and the spinal cord. Whatever affects the brain and spinal cord, many diseases, mind-boggling number, all are not dealt with the neurosurgeon. The neurosurgeon deals with some cases, the neurophysician or the neurologist deals with some cases, and then you have some cases which the general public thinks is a neuro problem, as they put it. It could be psychiatric. It could be psychological. All right. So the neurosurgeon deals only with those problems or diseases affecting the spine, which can be treated surgically. So that is basically a neurosurgery's point. Now a child with Down syndrome, Down syndrome is something that everyone knows of. A neurosurgeon has no job to play. All right. A child with cerebral palsy. who is the way the unfortunate child is because of lack of oxygen supply to the brain at the time of birth. The neurosurgeon has no role in it. People come to you thinking that, oh, I'm going to a neurosurgeon and this is a problem which can be solved. No, there are limitations to neurosurgery. Not everything that concerns or every ailment that originates from the brain can be treated by the neurosurgeon. We have a neurophysician, we need psychiatrists, we need psychologists and plenty more people to do a job which is complete. Okay, so that is what neurosurgery deals with. Ailments of the brain are mainly tumors, some congenital problems in the brain which are causing pressure on the brain like cysts. And then there are some head injuries which form a major bread and butter, as you say, of the neurosurgeon's paraphernalia. Then in the spine, you have stenosis of the spine, you have spinal tumors in children. Then you have, in neurosurgery, there are subspecialties. Again, subspecialties. You can be a pediatric neurosurgeon, you can be a skull, sorry, skull-based neurosurgeon, you can be a vascular neurosurgeon. So these sort of divisions and subdivisions just keep going on. So it all depends on what is your environment, what is your input, your patient input and what sort of institute you are studying to support your special. Okay, so that is an outline of what neurosurgery deals with or what neurosurgeons need. Anything else? That's a very nice outline. I remember we spoke about this off camera before and you had said that when you were doing neurosurgery or when you were studying back in the 90s, it wasn't a very sought after field in terms of for students didn't really want to get into it. But now you see this change where neurosurgeon is really revered. Why was that so? Was there a change in techniques over time? Was there change in ability to do work over time? What's happened since you're beginning to now? See 25, 30 years ago when anyone used to say, I want to do neurosurgery, they were looked upon as being a little freaky that who want to do neurosurgery because neurosurgery was associated with working for long hours, sitting in dark corners. In fact, let me tell you a very interesting episode about one of my teachers. He's no more. He started the neurosurgery department in KEM Hospital, Bombay. which was, I mean, I think maybe 50 years ago. At that time, neurosurgery was such a new field that there was nothing like a department. And the surgeries which he had to do were done in the general surgery operation theater. After the general surgery, list of operations was finished. So on the table where they did piles and where they did hemorrhoids and surgeries which are infective, after that the neurosurgery was done because neurosurgery This is just to tell you how much it was pushed into a corner. Neurosurgery was not one of the in-thing. Neurosurgeon was not one of the in-thing to be profession. That was 30 years ago. Now, and that when I said that I want to be a neurosurgeon, first a lady and that to neurosurgery means people think they're completely zonked. Anyway, over a period of time, neurosurgery has evolved and I've been fortunate enough to watch it evolve. Earlier colleagues, friends, when they appeared for a post-graduation exam, you have a merit list. My first choice is cardiothoracic. My second choice is plastic surgery. My third choice is that. So when you ask a person, oh, you've got a seat in your super specialty. Yes. What did you get? Neurosurgery in a very low voice. because that was at the end of the list. And you feel you don't congratulate the person, you sympathize with him. That he didn't get a seat in any of the other specialities. So, you know, so there is always vacant. No one wants it. Now, I'm very happy to say that over a period of 25, 30 years, when we have this general entrance exam in India, where they prepare a merit list, the second and the third people who get a third and a fourth rank within the first five. take neurosurgery as their first choice. So this is a really heartening thing because now neurosurgery has found its place in the field of things. Now, why has that happened? And I'm sure that it's not only for neurosurgery. It must be similar in all other subspecialties also. But neurosurgery is the most new or the more, the youngest, the baby of all the subspecialties. Cardiosoracic has been there for time, a long time, and so on. One of the main things which has helped neurosurgeons to advance is technology. Earlier when we used to investigate a patient with a headache, it was a laborious process to find out whether he has a clot in the brain or not or whether he has a tumor in the brain. Took a lot of effort on the part of the radiologist, on the part of the neurosurgeon, and we put the poor patient who's already ill through a very tough time in order to get the information we required. Nowadays, this information comes out within seconds. Just put him onto the CT scan table and in less than a minute the scan is done and you have your result. So a large part of where neurosurgery is headed has been due to technological advances. The CT scan was one of the breakthroughs and then there have been many progressive breakthroughs of doing an MRI. and after that, PET scans. And then in the MRI field also, there are specialized, what would you say? MRIs give you different information of different aspects of the brain. So now it's become very advanced. Then you have a functional MRI, and you have MRIs which will see the tumor and tell you the content of the tumor in terms of its chemistry. So these things have advanced a lot. And the doctors have been have to keep up with that and find that since we are now having so much more information than what we had 25 years ago, let us see what more we can do from our side to end the picture. Can I ask you, how did you cope up with this transition over a few years time from how you used to handle these cases before till the time today? Now. See, when I joined neurosurgery, that was way back in 19... Say, I did my neurosurgery