Through the Neck & Into the Brain

The 20-year-old baker in the University of California hospital in San Francisco was dying of a tumor at the base of his brain. The swelling growth was pressing on the basilar artery, one of the brain's major blood suppliers, and eight of the main nerves in his skull were being compressed into uselessness. The patient's speech was garbled and slurred, he regurgitated much of the little he could eat, he had double vision, part of the right side of his body was paralyzed, and he suffered from fits of uncontrollable, inappropriate laughter.

The tragedy was compounded by the fact that once X rays and arteriograms had confirmed their diagnosis, the doctors were stumped. Bold brain surgeons have been probing and cutting deeper and deeper inside the human skull, but the floor of the brain box, where the patient's tumor was growing, has remained virtually inviolate. Nerves, arteries and other vital parts of the anatomy are all crammed into that small central sanctuary behind the nose and mouth. There they rise through openings in the floor of the skull and reach toward the brain above (see diagram). So complex is the collection of vital mechanisms, it has defied generations of neurosurgeons, and the young man seemed doomed.

Window in a Pivot. Then his case came to the attention of the neurosurgery department at the University of California Medical Center. There, like so many neurosurgeons before him, Dr. George C. Stevenson had been challenged by that seemingly impregnable floor of the skull. While studying blood flow in the brains of monkeys, he had learned how to slice through the anatomical maze at the brain's base with the aid of a binocular surgical microscope, and he had practiced putting tourniquets on the basilar artery.

He and his neurosurgical associates at the university had tried parts of such an operation on 33 cadavers. They found that while nerves, blood vessels and other soft structures were difficult enough to cut through, the worst obstacle was an important but little-known bone, the clivus, which balances on the very top of the spinal column to form a pivot for the skull. There was only one way to get past the clivus, and that was to cut a window in it. To make this possible, a whole trayful of special instruments had to be designed and built. Those instruments were ready when the young baker was admitted to the U.C. hospital.

Atlas of Anatomy. The surgeons needed free access to the patient's neck region, so they cut a hole into his windpipe and inserted a tube through which he got all later anesthesia. They clamped his jaws tightly shut and fastened his head in a frame to hold it at an unnatural angle--at first, 15DEG backward and 20DEG to the left. They made a long incision from below his ear around past the windpipe. At last, U.C.'s Dr. Roland K. Perkins and Dr. Ronald J. Stoney could start moving closer to the target.

It was three hours before they got there because of all those vital parts in the way. The list of items that had to be delicately dissected and pulled aside reads like an atlas of anatomy. The surgeons had to fracture the top vertebra with a Hall air-driven drill, and then the seclusive clivus was exposed at last. They attacked this with an air drill, and cut a 1-in. by 2-in. window in the bone's sloping forward face. This exposed the tumor.

Some of it was soft enough to be removed by suction, but parts of it had to be cut away. As more and more was removed, the surgeons could see the basilar artery straightening out. They could realize the release of crippling pressure on the patient's nerves. The window in the clivus was sealed with a piece of the patient's own muscle, and the tedious job of putting his delicate structures back in place began. The whole operation took eleven hours.

Back to Work. For a week the patient was immobilized with sand bags to promote healing. By then the nerves and muscles on his right side were already improving, and within a month he had full use of his right arm. Last week he was back at work.

His had been a relatively rare cancer, but the operation is expected to be equally effective for more common tumors. Even some noncancerous conditions, including strokes caused by the bursting of a brain artery on the floor of the skull, now seem susceptible to surgical therapy. Even as Dr. Stevenson was reporting this week to the Harvey Gushing Neurosurgical Society in Manhattan, surgical teams from two other medical centers described their own successes with similar operations.

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