Medical Elective: J’s First Week in Neurosurgery

When neurosurgery is mentioned, the tough-as-nails, practical, go-getter kind of personality is conjured up. These are neurosurgeons. They’re badass, you know, they’re the only ones who dare to go into the cranial vault. Otolaryngology and dentistry muck about the rest of the head, orthopaedics do spine and sometimes brachial plexus/peripheral nerve injuries, plastics and ophthalmology also use microscopes but nobody messes with the big boss itself: the brain.

It came as a bit of surprise that the neurosurgery residents give off such a laid-back vibe.

That said, they’re there at 6.30am in the morning and usually leave past 6.30pm in the evening. Excluding night calls, they’re pulling 12hr shifts and having to take care of baby kids in the meantime (one of the residents’ baby girl’s picture was on the OR computer, she was ADORABLE).

Over here in Canada, the students get to do things they wouldn’t have done previously. For instance, during morning ward rounds, one resident passed me a sheet and said, “Hey, J., I’ve got a neurosurg consult for you. Go and see her. Not now, but later around 9am.” It was a consult from Neurology for a patient with headache and change of mental status of 2 weeks duration, multiple lesions on MRI and suspected granulomatous angiitis. Purpose of consult was for biopsy of lesion. In the mornings, students can help write progress notes, which are notoriously short and to-the-point in neurosurgery anyway. For example, a patient with a frontal lobe bleed: “Still not verbalising. Obeys commands. Plan for continued observation.”

Besides the teaching lessons, most of the time is spent in OR (Operating Room, known as Operating Theatre [OT] in Singapore) or in the clinics. This week, J. watched an excision of a fairly small esthesioneuroblastoma, which was a collaboration between a visiting ENT surgeon and a neurosurgeon. The neurosurgeon did a frontal approach to allow the ENT surgeon to excise the tumour. The other major operation J. watched was an anterior corpus callosostomy for a patient with Lennox-Gastaut Syndrome to reduce the frequency of her “drop attacks” (usually atonic seizures). That was a long operation, taking about an hour to set up and 5 hours to gently dissect through and cut the anterior 2/3rds of the corpus callosum, taking care not to completely sever it at the risk of causing dissociation syndromes.

In the two clinic sessions, J. first shadowed a resident in his clinics (the attending was a spinal surgeon). The typical case is that of back pain and spinal stenosis, though none of the cases were very typical. There was one case of a follow-up of temporal lobectomy to control severely elevated intracranial pressure post head trauma. It serves as a valuable lesson to us that jumping out of a moving vehicle while severely inebriated is not a good idea. The second clinic with a more general neurosurgeon saw J. actually taking clinics, taking a history and examination before discussing the case with the attending and dictating the case records.

It’s a good start. You know things are going to be interesting when the first rounds you attend have a patient with gelastic seizures secondary to a hypothalamus lesion.

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