course in 1990, I started it. But before that also, I had worked in neurosurgery. CT scan had just about come in. So I didn't really do the nitty gritties of what even my seniors have done of angiograms and running to the dark room, developing a plate. And we used to deal with shadows and dots and dashes. It could be, it may be, this is what the x-ray thinks. And we used to come to a diagnosis based either on elimination or relative to that. Now there is no doubt about the diagnosis. It just hits you in the face with the modern technology that you have. So how did it, so when I, ever since I was a student, CT scans were there and they're just coming. And then... By the time I finished my three or four years of neurosurgery, MRIs had just come into the institute where I was working. Of course, it must have come earlier in the Western world. And then you learn on the job, because there is the radiologist who has done some training of how to read the scan. And it was a very interesting period, because the radiologist may not be very well versed. I am, as a neurosurgeon, I'm a little better versed because I know what to expect. The radiologist has his input. about MRIs and about the new newer modalities. And we have our clinical input. So earlier, I still remember that I used to be called to the radiology department to ask me what I think it is. And many times I have gone to them saying, what do you think? So it was a very nice atmosphere of both of us teaching each other and learning from each other. Okay. I have one more question. How. Were people more, how did you deal with the patients and educating them? Were they, I mean, as you mentioned, things started coming to you. The results were very clear, very authentic. And how was it mentioned to the patients? How was it translated to the patients? See, mainly when the patient comes to you, he doesn't know what it was like. They're very ignorant about that. Yeah, he or she only comes to you with a problem or nowadays with the diagnosis. Neurosurgeons hardly ever diagnose nowadays. Sadly so. Someone else diagnoses and say you need to see the neurosurgeon. Now patients even earlier and even now and this is mainly up to the individual surgeon. When you talk to the in today's day and world and even earlier at least I used to do it. You have to tell the patient what his condition is. You have to tell him what are the options available. I'm talking about myself, everyone may or may not agree to that. And I'm keeping things like litigation and documentation completely out of the picture. Those things have come in the last few years more. But I believe that you have to tell the patient in a way he understands. Don't say that, oh, he's from the village, you won't understand all this. That's your job. to tell him things in a way he understands. He should learn the gravity of the situation. Then you give him the options. If you don't get operated, this is what I see happening to you in the next five years. If you do get operated, this is what I see happening to you in the immediate post-operative. And in very few cases, in some cases, you can even say that he may be paralyzed. He may lose his speech depending on what you are operating on, which area of the brain. He may lose his speech. He may lose his memory. He will definitely have a personality change. He may become paralyzed on one side. He may slip into coma and God forbid, he may die. Okay. So depending on the gravity of what you are operating on, not all of them lead to death. But earlier, even the people who were not in the medical field. They are sending us to a neurosurgeon. You may not see the patient, but that today, fortunately, is not the case. Intensity is. Yes, and the risk associated with neurosurgery has drastically decreased, again, because of preoperative and intraoperative advances and postoperative care. And we have a lot of support from other specialties for postoperative. You have what is called an intensivist today in the... So many things, I mean, the neurosurgeon cannot say, oh, we have become great. It was always a teamwork. The neurosurgeon thinks that since I have operated, I am the king. That's a sad state of affairs for the guy who says that. It's a very keen. Yes, very much so. And another thing is, that's what I used to tell my students all the time. Everyone thinks that if I want to become a neurosurgeon when you're a student, I have to spend maximum time in the OT. I have to do lots of operations. I have to learn how to operate. I have to assist and operate with my boss or with my teacher. The outcome of a neurosurgical operation or the outcome of a patient from the time he steps into your office till the time he leaves the hospital is divided into three areas. There is a preoperative phase, which as a neurosurgeon, and I tell my students, you have to concentrate on. So, then there is the operative phase and there is the post-operative. So, if 100 is your number for everything that you do for the patient, 20 percent is pre-operative. If you have not done that 20 percent properly and 40 percent is post-operative and 40 or 50 percent in the center is your actual operative skill. Okay, 20, 50, 30, you can put it that way. So if you think that I'm a neurosurgeon, I'll just walk into the operation theater, operate, close the skin, and walk out, and my patient will do well, no. You have to concentrate on pre-op, and you have to concentrate on post-op to make your operation finally a success. That is what my message I've been giving to the students over the years. And that is very true, at least. That is what I have observed. Do you come across any challenges during the time from the beginning to now? No, there are many, a situation which could see I have worked in a variety of hospitals. I've worked in government hospitals where the facilities were very, very basic. I have worked in private hospitals where we have had quite a paraphernalia of things at your disposal. A patient who comes to you is challenging, that same patient in a very big setup in a private hospital where you have everything that you need is not as challenging as if he lands up to you in a government hospital in India where the facilities are extremely busy. So the bigger challenge for a neurosurgeon is to work in an institute which has very few facilities. make the patient go home. What is my favorite saying is, above all, do no harm. That is a very common saying all over in neurosurgery. Because 90% of the patients, immediately post-op, will be worse than what they were pre-all the time. But give them two, three months and they will improve to what much better than what they were before surgery. So this is the time the brain takes to readjust or to compensate. So, challenging cases are many. And like I said, in the government facility, it's