By Dr.Ravindra Patil
Chief Neurosurgeon of Samarth Neuro and Multispeciality Hospital [Miraj, South Maharashtra] Dr Ravindra Patil writes about how he could operate a difficult case with the help of surgical navigation.
Mr Mahantesh Shellikeri is from Belgaum. He had a rare disease called Neurofibromatosis. He had two tumours pressing on the spinal cord in his back and as a result he had lost the ability to walk in the past two months.
Neurofibromatosis (NF) is a conditions in which tumours grow in the nervous system. There are three types of neurofibromatosis, type I (NF1), type II (NF2) and Schwannomatosis. The tumours in NF are generally non-cancerous.
Non-cancerous tumours are of course good as compared to cancerous tumours, of course, because they don’t grow rapidly and spread to other parts of the body. But Mahantesh’s bad luck was that he had NF tumours in in spinal cord. He had been previously operated in the lumbar spine for the removal of an NF tumour 13 years ago. The surgeon had removed the tumour at the level of the second lumbar vertebra [L2]. But sadly for Mahantesh, the neurofibromatosis tumours recurred! This time it was at the 12th thoracic vertebra [T12] and first lumbar vertebra [L1].
Due to the regrowth of the tumour, Mahantesh developed weakness in both lower limbs. As the tumours grew, gradually he could not walk. His MRI scan showed multiple spinal tumours at the level of the T12, L1 and L2 vertebrae. So he was referred to a neurosurgeon. The neurosurgeon explained that the surgery was very risky as the tumours were small and would be difficult to locate exactly and during their removal Mahantesh was likely to suffer permanent weakness or paralysis of his lower limbs and partial or complete loss of bladder and bowel control.
And if Mahantesh was not operated soon, then too he was likely to suffer permanent weakness or paralysis of his lower limbs and partial or complete loss of bladder and bowel control!
There was another complication. Mahantesh’s wife has poliomyelitis. She is a differently abled and challenged person. She needs a stick to support herself when she walks. So if Mahantesh suffered paraplegia, she would not be able to help him survive.
Besides, the cost of surgery, if it were attempted, would be high.
Thus Mahantesh Shellikeri and his wife were indeed in a desperate situation. Their extended family helped them a lot during their helpless condition.
Many neurosurgeons were consulted for Mahantesh’s treatment. All explained to them that surgery is a risky step because there was a high chance of Mahantesh developing complete paraplegia and bladder plus bowel incontinence.
One of Mahantesh’s relatives is a doctor. He met Dr Somnath Kheradkar, who suggested my name for another opinion.
When Mahantesh and family they came to me, they were very apprehensive and did not have much hope. I reassured them, explained about the disease, although they knew so much.
It was clear to me that if Mahantesh was not operated soon, he would loose control over his lower limbs, bladder and bowel. The surgery was risky.
But we had one advantage. At Samarth Neuro and Superspeciality Hospital where I work, we have surgical navigation system which is very useful in fine brain and spine surgeries. Mahantesh’s tumours were small and would require accurate removal. The surgical navigation equipment would help me pinpoint his tumours and remove only the tumours without damaging his surrounding spinal cord tissue. I would remove the least amount of vertebral bones and leave his spine intact.
I explained Mahantesh and family about the one almost magical and extremely tool that Samarth Hospital has, namely Surgical Navigation and how it would help me pinpoint the tumours and remove them accurately.
Mahantesh and his wife had many. I answered them all and cleared all their doubts. Then they became were hopeful. They were willing for surgery. But they had reservations about the cost.
But it was a special case. Nearly all neurosurgeons had refused to operate and almost all had advised that the risk of the surgery was far more than the benefits.
I was willing to take the risk of surgery only because of surgical navigation guidance system in Samarth Neuro and Super-speciality hospital where I work. That system would give me the almost magical advantage of doing accurate surgery without and permanent aftereffects.
Surgical navigation would help me find the tumour inside the spinal canal. Also, I could reduce the size of the incision. Besides knowing exactly where to cut and what to remove, the time of the surgery would be much reduced. This would result in less post operative pain and faster healing. The possibility of infection would also be somewhat reduced.
The surgery would have been very risky. Had I operated without navigation, I would have been forced to remove one or more levels of his vertebrae which in turn would cause complications during and after the surgery.
Then we posted him for surgery at the earliest. We did the surgery at reduced charges as Mahantesh Shellikeri’s financial condition is weak. We had CT scan and MRI scan images of his neurofibromas. We started the surgical navigation system after feeding the CT and MRI images into its computer system. We fitted the trackers of the navigations system at exact locations.
Now we knew exactly where to cut and how to cut. Some of our surgical instruments have markers. Thus the markers fixed on the patients and some of our surgical instruments showed up clearly on the 3D screen of the surgical navigation system. With the help of these images and our skills we operated.
We localized the level of the tumour exactly. Then we removed the exact amount of the bone to excise the tumour. We opened the duramater [a stiff covering of the brain and the spinal cord] and I dissected that tumour carefully away from the spinal cord. Afterwards I removed both the tumours located between the T-12 and L-1 levels as also the tumour below the L-2 level.
We were able to remove both the tumours in a single surgery most important of all, the surgery was successful.
Then came the post-operative care. Apart from nursing care and doctors’ rounds came in a very important care giver, the physiotherapist. She motivated and guided Mahantesh to move his limbs as the pressure of the tumours on the nerves was relieved. Mahantesh was surprised that he could move his legs. Remember, he had lost the ability to move his lower limbs when he came to me.
From merely moving his lower limbs to being able to walk was a gradual journey for Mahantesh. But he accomplished it and was able to walk with the support of a walker. But we are moving ahead too fast.
First came Mahantesh’s discharge from Samarth Hospital. We discharge him on the seventh day after surgery.
Many months have passed since Mahantesh was discharged. His would was very small, thanks to navigation assisted surgery. So he did not require much wound dressing. His surgical wounds healed fast.
The Shellikeri couple lives in Belgaum and hence it is too far away for them to come for follow up visits. Local doctors in Belgaon take care of Mahantesh’s routine problems.
But Mahantesh’s wife Mrs Shellikeri called me once after many months to tell me that Mahantesh is progressing well.
With our efforts we were able help Mahantesh walk again. I hope to god that he does not get more episodes of Neurofibromatosis either on his spine or anywhere else.
The Shellikeri family is happy about the results.
Samarth Neuro and Superspeciality Hospital has 100+ beds & specializes in emergency surgery for neurological issues/disorders & diagnostics.
Samarth Neuro and Superspeciality Hospital
