Ryan - Week 3

Things this week have gone well so far and I'm still really enjoying getting to see surgeries. This week in the OR was pretty much like last. My first surgery was for a patient suffering from bilateral stenosis in the lumbar spine. Dr. Boockvar operated to alleviate the compression of the spinal cord by cutting through her back. Once the lumbar spine was dissected, Dr. Boockvar called me over to show me the work he had done up close and teach me a little about the anatomy of the lumbar spine. I also met up with Brandon and Liz to watch a craniectomy for a Chiari malformation. Since there was a lot of pressure and tightness in the dura of the patient’s brain, Dr. Greenfield used bovine pericardium to replace the dura so that it would be a little looser. In another surgery, I saw Dr. Boockvar perform a suboccipital craniotomy and resection of a very large meningioma. For the past two weeks while observing Dr. Boockvar’s surgeries, I’ve noticed that he works very efficiently and quickly and only participates in the actual resection when surgical residents are present. The residents open and close the surgery and assist Dr. Boockvar for the more difficult portion of the surgery. The meningioma surgery was really long, however. Going in, Dr. Boockvar said it wasn’t going to be a quick one but I had no idea it was going to take him 3 hours to remove the tumor from the base of the patient’s brain. Usually, it takes him about an hour to an hour and a half. Since the tumor lacked a defined exterior boarder, Dr. Boockvar had to remove the interior by way of large chunks and then, working outward from there, he shaved off the remaining tumor tissue in slices. This shaving process is what took up the bulk of the surgery since Dr. Boockvar had to be careful to salvage as much healthy brain tissue as possible while maximizing the amount of tumor resected. After 6 hours of surgery, the patient was pretty much closed up but the surgical staff noticed that they were missing one of the cotton “patties,” which look like cotton squares on a string. We looked everywhere for it but since we couldn’t find it, the patient had to be x-rayed to make sure that it wasn’t left inside the surgical site. Luckily the x-ray came back negative. My last case of the week was an anterior cervical spine discectomy and laminotomy with a two-level implantation of this vertebral body support device. Basically, Dr. Boockvar fused three of the patient’s vertebrae in her neck together to alleviate her pain caused by degenerating intervertebral discs. It was cool to talk with the implant device company’s representative who was in the operating room with us about their device and how it supports the vertebrae while inducing bone growth from the vertebrae, causing them to fuse together.

This week in the clinic, there was a new student today named Molly shadowing Sherese, Dr. Boockvar’s nurse. She’s going to be attending Boston College and plans to go into nursing school, so shadowing Sherese is a pretty great way to get to see if nursing is truly right for her. Plus, she was able come into the OR with us. The patients this week were basically the same complaints/comments that I’ve seen so far this summer: radiating back and leg pain, headaches, tiredness, etc. Many of them were brain tumor patients, more specifically glioblastoma multiforme, which is what I study in lab back in Ithaca. So it was pretty neat to get to see people living with the disease that I’ve spent the past year studying and hear about and see their symptoms firsthand. A lot of these patients Dr. Boockvar wants to include in his clinical trial studies to try to help prolong their longevity as much as possible while helping to contribute to the scientific knowledge of the disease. One of the drugs that Dr. Boockvar seems to love to suggest is Avastin, an anti-angiogenic therapy that inhibits new blood vessel formation, which he includes in a lot of his clinical trials because of the positive results seen in previous clinical trials. Aside from all these brain tumor patients, there was one consult in particular where the patient was very irritable and upset about the fact that after his surgery to drain a cyst that was impinging upon a nerve in his head and causing an obnoxious ringing noise, the ringing, or tinnitus, came back. Dr. Boockvar suggested that this might be due to a blood vessel rubbing up against the nerve but overall this is a very peculiar case that he and his colleagues are perplexed by. I’m eager to see how this case will unfold further and am hoping that the cause of this ringing will be identified and addressed. In the meantime though, Dr. Boockvar has assigned me to research pharmaceutical drugs that treat tinnitus. What I’ve found so far is that there is a broad spectrum of drugs used, such as antidepressants/anti-anxiety, antihistamines, and anticonvulsants, depending upon the circumstances specific to the patient. Another interesting consult was for an old woman who had a brain tumor resected and is now undergoing therapy to make sure it doesn’t recur. Her husband was an entertaining guy who apparently works as a patent attorney because, following a short discussion of what I’m studying and my achievements to date, he suggested that I should come work at his office. Too bad I don’t really want to live in New York City after graduation…

This week’s Multidisciplinary Brain Tumor Conference was pretty much the same as last week but what was most interesting was when a patient of Dr. Boockvar, that I had seen earlier in the day today, was discussed because I knew exactly who they were talking about. At our weekly summer immersion update meeting with Dr. Wang and Dr. Frayer, we again went around the conference room again and shared our most interesting experiences for the week and how our projects are going, while eating pizza. Since last week, I’ve been talking with Dr. Boockvar and the other neurosurgeons about obtaining some of their endoscopic pituitary tumor resection videos so that I can analyze the pixel color of the tumor vs. healthy tissue using a computer program called Matlab. This information might lead to developing a light band-limit filter that could help the surgeons operate more quickly and efficiently. In order to do a great job on this project, I sought outside expertise and met with Dr. Sushmita Mukherjee, a professor in the Weill Cornell Medical College who studies the use of multiphoton microscopy and how it can be used for real-time diagnosis of cancers in a variety of organs. I thought to meet with her about my endoscope band-limit filter project because her work is also being utilized for providing intra-surgical guidance. We discussed many things like what I’m studying in Ithaca, my program involvement here in NYC, and how to best address the project that I’m currently working on. In particular, she suggested that I look into narrow band imagining (NBI) and how gastroenterology already uses this technology to better identify tumors in the gastrointestinal (digestive) tract using blue light. It could be possible that this same wavelength light, which illuminates underlying vasculature, might also work to better identify pituitary tumors. Tumor tissue is well known to have disorganized, tortuous, and leaky vasculature so using this light to see this difference in blood vessel structure, the surgeons are better able to differentiate between tumor and healthy tissue. I’m hoping that after analyzing the endoscopy videos from the neurosurgeons, my findings will suggest that neurosurgeons should use the same technology that the gastroenterology surgeons use because it will be the easiest and most cost effective solution.