more of a challenge. But then when you do something good, it's more heartening and more fulfilling also. Not that in private it is less. I am in no means trying to say that technology and facilities are making the surgeons kill less because you must know what technology and what facility to use when to the best in the patient's interest. In that case, what all goes into deciding when to go into surgery in terms of patients because you're doing it in the best of their interest. You know in lots of cases, 90% of the cases, they're going to be worse off for the first few months. So then what does things go in making that decision? So when I told you that we explain, put things on the table for the patient and you tell them... that when you go for the operation, this is the high risk involved. I told you all the complications that can happen. Whereas if you don't operate, what will happen? Gradually there will be deterioration and things will keep getting worse. Now, whenever any surgeon, not only a neurosurgeon and this is not something that I'm saying for myself, most surgeons agree with it. Whenever you go in for a surgery, you go in for what is called a risk benefit ratio. That is something that we learn to assess when we are students, more than the nitty-gritties of operation is there. So when to operate, what is the benefit of putting you through this risk? And what are the chances that we will emerge successful and send the patient home? So this risk-benefit ratio is something that you learn gradually with your experience and over the years. And it varies from patient to patient. patient. There is no generalized rule. And when you say brain tumors, location of brain tumors is extremely important with the outcome. So, depending on what, because your brain controls the movements, let us just take movements. I am not talking of speech, I am not talking of memory. So, if there is a tumor in that part of the brain which controls the movement of the limbs. and you remove the tumor, chances of him getting paralyzed are very high. Because if you have a tumor right in the frontal or the front part of the brain, the patient may have deficits but that will be behavioral which is not very obvious except for the immediate family. So what is an A person going to say? This person operated on a brain tumor and the patient became paralyzed on one side and look this other doctor operated on another brain tumor and the patient is fine. So there is just no comparison. And when do you, there are chances, times when you have to learn to wait and watch, especially say in head injuries. And over a period of time with some of the research and some of the teaching and what other people say, there are percentages, we deal in percentage. The percentage chance of this complication happening. is a very fixed percent which may vary. So it is what is the problem with the patient, what is the patient's background, according to that you decide whether there is going to be a risk or what are the complications you are expecting with this surgery versus just wait and watch it may resolve. You see not in tumors I'm talking of head injuries that way. Yeah. So I also would like to ask you, do you see any signs, probably even before a patient goes to the doctor and see, is it like all of the strokes or something like that? Is there any kind of signs that people are not ignorant about, that should be watchful of? Say headache for example is one. Everyone gets a headache. There is not a single person who has not had a headache. The timing of the headache, the intensity of the headache, what factors relieve the headache. So headache is one point. A very big pointer that you need to see a neurosurgeon or a neuro physician, more likely a neuro physician is fits. A person having seizures or a person having... becoming suddenly unconscious. There are many reasons for becoming unconscious, starting from your sodium levels falling or you're having a heat stroke. Many things can get you unconscious. But when you have a seizure, when you become unconscious, you have persistent headache, which is not going away with your regular croissants and analgesics, or it keeps reappearing after going on. or along with the headache you have visual problems, you have ringing sounds in the ear. And of course, the main, the number one point is headache relieved by vomiting. So if you have severe headache and the patient says, I feel nauseated, and then once I throw up, my headache is better. That is a very, very big point. Early morning headaches, usually tension headaches, stress headaches come at the end of the day. Morning you will get up fresh. When you have, when the patient comes to us with headache, we say, is this headache when you get up or at the end of the day? So when a patient says, no, early morning when I get up, I have a headache, that is a stronger pointer that says something wrong in the brain. So these are the criteria of the dashboard. Maybe I have missed out a few, but mainly it's headache, seizures, loss of consciousness. You mentioned head injury and you mentioned tumors. What are the other sort of major things which you see as a neurosurgeon? Yeah. See, there are many malformations more so of the spine and in children. I think at this stage I should tell you one interesting thing in neurosurgery, pediatric neurosurgery against the subspecialty. Children very rarely have brain tumors. Right? If you see cancer as an ailment, you see more cancer in adults. Am I right? You rarely find, you do have childhood cancers. I'm not saying no, but majority of cancer is something you associate with adult life in neurosurgery. Children who have tumors, 80% of them are medical. A majority, when a child comes with a brain tumor, 80% chance that it's going to be a medical tumor. So in pediatric population in children, the number of cancer tumors or cancer situations is very high, unlike cancer in the rest of them. That is one thing. And what else did you ask me? I had just asked what other things you see. And also, wait, sorry, just because you said malignant, could you tell us the difference between a malignant and a benign tumor? What other things do we see? We see malformations in the spine, malformations in the brain. These are congenital problems. OK, some of them which progress with time and which can be dealt with on a surgical basis. like atriobinus fischirathotus, what we call as AVM's of the brain, malformations of the brain. Then you have cysts of the brain, which are congenital. All these things can be dealt with surgical. Spinal malformations, you have spinal tumors. And some are malignant, some are not. Now, what is malignant and what is benign? Like everywhere else in the body, the same rule applies. Denying means a tumor is an abnormal growth of cells. Now