Medicine is all about uncertainty, with neither diagnosis nor surgery or the process of recovery offering any guarantees
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There are some patients whom you can diagnose the moment they saunter into your clinic. Sometimes, it’s in the way they walk, either in their limp or the way they get into their chair. Sometimes, it’s in the hand they prefer to use to pull out their papers. Occasionally, it’s in the way they greet you—the intonation of their voice, the sound of their speech, the tilt of their head.
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In the first few minutes while a patient is settling down to narrate their story, a physician is accruing their compounded wisdom of the patients they’ve seen over the years to decipher what the problem is. There is an innate tendency in a doctor that prompts them to evaluate themselves before they evaluate the patient. Unless you’re a bariatric surgeon, where diagnosis isn’t much of a challenge; in neurosurgery, the possibilities are numerous.
The diagnosis is often challenging, but like in the case of Mr Joshi, it was staring me in the face—quite literally. The right side of his face was twitching incessantly. The forehead jumped as if it wanted to leave his body, his eye fluttered in a staccato fashion, the cheek was reverberating, and the angle of his mouth moved like it was dodging bullets. The left side of his face was placid and stayed still, a silent observer to the cacophony of its other half. He used his hands with futility to try and stop these involuntary movements so that he could start talking. It was one of the most severe forms of a hemifacial spasm I had seen in my life. Most patients have much milder versions of this, with a twitch here and a twitch there.
Nikhil Joshi was a retired insurance agent in his early 70s who had been plagued by this problem for over a decade. He wore a crumpled white shirt that was half tucked into his loose grey striped pants and carried a khaki bag, a look that some creative geniuses like to carry. His stubble was uneven too—the contracting muscles of his face must have made it hard for him to shave on the right—which only further typified the creative look. “He finds it exhausting even to make conversation,” said his wife sitting next to him, agonised. “Brushing my teeth, chewing my food is also very difficult,” he spoke for the first time, his voice transforming into a stammer from the twitching. Air escaped from the angle of his mouth, further muffling the sound.
“Do you feel any pain?” I asked, and he nodded his head sideways to say no. I wanted to differentiate it from another separate entity, where patients have sharp shock-like sensations over the forehead, cheek, or jaw, but without a spasm. We call that trigeminal neuralgia, where the sensory nerve to the face is compressed by an artery or vein in the back of the brain. In Mr Joshi’s case, it was his facial nerve, the nerve that controls the motor function of the face, which was being distorted by the constant pulsations of a large tortuous vessel pounding on it. I plugged in his MRI to show him the problem.
He was aware of it, but was scared to have an operation, which would entail mobilising the artery from the nerve such that there is no conflict between the two. It’s the same thing I do when my seven- and nine-year-old daughters fight: make space for them. Adopting surgical strategies to parenting is my thing.
“I have tried lots of medication, but it hasn’t helped,” he said, as I struggled to decipher the words coming out of his mouth. “Someone told me to even try marijuana, which I did, but it was of no use,” he confessed. “Have you tried Botox?” I asked; Botox, when injected at a different dose from that used by women as face fillers, can relax the muscles of the face, providing some relief. “Five times in ten years!” his wife answered. “It improves the condition very little, as it works for a few weeks and then it’s back to normal,” she spoke for him. “I think we should try and eliminate the root cause of the problem,” I said, trying to broach the real issue, “and that, I’m afraid, only surgery will do.”
“Guaranteed?” he asked, nodding his head in the way Indians do whist seeking an affirmation. “I can give you a guarantee of more than 90 per cent,” I told him, as if we were striking a deal. “The 5-10 per cent that remains will depend on how much the covering of your nerve has already been injured by the constant hammering,” I said, to cut myself some slack, adding, “and also, you have to leave something to God,” I looked straight at the three ashen lines on his forehead. He agreed to that with folded hands. “Yes, sir. Yes, sir,” he acknowledged God fearfully.
The thing about medicine is that all patients want certainty, but medicine is all about uncertainty. The human body is both simple and complex in simultaneity. Exactly the same surgery performed on different patients often yields varying results—unless you’re an obstetrician conducting deliveries. This is hard for patients to understand and doctors to accept.
A week later, he was under anaesthesia. We made a small incision behind the ear and drilled out a coin-sized piece of bone. I cut the dura covering the cerebellum and softly retracted it after releasing brain fluid, which would lighten the pressure inside. I zoomed the microscope smack onto the facial nerve after meticulously dissecting the web-like strands that traversed the blood vessels. There was an abnormally large artery grooving against the shoulder of the nerve and lifting it up, with another smaller one coursing through and through the nerve. “I can imagine why this guy’s face was gyrating away like that,” I told my colleague. We mobilised the artery from the nerve, and as I held them apart, my colleague perfectly placed a piece of fluffy Teflon between them, which served as a padding to keep them from touching each other. We did the same with the other smaller vessel. “I’m happy with this, are you?” I confirmed with him to check. “Yes,” he said unflinchingly, and so we closed.
When we wheeled him into the ICU after he had woken up, I went to check on him. I was a little shaken to see that his spasms had gotten worse. His eye would not open and his mouth would not move. The twitching persisted; in fact, it was even more rampant. Most patients have complete cessation of the twinge almost immediately after surgery. A zillion thoughts crossed my mind. The family was suspicious of my 90 per cent guarantee. I went back and analysed my surgical video and confirmed I had done a perfect operation. It has happened to me once before where I had decompressed the incorrect nerve, and had to go back the next day and rectify it. It’s a nightmare for any surgeon.
I appeased the patient and the family to hold on a little. By evening, the eye started opening. The speech returned. The spasms were down by 50 per cent. The next morning, they were gone, never to return. For the first time in 10 years, he was able to smile symmetrically. We still don’t know why some patients recover almost immediately after this surgery and some take a few weeks or months, while very few don’t improve at all. And that is why medicine is so mesmerising.
He returned two weeks later to remove his sutures. Clean shaven. Ironed shirt, neatly tucked in. Tighter pants. The same khaki bag, though. “Thank you for saving my face,” he said profusely. “Now don’t come back shaking something else,” I joked with him as we hugged each other good bye.
The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals.
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