Split cord, but unbroken spirit

A genetic defect in the formation of the spine in a foetus means severe impairment of motor and sensory functions. Neuroscience can fortunately, address neural tube defect to magical results

THE conception of the human embryo, the genesis of organs, and its eventual delivery in the form of a healthy baby is one of the most magical natural phenomena and yet, one of the most mundane. Magical because around twenty thousand processes need to synchronize to code an equal number of genes. Mundane because this is also the approximate number of babies that are born every hour across the globe; we share our birthday with about 20 million people.

The crystallization of the brain and spinal cord, probably owing to my inherent bias, is the most captivating. Simplistically, the central nervous system appears in the embryo at the beginning of the third week after conception as a slipper-shaped structure called the neural plate, which then gently and purposely elevates, folding its enigmatic edges into a tube. The cranial end of the tube closes around the 25th day and allows for the development of the brain, while the tail end seals a few days later promoting spinal cord development over which the rest of the musculoskeletal system and skin develops.

Varun was born with a small lemon-sized lump over his back. His parents were told to keep a close watch, as this was a cutaneous harbinger of a neural tube defect. The bottom end of the neural tube had not closed in the designated and sequential fashion, an aberration in one of the few thousand processing patterns. Luckily for him, the skin covering had formed coherently, not exposing the spinal defect to air, often seen in more severe failures.

In cases such as these, where severe defects are noted on a prenatal ultrasound, utilizing the augmented progress of surgical sciences, the foetus is exposed via a caesarean section by an obstetrician, the defect repaired by a neurosurgeon, and the baby placed back in the uterus for normal gestation to continue. This is sheer wizardry.

At four years of age, after having attained the usual motor milestones, Varun’s parents noticed the swelling increasing in size. He started having recurrent falls and losing control over his bladder. This happens as the spinal cord gets stretched, resulting in a dysfunction of the nerves responsible for bowel and bladder function and lower limb strength.

An X-ray showed that the arches had not fused at two lumbar vertebral levels. We call this spina bifida. It is through this defect that the spinal cord herniates, causing undue stretching and varying degrees of motor and sensory dysfunction. The MRI showed not only the little lump tugging on the spinal cord but also the spinal cord being split into two tubes four levels above, which we call a split cord malformation. For all that was going on inside of him, Varun displayed a stoic bravado, smilingly.

“Will he be able to get married?” was the first question the parents of this child asked after I had explained the details of his condition and the implications of surgery to untether the cord. While this appears to be the primary aim and life purpose of every Indian parent, theirs was a genuine concern arising from the preceding discussion: this entity or its treatment could be associated with sexual dysfunction later in life. Nonetheless, I have had this question asked to me by parents of kids with brain tumours, epilepsy, vascular anomalies, and even persistent backache. “We will cross that bridge when we get there,” I placated them.

“Will I able to play football?” was Varun’s more pressing concern–and rightly so. Children perceive the world more tangibly and calmly than adults. They are not mired by the chagrin of adulthood; their desires are simple and rudimentary, and joy is all they seek. I nodded an “of course, yes,” with audacious optimism.

A few days later, we made a straight and smooth incision down Varun’s back, neatly curving around the lump to incorporate it. We dissected through glistening pearls of fat leading us to the bony defect, and I was once again struck by how tissue in children is so pristine and clear, unalloyed from the wear and tear of adult life. The principle in any anomaly surgery is to expose the normal level above and below and only then proceed to fix the pathology. We proceeded to do this and untethered the cord. We ascended a few levels higher, converting the cord that had been split into a single tube by removing a wedge of fibro-cartilaginous tissue dividing it. We closed the defects in multiple layers, the more tedious part of the operation being to ensure spinal fluid doesn’t leak out, an entity that can be pesky to deal with post-operatively.

The global incidence of neural tube defects varies from one in a 1000 to one in 100 depending on the population one examines. India oscillates somewhere in-between. Besides strong genetic factors, the risk is directly linked to inadequate consumption of folic acid prior to conception and pregnancy. Several NGOs and family welfare programmes are supplementing these nutritional deficiencies in rural India.

Varun made a steadfast recovery over the next few years. Damaged nerves, like many other things in life, take time to recoup. He had to be catheterized at regular intervals to drain urine and his stool had to be digitally evacuated for a few months. On the brighter side, the strength in his legs had recovered sooner than expected and he was no longer falling. Every year that he followed up, he was stronger, sharper, and more determined.

A decade later, as he transitioned into a handsome adolescent gaining both form and function, he captained his school football team to a national victory. The split in his cord could not crack his crux. A fissure had, in fact, fortified his foundation. For everything that divides, the human spirit unites. Varun reminded me of this once again.

 

 

19 Comments on “Split cord, but unbroken spirit
  • A Kumarswamy says:

    Excellent.. Closest that the neuro comes in comparison to HIM

    Reply
  • Supriya Correa says:

    Goal!!!!
    Bravo Varun! But of course, the football “Hand of God” has been effortlessly dealt by you off the field, Mazda!
    Spina bifida:0
    Mazda & Varun: 1

    Reply
  • Dr. Neepa says:

    Well written, as always..
    Nice to know that the child is doing well..

    Reply
  • Priyadarshan Pradhan says:

    Thank you doctor Saheb for penning this.
    Forwarding

    Reply
  • Mehrook says:

    So true.
    I heartily agree with A. Kumarswamy.
    Keep up the good work.

    Reply
  • Khyati says:

    Varun & Dr Mazda team is winner.aptly said.. “For everything that divides, the human spirit unites. ”..kudos..!!

    Reply
  • Avinash Karnik says:

    Very well explained. 👌👌👌

    Reply
  • Mahashweta Biswas says:

    I love Varun’s spirit & his complete trust in his doctor You. Great teamwork. Kudos to Varun.

    Super Mazda

    Reply
  • CHANDAN R. SANJANA says:

    Excellent piece of writing as always. God bless Varun and his fighting spirit and may he achieve everything that he has set his sight on to achieve.
    All the credit goes to you and your team and the expertise in your surgery to give him this quality of life. To me it is wonderful to know that now there is a cure for almost everything that a human being can be afflicted with. And God bless the Hero’s like you that make things happen. 🙏

    Reply
  • Gloria Msampha says:

    Beautiful ending for the little boy. Can’t imagine the pain the parents went through when Varun was going through the tests and the operations to fix their little boy. It would have been years of looking after a boy with disability. Just to show that God does exist. Wonderful story as always.

    Reply
  • Hutoxi Doodhwala says:

    Excellent example of advanced science and technology, doctor’s skill , and the child’s grit.
    Superbly written as usual. Too good Mazda!
    May you always be blessed by Ahuramazda and continue to heal all that come to you for help.

    Reply
  • Rita Singh says:

    Excellent information doctor.ur a genius and thoroughly dedicated to ur work.Both together always bring best results.

    Reply
  • Megan Correa says:

    Mazda you’re like a kid to me…if you operated on him 10 years ago, imagine how young you were and how skillful a surgeon you must be…you are truly so talented…amazing!

    Reply
  • Raj B says:

    Great job. Well explained.

    Reply
  • Dr Shivkumar V Dalvi says:

    Congratulations,Dr Turel.u’ve simplified a complex subject so beautifully,giving scientific n important details to garnish ur article.The final result was a happy icing on the cake.Grt going.Do continue ur writings.

    Reply
  • T George Koshy says:

    Mazda..u have a flair for writing and making complicated embryology and neurosurgery seem so deceptively simple..thank God the kid recovered..keep writing ..don’t stop writing and operating..

    Reply
  • Vinod Ahuja says:

    You continue to astound. Your article’s are well written and thought provoking. Thanks.

    Reply
  • Farengiz says:

    Wonderfully penned. Bravo Mazda !!!!

    Reply
  • Zubin Bhesadia says:

    Dearest Mazda,

    You are a Neuro-magic Master with your scapel & pen just as Dumbledor with his Wizardry-magic in the Harry Potter series!

    Moving from the movie anecdote to reality, the Win Factors for Varun were:

    1. His undying spirit, his ambition to become a football player, his parents constant care & follow-ups…and your “of course, yes,” with audacious optimism that boosted his spirit manifold.

    2. Your expertise in discovering the root cause, planning out the process, executing it with pin-point precision & ensuring a successful & favourable outcome…with the luck factor being in the affirmitive with you & Varun. And undoubtedly, the whole team of professionals who also are a part of the Success Story.

    Such experiences laced with faith, opitmism & positivity & success are the ones which become a Treasure Trove to reflect upon when you take up the next set of cases to work upon or when things go tough at times in life. They also radiate inspiration onto others who are facing similar scenarios & help tne cope/rise again & also onto those who want to become a Doctor or Surgeon to heal the world & make it a better place.

    Remember the Phoenix bird from Harry Potter whose tears have magical powers to heal wounds almost instantaneously? Such is the story of Varun & all others in distress who have risen once again with your efforts at the Phoenix & your expertise & equipments which have the healing power equivalent to its tears.

    So my dear Mazda – the Dumbledor of Neuroscience, keep creating more stories of magic & happiness along with your Team of Wizards. More power to you…always.

    Reply

Leave a reply

Your email address will not be published. Required fields are marked *