this growth of cells can be completely, it will grow so fast and it will grow so frequently that a few cells can start the process again. So if I remove a malignant tumor, the concept is a malignant tumor in the brain or anywhere else spreads beyond the sight of vision. So you think you have removed the tumor, but there is definitely a lot of tumor cells in the tissue. And then we have what is called chemotherapy, adjuvant therapy, radiotherapy. A non-melignant tumor is nicely encapsulated. It has a covering of its own, or a part of the brain becomes its covering. And to use a deamonster, you can shell it. A melignant tumor, even if you have a few cells left behind. is unlikely to again grow into a full-blown tumor. All right? I'm sorry, a benign tumor is unlikely to grow into a full-blown tumor. Whereas a malignant tumor, like malignancies elsewhere in the body, has a very high tendency to recover. Okay? So that is the difference between a malignant and a benign tumor. What is the recovery time for these kind of surgery depending on the various stages? No, recovery depends again, like I said earlier, on the site of the tumor. Where is the tumor? Sorry, if you have a tumor which is located in certain areas of the brain, which we call as a non-elucidate, one of the non-elucidate areas of your brain is the frontal bone. That means it does have a function, but it's not an obvious function. like it looks after, it is your behavior, which is affected if your frontal lobe. Now, if you have a tumor which is sitting on that area of the brain, which controls the movements of one side of the body and the patient is paralyzed on that side after removal of the tumor, even if it's a benign tumor, may become paralyzed, may not. His recovery will take anything from six months to a year. If you have a patient who has been operated for a tumor, which is right in the area of speech, his ability, this will become a very complex thing. He cannot understand the speech that is told to him. He cannot say what he wants to. And it's a very complex thing for him to recover. He will be walking, talking and eating. For him to recover, to become a useful member of the society and go back to his work. We take years. and it may not be complete. So it's very difficult to say what is the recovery time. And recovery time depends on what state the patient came to. Patients who come in the early stage get operated, recover to their original levels much faster than those that have come in a later stage. Because the problem with all tumors and malignancies or even non-malignant, the pressure on the brain has remained for how long? You have removed the pressure after the surgery for it to come back. You see, it will take time and it all depends on where was it. Can you talk to us about the plots in the brain? Plots in the brain? Yeah. How do you deal with them? Why do you get plots in the brain? First, number one, I think I should tell you a little bit about, very little bit about the anatomy of the brain. I mean in the brain, you can have a clot in the brain substance, in the tissue of the brain. You can have a blood clot in the ventricle. Ventricle is there are small areas of the brain which are filled with water or CSF fluid, it's fluid. It is called cerebrospinal fluid. You can have a clot inside that. You can have a clot. over the brain but not inside it, in between the gap between the brain and the bone. Okay, so now clots in the brain can come for various reasons. Commonly it is hypertension when the blood pressure goes very high, you're one of the there are the finest arteries of your brain are what we call end arteries that means normally arteries connect with each capillaries connect with each other. There are some which is almost just about the size of your, the diameter is the size of your hair. So these are single layered blood vessels. And the pressure rises when your BP machine shows 200 hai aapka pressure, upar wala 200 hai, 230 hai. Added to that, there's diabetes, which makes those vessels weaker. One small vessel will rupture. When it ruptures, it's pumping out blood at a pressure of 220. All right. Now what happens? It cannot continuously pump out. Patient will die. He may even die anyways. What happens is it pumps out the blood in a whoosh. It starts collecting there. The blood has nowhere to go. The brain is a closed box. Your skull cannot expand. If that sort of a bleed happens in the stomach or in the chest, there is plenty of space which is not there in the brain. So the pressure rises in the brain because there is no space for this extra blood. Even if 40 ml of blood come out into the brain, there is no space for it. So 40 to 60 ml will raise the pressure inside the brain. Once the pressure inside the brain rises, it will become more than that 200. It will stop bleeding. counterforce. So this is nature's mechanism to stop the bleeding. But it can produce a devastating effect. So that was one way in which clots form. Another way in which clots form is in the elderly who are basically on aspirins, warfarin, anticoagulant drugs because of a cardiac condition or because of a prior stroke or because of a malignancy. They tend to have the ability to bleed very easily. they have a spontaneous brain because their normal coagulation time, their normal time of blood clotting has been altered. So those can have brain clots. And then the third reason why you can get brain clots is head injuries. Those clots rarely are inside the brain more likely to be what we call as extra-dural or subdural hematomas. depending on the size, depending on the site, most of them need to be removed. And these are very rewarding surgeries because the patient recovers very well. Which one of this is the most dangerous in life that they do? That is inside the brain, especially because of hypertension. Because these are very small vessels which are as thick as your hair, which are the size of your hair, are the ones which are in the brain stem. And any bleed inside of the... brain stem, what I'm calling as that area of the brain can be fated. Why? Because those in that part of the brain, you have all your control centers for your heartbeat, for your consciousness, for your respiration, everything. So that area, which is so vital to making you what you are, to do all the automatic functions has been bombarded. So you have an unconscious patient, a comatose patient. And if they're not given any medical aid, then it can be very fatal. Even with medical aid, they can be fatal. Again, for these things, we have a mortality. If this is the age, this is the size of the clot, the patient has diabetes, the patient has hypertension, chance mortality rate will go down to 20%. But it's a young patient. He doesn't have diabetes, but he does have hypertension. Then the chance mortality will rise to around 40, 50% that he will survive. So it depends on the situation. You mentioned about brain regions. Are there certain brain regions then where you just, as a surgeon you say, we probably shouldn't do a surgery here. If something is there, you just let it be. That is one of the places where neurosurgery has evolved. There was a time When certain areas of the brain were sick or sent, no neurosurgeon, you can't operate there. Oh, that's too deep. Oh, that's too dangerous. With technology, with help in the operation theater, you know, intraoperative MRIs, robotic surgeries that we were talking about earlier, and endoscopic surgery, almost there are now no areas of the brain where you say you can't reach. But those areas where we used to say earlier that you can't reach still remain when you do reach them extremely high risk. Like I told you, if you have, if you're dealing with that area of the brain which controls your heart function, your beating of the heart, your respiratory function, and you create, I mean any problem happens there, human, technical or other ones. The risk is very high. So now there are really no areas which are not to be approached anymore and those are getting better and better. So now you have overcome all these things or there are still some areas where... No, hardly any. But then not everyone, like if I get a brain stem glioma and I'm working in a government hospital or I'm working in a place which is very far away from the city, I cannot move over there. It is unapproachable because I don't have... what I need. Whereas that can be approached when if you have endoscope use, if you have all the facilities that you need. And most important, post-operative care. You have to have a ventilator available, you have to have an intensivist available, because recovery doesn't happen just by itself. You have to predict the complications and prevent them. You don't wait for the complication and treat it. in the postoperative. So, it has become more of an issue of availability of technology and resources. For these sort of cases. Can we talk about the robotics part then? We mentioned it and we had mentioned it before recording. So can you talk about how robotics has... I seem to be very honest. I haven't done or dealt much with neurosurgical robotics or I haven't worked in a robotic lab, alright, where they do the surgery. But mostly I think to my, the best of my understanding, I'm not correct, I'm not the right person to answer this, but I will tell you what I know. You program a machine, you give it some data to act in this fashion based on what it has already been fed into. You feed these robots, you assess them. Robotic surgery again is not a one-man show. You have to have the neurosurgeon involved, you have the radiologist involved, you have to have the people who actually... the technicians involved, the technical area, and you put the patients MRI or scan, all the information that you have got of all your high-end investigations, you feed it into the computer. Okay? And then it will tell you then, you will tell that this is the area of the brain that you want to be removed from the tumor which you have to remove. And you have to program that robot to do the job. So, what is overcome with this robotics is the physical handling and the skill is what I think. But like I told you I have not done it before so I stand correct. But this is available in very few centers now, but I'm sure that in the next five years, it will become all over the place. And again, you see the things when endoscopy came, everyone patients come and say, yeah, keyhole surgery, you cannot do keyhole surgery. And then other technological advances in surgery came. Everyone wants to ask that. The idea as a surgeon to know and learn about the technologies is to find out which will be applicable for which scenario. You cannot do endoscopy for all neurosurgery. So patients come with this, when we talk of a surgery, they will say, oh, nowadays we have heard that you can just make a small one inch keyhole and remove the tumor. You can do that for certain tumors in certain areas. You can't do it in every day. And if you think, I mean, no one will attempt to do it just to say that, oh, I also did. No, that's dangerous. So you must know about all these new advances so you can make the best use of them. As and when it is applicable and where is it applicable is something that is up to the neurosurgeon's job to learn. One of the things which I wanted to ask you about is your research because apart from surgery itself, you've been doing, you've done a lot of research work as well. Yeah, but research I have done is not really a lab oriented research, which I would have loved to do. But unfortunately, when you are working in a place where there is a lab facility, either you're too busy, so you don't have time for that, or research is more done by taking project, the sort of research that I have been involved with is that I have seen hundred patients with this particular type of tumor. I may not have operated on them but they have been operated in my hospital by various surgeons. So we study everything about those hundred patients and believe me this is what you call it is not the research where you sit in the lab and study things. That is a different category. This research, we come to sometimes conclusions that hit you in the face only because you've sat down with everyone. So that sort of research is really very interesting and doesn't require money, it only requires time. And most of the other, rest of the research that I have done is more when you're teaching students, when you're students with me, you give them a project. and you just supervise what they are doing and that has it. But unfortunately, I have not had the chance or the opportunity to work in a pure neuro lab, which even now if I get the chance I'd like. No, I think that's very interesting because I come from a background of doing lab work and that research. So what is, you said 100, you looked at 100 patients in a particular tumor, for example, what is something in your experience which you found, which you found very important or interesting from? See, when you look at a series of patients and you start from the nitty gritty, what did 1 to 100, what were they presenting? Number two, what were our examination clinical findings? Number three, what did the investigation show? Number four, what was the patient's condition before the surgery? Number five, what is the type of surgery that we did? And what was the outcome? After six months, how did the patient proceed? You will find a pattern. You will say, oh, all those patients who came with grade 3 weakness, a partial paralysis and we removed the tumor became completely all right. But those who came with