The surgical roller coaster

Stick your tongue out for merdquo I requested 56yearold Liza as I checked to see if it jutted out straight in the centre or deviated to any one side It made a sharp swerve to the right denoting a weak hypoglossal nerve on that side The hypoglossal is the last of the 12 paired cranial nerves that supply motor control to the tongue allowing one to speak swallow and move stuff around in your mouth Itrsquos also the nerve that helps Americans roll their Rs and Maharashtrians liven their s Now that you have tried out both accents we can get back to LizaHer nerve was feeble because of a tumour that arose from it after having gradually grown to the size of a Mediterranean lemonwhere it compressed her brainstem making it hard for her to even walk unsupported ldquoWe have to get this thing outrdquo I told her assuring her it was not cancer but a benign tumour that we call a schwannoma receiving its name from the outer covering of Schwann cells that encircle the nerveldquoIrsquom HIV positive you do know thatrdquo she reiterated tentatively ldquoThatrsquos finerdquo I said brushing it off aware that HIV is now a wellcontrolled easily managed entity in a majority of cases ldquoTherersquos just a slightly increased chance of an infectionrdquo I said casually ldquobut itrsquos nothing we canrsquot deal withrdquo Little did I realise that these words would come back to bite me in the backsideThe next morning we opened up the back of her head behind the ear in the usual fashion The cerebellum was tense and became soft after the release of some cerebrospinal fluid With gentle retraction of the pulsating brain we saw part of the Mediterranean lemon glistening back at usIt was like a sighting of a yellow moon after waiting for a cloud to pass except that in this case we were moving the cloud We entered the tumour patiently coring it from its centreuntil it collapsed on itself relieving the tension from the stretched hypoglossal nerve With a set of sharp instruments and soft movements we teased off the last bit of tumour from the nerve which appeared weary but intactEvery single time I remove a tumour like this which obscures most of the anatomy when we begin but brings into view the entire panoramic vista of nerves and arteries once it has been removed completely I canrsquot help but marvel at a beauty that one can never quite be bored of It is simply mesmerisingThe next day she woke up crisp with no further worsening of tongue function She could eat chew and swallow and I was confident that with some orofacial rehab she would regain normal function in a few months As long as the nerve is not damaged completely it almost always heals over time ldquoYoursquoll have to work your tongue in ways you havenrsquot beforerdquo I said in jest a few days later when she was dischargedWhen she came back a week later to remove her stitches I noticed some pus seeping out of the wound This is always an ominous sign A CT scan showed it was tracking out from deep within ldquoWe have to take you back to surgery and wash this thing outrdquo I said to her my head in my hand ldquoCan I not just take some antibiotics to see if it settlesrdquo she reasoned I said it was an option but cleaning it up from within would help allow the antibiotics to act better and we could also send the pus for testingrdquo She agreed meekly It pains a surgeon just as much as it hurts the patient to go back to surgeryWe took her back and washed out all the muck that had defiled such a pristine operation We valiantly attempted to refurbish it to a state where we left it last akin to restoring the Mona Lisa Once again we thought we had done a pretty good job as she was up and about the next day in mint conditionThe day after when we went on our rounds we noticed she was talking abnormally not responding to simple commands and refusing to get out of bed All she did was moan in pain Her neck was stiff We stuck a needle in her spine to drain some fluid via a lumbar puncture and as suspected the results proclaimed meningitismdasha lifethreatening infection to the central nervous system We had to step up the antibiotics and pray ldquoWe have to hope she responds to the medicationrdquo I told her daughter Grace feeling dejected and confused by the mayhem her mother was being put through but stoically accepting it all the sameMy car key was strung to a keychain that coincidentally had her name Grace etched on it and I pulled it out and gave it to her The other side had lsquoGritrsquo inscribed on it I think seeing it made her feel better Two days later Liza was back to her usual self eating her breakfast taking walks in the hospital corridor and making jokes with the hospital staff My anguish was finally subsiding She told me she was eager to go home ldquoSoonrdquo I said ldquovery soonrdquoShe was getting better each day until one morning I walked into her room smiling to wish her a good morning but she was still asleepGrace explained ldquoShe went to sleep with a headache so Irsquom just letting her rest it outrdquo ldquoWake up Lizardquo I shook her first gently and then with some vigour She refused to budge and all I could hear was heavy breathing I dug my fist deep into her sternum but there was no response even to pain ldquoShersquos deterioratingrdquo I shouted The crashcart came in and we thrust a breathing tube down her throat to secure her airway What had been a tranquil room in a hospital ward suddenly transformed into a battlefield We connected her to a ventilator and got an urgent CT scan She had suffered a massive haemorrhage in the cerebellum It was as if a bomb of blood had burst in her headWe rushed her back to surgery excising part of the cerebellum and removing all of the blood clot She came out alivebut never completely woke up We eventually sent her to rehab the roller coaster finally at a precipitous standstill One day a few months later Grace messaged me to say ldquoShersquos opening her eyes and moving aroundrdquoIt had been one hell of a rideThe writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals