Decision making in Neurosurgery for Patient and Family
Neurosurgery deals with ailments that can affect the brain and spinal cord from the time a human life is conceived in the womb upto the last day of its life.
Decision making in neurosurgery is crucial at both extremes of age and in between. Let us consider the following two circumstances, a new human developing in the womb with defects of brain and spinal cord and an elderly human, who has lived healthily so far but is now lying unaware of the internal and external needs of the body. In these situations, the decision regarding the type of medical management is very important for the quality of life of the affected individual and also for the family.
The brain, spinal cord and nerves are made up of cells called neurons. Neurons are extremely sensitive to injury. They cannot tolerate absence of blood supply (nutrients) for more than a few minutes. Once damaged they do not regenerate, but sometimes may recover partially depending on the severity of injury. Therefore “time is money” when it comes to treating the brain, spinal cord and nerves. Neurosurgery mostly deals with emergency and critical conditions. Time is critical for preserving the neural integrity and functionality of an individual.
Decisions regarding treatment have to be made by the family members and their doctor in short span of time, as the patient is often unable to understand his/her condition and take appropriate decisions. Unlike other medical specialties, here the family members go through a rough period as the patient is not functional due to paralysis, weakness, pain in limbs and altered level of consciousness.
Decision making is easier when doctors and family members place themselves in the position of the patient. What does a human being want or expect apart from the material worldly things? It is to have healthy life, and not to lie in bed dependent for all or most of daily needs. In short to live a meaningful life and be physically and functionally independent till their last breath.
Fortunately neurosurgery has shown tremendous progress in terms of outcome of treatment in the last two decades. We have moved from salvaging life to preserving neural integrity and functionality of an individual. When treated at the right time, it is now possible to stop damage to neurons and also aid in recovery.
Common neurosurgical conditions:
- Head injury
- Bleeding (hemorrhage) in brain
- Brain and spinal cord tumour
- Spinal cord injury
- Intra uterine anamolies of brain and spine
- Spondylosis/ disc problems
Apart from time, what are other important factors that affect treatment and recovery in neurosurgical conditions?
- Level of consciousness at the time of incident and at arrival at the hospital - indirectly indicates the extent of damage the brain has suffered due to the incident and sometimes due to lack of adequate breathing and blood pressure while on the way to hospital.
- Weakness and numbness in limbs at time of diagnosis- indicates the location of damage in brain or spinal cord; duration of weakness/sensory loss indicates the possible extent of damage and the probability of recovery.
- Breathing pattern/ Blood pressure/pulse rate- these are vital functions required for survival of our body organs and these are controlled by the central area of the brain; damage to this structure indicates poor outcome
- Ability to cough - like breathing, cough is also controlled by brain. Inability to cough, leads to breathing/ swallowing problems which can lead to lung infection.
- Control of urine and stool- is lost when nerves supplying these functions in the spinal cord and brain are damaged.
- Extent of damage seen on the CT/ MRI of Brain or Spinal cord- scans demonstrate the structural damage and if it correlates with the present clinical condition, it can be used to prognosticate. Structural damage seen on the scan is more likely to leave behind functional damage.
- Other pre existing medical problems- like diabetes, hypertension, cardiac or respiratory problem if are not under control will cause secondary damage to the already damaged brain and spinal cord.
- Overall functionality of the individual prior to the event- activity of an individual prior to any of the incidents determines how well the body can tolerate injury and recover with good functionality.
Common Questions asked by family members:
1. Will the patient be normal after treatment?
The extent of drop in physical and mental capabilities along with corresponding structural damage demonstrated on imaging determines to what extent they can reach to normal, near normal life.
2. Why did it happen suddenly and what is the cause?
Ailments can occur suddenly or insidiously. They do however give some subtle cues which are often missed and analysed only retrospectively. There is no definitive reason known for most brain or spinal tumours. Spine problems related to disc and joints are degenerative in nature which means due to wear - tear.
3. What will be the duration of surgery?
Time taken for surgery only indicates the complexity of surgery, time taken to increase the safety margins, reduce the probability of having intra operative problems and hence give good functional outcome. So each surgery and surgeon/institute have their own set of protocols based on these factors. There is no neurosurgical procedure that will be over under three hours (from going into OR to back to room).
4. Is it very risky?
The risk associated with a surgical procedure remains same across all age groups. What determines risk is the prior functional status of the individual, other medical conditions like heart, breathing problems, previous stroke, addictions/ habits, previous surgery for same problem. These factors determine how well a patient will tolerate anaesthesia.
5. Will the patient tolerate this surgery at this age (usually with reference to elderly)?
Age is no factor to consider for any procedure. What is required as we age is to have the ability to be able to live independently and be able to take care of self. To achieve this what are the risks worth taking depends on my present functional status and other problems as mentioned in question 4.
6. Is he or she out of danger?
What is danger? If a person is kept in hospital then he or she has not fully returned to normalcy. As long as one is dependent for his daily activities there will be possibility of new problems cropping. Once they are able to perform their usual routine then the risk factors become universal (same as that applies to anybody else of their age, medical and functional status). Above all some things are beyond human control and we have to accept it gracefully without playing blame game. No doctor will want to see their patient suffer.
7. How long will they require to be in hospital?
Hospital stay depends again on their functional status with or without any surgery, the extent of dependence for their daily activities, familiarity of family members about how to look after them/ rehabilitate along with physiotherapist. It is not necessary to stay in hospital after treatment of their condition, as the neurological recovery takes weeks to months time.
8. How much will all this cost?
The cost of treatment runs high especially for those who have very poor neurological condition at presentation. The cost is same across all private hospitals except those which have medical college and have charitable trust.
9. Can it be done anywhere else with lower cost?
Yes it can be done free of cost at all government run hospitals having neurosurgical facilities.
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