grade 2 did not recover at all, remained at grade the level of movement by grade of 2. Or you will find that when you deal with some tumors over the speech area or over the areas where there is memory involved or behavior in you, you will find that Okay, these tumors of this type, that is location, but it was management, it was benign, what type of tumor, this is more, you'll see it and you learn this is not earth shattering research, which will come in all the journals and you know, make a biggie. But it is always at the back of your head that when you again see a patient of a similar tumor, so I think I'll tell you something very, very interesting on which no research has been done. We have what is called a GCS scale, a Glasgow Coma Scale, to assess how conscious is a patient. Okay, that's a very, very basic tool, a clinical tool. It's a scale done in Scotland at the Glasgow University. You have to give them credit for what they have done. This is one of the results. Now when you have an unconscious patient and he remains unconscious for quite a few days, how is the patient today? A nurse will ask for a doctor. He's not conscious. Now that not conscious is a wide range. So is he semi conscious? Is he just lethargic? Is he completely comatose? Is he deeply comatose or stuporous? So this is called a scale. Now, and that scale goes from three to 15. There is no zero to one. I won't go into the details of the scale for lay people may not be very interesting. But when you see many patients of head injury and with this scale, between the scale levels, simple thing, the scale is eight on 15. He will not talk, he will not obey what you're telling him. If you give him some water to drink, he will drink it. Or if you just put the cup to his lips, he will do the drinking action. You show him a mobile phone, not a grenade, but a little higher. When you ask him, what is your name? He cannot talk. He cannot answer because he has an injury to that part of the brain. Do you give him a mobile phone and the person at the other end is a familiar voice, which says, hello. And his name, he will reply. I have seen this happen. Don't ask me why and how it happens. Now, if I could see a hundred patients like this. And I could study them. I'm sure that anyone, no big credit to anyone, but you could come up with that. With something as to why it is happening. So you ask him, what is your name? He will not reply, he will not even understand. But the same question coming on the phone, or again, you talk to them in, this is not something new, this is known. You talk to them in the first language that they learnt when they are coming out from a forum. They will respond. You're talking about interesting cases. This is not a surgical challenge. They're interesting. When I was working in Amtaba, which is purely Gujarati. It's in the state of Gujarat. There was a patient, unconscious lady who had fallen from the train. And no one knew. She was, as we call it in the general hospital, it was at the government hospital, unknown. And she was unconscious. All right? Every day, we had basic facilities there. Every day we tried to see whether she's woken up and all that. What is your name in Hindi, Gujarati? She was in the state of Gujarat, Marathi, that is her social. No response. And she would just open her eyes, give you a blank stare. And that is it. One fine day when I and this went on for weeks, three, four weeks, one fine day when I finished examining her and trying to wake her up and I went to the next bed, it was a general ward. From the back, I'm hearing just two words, Manchi Nil, that is drinking water in Telugu. Now I had worked in Hyderabad, I knew a smattering of Telugu. So I immediately turned around and I said, this lady is from, is talking Telugu. So in Telugu, I asked her, what is your name? I got an answer. In Telugu, I asked her, where are you from? I got an answer. Then when she completely woke up and she recovered, fortunately for her and for us. She could talk Hindi. She knew Hindi. But when she was in that stage of coming out of the coma, she did not respond to any questions in Hindi. But she responded to questions in Telugu at that stage of coma. Now, why does that happen? There are certain clues we have, but we don't have an explanation. In medicine in general, when you don't know why you have many theories because you don't have the answer. So there are many theories. So I'll just leave this. Now there's not the forum to vote. Yes, coma was something that I wanted to talk to you about. How people all of a sudden, people become unconscious. All of a sudden, everything is very all of a sudden. So why it could be for the reason that it could be for the simple reason. I don't know how to put it across to you as a medical thing, but what causes diabetes? Variety of factors. Variety of factors. If it's a diabetic, a low sugar or a high sugar. Alright? If it is a very old person, a very low sodium level, for old people we keep saying less salt, less salt. It's not always the case. They will not go into coma suddenly, but they will slip into coma within a few hours. So, you have diabetes, sodium levels in old people, a seizure, following a silent seizure, you may not see the seizure. All seizures and all fits don't come with, you know, movements of the jerky movements of the limbs and rolling of the eyes. It can be a silent seizure at the end of which the patient is unconscious. It can be a head injury. patient will be immediately unconscious, immediately on the way. And then there are, then it can be a tumor which has grown, the brain has compensated and suddenly the two of the compensation seasons the patient becomes unconscious. It can be a bleed in the brain, unconscious. It can be an infarction of the brain. The patient has become unconscious. Anything that increases the pressure in the brain is very likely to make you unconscious once the limit of that increasing pressure has been. Is it in any way a protective mechanism falling into unconsciousness or no? Is it just continuous damage? All unconscious is an alarm bell for the people around that there is now something seriously it is not really a defensive mechanism at all, protective. Um... Oh, the question escaped me. Give me a second. I wanted to ask about the brain plasticity because you said people recover from different surgeries it depends a bit on which location it depends a bit on what but in your experience what oh how plastic is the brain you in the sense you did say certain areas recover better than others but what all are the things which depend? See basically what is neuroplasticity now it is coming up in a much bigger way and we are finding out many more things. Sorry, the earlier teaching was that after the age of five or seven years, the brain growth doesn't take