As I moved the tumor away from the spinal cord I saw what appeared to be nerves within the wall of the tumor… and they were cut. ‘That’s impossible…it couldn’t be’, I thought. ‘It just didn’t make sense’. Immediately I thought the pathologist’s interpretation had to have been wrong. It must be a tumor that arose from the nerves themselves and not a meningioma. So I took a biopsy from another area of the tumor and sent it to him for reexamination. Several moments later the pathologist called back into the room and said it was indeed a meningioma.
So I inspected the area between the tumor and the spinal cord again. Perhaps, I thought, the tumor arose from the dura laterally and as it grew slowly toward the spinal cord it displaced not only the spinal cord but the sensory and motors nerves along with it. The thing of it was, I couldn’t trace these ‘nerves’ back to the spinal cord where the motor nerves exit en route to the biceps muscle in Annie’s right arm.
Perhaps these ‘nerves’ were actually sensory nerves that were pushed down by the growing tumor toward the motor nerves and then looped backed on themselves to join the other sensory nerves. Regardless, I thought, because they were so adherent to the tumor wall, they were very likely permanently damaged anyway and not functional.
To be sure, I stimulated them with a nerve stimulator but there was no response.
It is at times like this during a case that I stop what I am doing and reassess the goal of my surgery…the purpose for subjecting this lovely elderly woman to a major operation. Sure it would have been nice to be able to completely remove the tumor, but to do so would have been, at least in part, to gratify my ego as the ‘best neurosurgeon on the planet’! No, my reason for operating in the first place was to decompress the spinal cord or to remove that pressure that was threatening to permanently damage Annie’s spinal cord and paralyze her from the neck down. And I had already accomplished that.
Besides this was a slow-growing tumor and Annie was 84-years-old, so the likelihood this tumor would grow back and cause any significant problems in the time that Annie had left was remote. Not to mention to extend the length of time Annie was under general anesthesia at her age would only increase the risk of post-operative complications.
And so it was at this point I decided that ‘the enemy of good is better’!
This is a truism that I have learned pertains not only to surgery but life as well. Often times we attain an acceptable outcome in whatever we may have set out to do and any attempt to attain ‘perfection’ only serves to undo all the good we have already accomplished. And so at times like this we should be happy with the ‘good’ we have done and we must bury our pride when our ego wants to be ‘better’.
As a safety measure, instead of merely suturing the dural tube closed, I inserted and sutured in place a tissue graft to enlarge the diameter of the dura. In this way, if the tumor did grow it would have twice as much space and thereby lessen the likelihood it would ever cause undue pressure on Annie’s spinal cord.
Immediately after the surgery, when Annie awoke from the effects of general anesthesia, I went into the Recovery Room to examine her. To my grateful surprise, the strength in her right arm and hand was completely normal! There was no abnormality or deficit of sensation or motor function. It actually was not the first time I have expected a neurologic problem post-operatively only to discover there was none.
Perhaps, those nerves were not working to begin with or that they were redundant and not needed, or perhaps it was just miraculous. Regardless, the way in which the events of Annie’s surgical procedure transpired certainly affected what I did surgically. And I am convinced that was the true miracle…that Annie came through the surgery fine, without any complications.
Soon after I checked on Annie, I went out to the surgical waiting room to speak with Jill. I sat down and began to describe to her the events of surgery. Half way through she interrupted me and said ‘you know, it seemed to me that the surgery was taking a long time so I said to myself, I wish he would just remove the part of the tumor that was compressing the spinal cord and not worry about trying to get the entire tumor out’. To which I replied, ‘well, that is exactly what I did’. Jill promptly smiled and thanked me for everything I had done. I reassured her that her mom was resting comfortably in the recovery room and was doing fine, her strength was normal and that she would be up and about in no time.
And so I left to make rounds feeling blessed that I listened to my conscience and the angels that always whisper in my ear, hoping I will listen.
“Do nothing from selfishness or conceit, but in humility count others better than yourselves. Let each of you look not only to his own interests, but also to the interests of others” Philippians 2:3-4
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