place. And that is why whenever any areas of the brain is damaged, they do not regrow. But now those concepts and those ideas are changing. Brain plasticity means plastic changes shape. It is something which is malleable. The ability of the brain to recover or to change to protect itself from whatever is the onslaught on it, a tumor, a bleed, waste pressure, eye sugar, whatever it is, that is plasticity and the ability of the brain to recover. In the brain, you have the main cells which are neurons. And of course, you have many other cells. The cyrus, you have dendrites and oligodendrocytes, many three, four other types, astrocytes. So these are some fancy names to the people who are not associated with. But these are all the supporting cells. Until now, we thought that these are non-neural cells, but then there are some cells in the brain which can grow to take up the function when the need arises. So neuroplasticity is a very evolving topic in our lives. And another ability of the brain is we know that the brain is divided into the left half and the right half, which is very, very distinct. But the amount of cooperation, though, if you say that this is a boundary line between two countries, the amount of cooperation that can be received from the other side of the brain is tremendous. So they found new connections. new linkages to take over the function of that part of the manager. This is a recent study. No, this is there. We know about it since a long time, but it does happen. So the more we study it, the more we come to know about it. And they do research in the lab, they find certain things, and then we try to apply it into clinical. That is the interesting part. Okay, I think for the last few minutes, I'll ask you if there's anything which you think would be interesting to cover, interesting which you think a general audience should like to hear about neurosurgery. I can give you the floor and yeah, you can go ahead. Oh, what do you think? I think if you want to sort of what do you want as a neurosurgeon to tell the public, neurosurgery is no longer a feared branch to... It is no longer a death knell that, oh, you have a brain tumor or you have a spinal tumor, or you had a stroke. Like all other ailments, the earlier you reach the correct place and the faster it is handled, the better is the outcome. That goes for heart attack, that goes for a blockage of any vein or what we, and that goes for a whole lot of things. For any trauma, you have got a fracture femur. If you are attended to immediately, then your fracture is going to get a much better outcome instead of waiting and infection setting in uncomplication. So same way to any problem with the brain, go fast. Even if you have a doubt, especially in stroke, which is not my field as a neurosurgeon, a very small part of the management of stroke is in the neurosurgeon's area, removing the blood clot or... doing a decompressive, a large infarctal, but it's a small portion. But number one is go fast. Number two, the sort of attitude people had that if you have a brain tumor, it's a death sentence, if you have a malignant brain tumor, it still works. That is no longer the case. neurological deficit. Neurological deficit means you have some deficit with walking, with talking, with vision, with speech, with hearing or any control of your bladder, whatever. That's a deficit, that's a neurological deficit, all death. Nowadays that is an exception. So it is no longer something to be feared just like any other. in the rest of the body, it is not. Neurosurgery is now coming on par. Because developments in investigative part of technology and in the operative part of the technology has taken very big advances and it continues to be there. But in your opinion, do you still think it's a very complex subject? Anything you apply your mind to and learn for five years and then keep on learning after that with each case in which you operate. The complexity tends to reduce. But to say people who don't know about it for them, it can be very difficult. So that's what I'm saying. So when you're in the field and this is what you're doing day in and day out. After there is one thing very interesting, but it never becomes routine. Every case is different and that holds good for many other branches of surgery also. But like if you have a peptic ulcer, you have an appendicitis, OK, or you have a liver mass. One, two, three, four. It is a routine. This is what is to be done. You do a cesarean section, you do a hystrectomy, so you do. Brain tumors, because of their location and because of the type of tumor, each patient has to do, there is no hard and fast. There are some very general rules, but when you, even after 20 years of doing neurosurgery or 30 years of doing neurosurgery, if I'm doing a major case, if I'm operating on a tumor, I have done many, many tumors. I still have to sit down the night before, see all the scans for myself. Once again, I already know the diagnosis, I've seen the scans 15 days ago when the patient came to my office and I saw them again when he got admitted two days ago. But the night before, I still sit down with him and I see whether there is anything in it which I have missed out, what I'm going to do, how I'm going to approach it, what are the problems I will run into. And what will I do if I run into it? So every time you operate, it is going to be something different. And if you treat each patient like that, then you have a very rewarding and a satisfying result. I can say I've operated on 50 men in German. This is one more, no. This 51st men in German is going to be different. And when you talk of your results, you should never go over, I mean, let it get up to your head. When we talk of the chances of complications in literature, when people say for this complication to happen in this surgery is 10%. If you haven't had a single complication after doing so many cases for that, your chances with the next case rises because you have to catch up with the research and the literature. So instead of becoming more complacent that I have done 50 of these sort of surgeries without a single complication, the chances of my developing that complication in the 51st surgery is progressively getting higher because you have to catch up with the statistics. I'm not going to be that. one solo neurosurgeon who does not fit into that category. Unright. So it's humbling. What is your approach for surgery, towards a surgery, and how do you go about doing it? Yes. I can tell you that in a very, yeah, I'll try. Is you first have to insight, which, you know, when we were students, we had, we were only doing the brain and the spine. And then we had students who were doing general surgery and they were doing orthopedics. So this will always tell us how much can you study for the brain ray, just 20 percent, it's such a small organ. What could possibly go wrong and how much would you study? Whereas we have the rest of the body to do. So when you, first thing is you have to do is what is called a surface marking. You are seeing that tumor in the brain in this area. How are you going to reach? Where are you going to incise? We don't uncap the brain. Tuck, not move. Okay? It's not like that. That scalp cap is not removed. The cap remains. We make a, we remove a disc of bone. over a certain area of the brain which is going to be the least traumatic approach to the tube. How do you remove that disc? Nowadays we have these high-speed saws. So, you first incise the scalp and turn it away and you expose the bone. When you make one hole in the bone, bone will be around an inch thick. You make one to reach the covering of the brain. You make a few millimeters clearance between the covering which is stuck to the bone. And then you just take a high-speed saw or a drill and you make a circle around it and come back to starting point. And you get a disc of bone out. This is the easy way. This which is what I'm doing since the last maybe five or seven years, ten years. Earlier we had to make multiple holes. and pass a flat steel, a flat plate of steel which can be bent from one hole and take it out from the other. In between you may end up injuring the brain and then pass a saw on the reverse direction and then give and saw the bone. It's called a diggly saw. That was very strenuous, very tiring because if you have a one inch thick bone imagine. taking out five pieces of two inches bones like that. Anyway, you uncap and you remove that disc. Then you are faced with what is called a dura, which is a tough membrane, which protects the brain. Then you have to incise the dura. Extremely close to the dura is the brain, which you do not have to. Millimeters is the space that you have to deal with. And then you raise that membrane when you're looking on the brain. Now you have to correlate where in which direction because when you look at even a 4 centimeter circle of brain, it looks very large when you have to find a 3 centimeter tumor at a depth of 3 centimeters. So, then you approach that, make a small opening and you go through that part of the brain which is least likely to create a deficit, create a problem. Then you core out the tumor and then you bring the rest of it out. It shrinks on itself. Most tumors are fortunately one centimeter under the brain surface. Some of them are on the brain surface or part of them are protruding onto the brain surface. That makes our life much easier. Did it ever happen that during the surgery you had something and instantly you needed to make some changes? Many times. That is why that's what I said. That there is nothing like a routine surgery. You sometimes encounter bleeding. You can see the blood vessel there, you can't coagulate it because if you stop that blood vessel and you block it, a large part of the brain which is being supplied by blood will be without perception. So you have to control that bleed without blocking the vessel. And we have many different ways of doing that. But of course you need a team in your operation theatre who is aware of what to do next. Those are rare instances. And each case it is reflected. I gave you a very, very simple surgery that I had done in which I learned from my post-graduate student. You have what is called a growing fracture. In childhood, when the skull fractures, during the healing process, because the bone is also growing and the dura and the brain is growing, the bone doesn't heal. In between the two edges of the bone of that fractured skull, The brain and the dura pops out. No, it's under the skin. It's nothing to raise your eyes about. So this is what is called a growing skull fracture. It's very safe. But if the child falls, it has to be treated. So we open the skin and we see that there is bone here. There is bone here in the ellipse with brain tissue protruding. What we have to do is find an edge. between a leeway between the brain and the bone, plane. So, and that is very dangerous because you end up with a lot of breathing and it's quite a messy job. My student gave me a very good idea. Go one centimeter behind the edge of the bone, normal tissue area, make a small hole there. You hit the dura from there, which is normal dura, and then you pass your instrument in front, and you will get your instrument out from the gap. So you've got your plane without causing any trauma to the brain. So this is something that you think on your feet. Now this is not research and this is not something that anyone has published. But when you start doing that, the time taken for the surgery reduces drastically. How long does it take for you to complete a normal? It can be anything from two hours to eight hours. And when I was a student, when we didn't have all these technological advances, there have been cases when we have assisted because I was a student and that took 12 hours. And that means the surgeon operating, the surgeon has also operated for 12 hours. The surgeon takes a break, the surgeon takes a break, we assist him to do something like everywhere else. That's okay. That's how we learned and we are grateful people treated us like that. They first learned and be where we are today. I think that's a very good thing to end on. Giving a whole breakdown of someone in a surgery, how all the steps go. Okay, so before we end, the very last thing which I ask all my guests is, if you have to give one piece of advice for the general listeners, any type of advice, what would it be? Regarding neurosurgery? Up to you. That's on you. Just one piece of advice to all our listeners, what would it be? That's a little bit complicated, whatever. Try and create happiness for yourself and everyone around you. First for yourself, only then you can spread it. That's what the politics is. How you do it, it's your job. If you can make a person smile or laugh in the day, then that's a day well lived. That is my, whatever you want to call it, message or philosophy. It's beautiful. Excellent. Thank you so much. Thank you for having me on. It was really nice talking to you and Farheen and you both had a lot of questions to ask. I have just learned so much. Yeah, well, I have more questions, but there's also limits of how long we should go. Otherwise, everybody's been set. We can have one more session. We can have another session at some point. Thank you so much. I hope for your time and for all the effort you did to put this up. Thank you, Farheen, also for being there to ask questions. with this program more interesting. Oh, thank you so much. Thank you everyone, and thank you everybody for listening as well. And yeah, till next time, take care. Okay, bye bye.