The Surgical Imbalance

Unsteady gait cannot be attributed to old age alone. A detailed neurological examination may help tackle an otherwise reversible problem

A seventy-two-year-old man was escorted into my clinic by his two able-bodied sons, each of them holding their father’s hand and elbow to support him better. He walked with a robotic tightness but with very little control over where his next step would fall. After about 8 minutes of trying to shuffle into a chair, he finally sat amidst a few moans. “Everything hurts,” he lamented. “My neck hurts, my back hurts, and I just can’t walk without support,” he groaned as he tried to adjust himself through his aches. “I feel like I’m walking on cotton wool,” he explained, narrating what many patients with cervical spinal cord compression specify.

“Any other problems?” I questioned. I usually allow my patients to finish saying everything they have to before I ask any leading questions. “My hands are weak and numb, and stuff keeps falling from them; I can’t button my shirt and my handwriting is like a drunk man’s,” he quipped. “How’s your control over passing urine?” I asked. He shook his head sideways and the corners of his mouth drooped with embarrassment at having to talk about it in front of his grown-up boys. “I’m extremely unhappy with my life,” he concluded.

In patients who have multiple complaints, I usually ask them one direct question to help me with my surgical decision-making. “Out of all your grievances, if there is one symptom I could help you recover from the most, what would it be?”

“I want to be able to count my money,” he said without the slightest hesitation, adding, “especially the 2,000-rupee notes. They just keep slipping out of my hand.” To lighten up the conversation a bit, I told him that I faced the same problem, but without any hand weakness to blame.

His MRI showed an overgrowth of bone and thickening of ligament that was compressing his spinal cord from the 3rd to the 6th cervical vertebrae. I pointed out to him the pencilling of his cord at those four levels. It was like a tourniquet that needed to be released for his spinal cord to be able to breathe again. Owing to the abnormal curvature of his spine that we could see, I explained why we would need to realign the spine by inserting a few screws and rod to contour it back to an elegant lordotic curve.

Within a few days, he was lying prone on my operating table with his head firmly fixed on a clamp. We use intraoperative neuro-monitoring for these cases that allows us to know if we are causing any damage to the spinal cord, because even a little manipulation in a compressed cord could lead to catastrophe. After cleaning and draping him in the usual fashion, we cut deeply down the centre of the back of his neck and separated the muscle off the bone. We then placed the screws as needed and cut a fine trough on either side of the four vertebrae to lift off the compressing element as a single block. This was executed to perfection but as soon as we decompressed the cord, there was a loud bellow from the back. “We’ve lost all our signals!” the physiologist exclaimed. This, in regular parlance, meant that the patient was completely paralysed – both hands and both legs. My heart sank into my stomach. This is the most unnerving piece of information you can ever give a surgeon in the middle of surgery.

The old man’s words, “I’m extremely unhappy with my life,” struck me even harder because I had potentially transformed that into abject misery. He would be awake but quadriplegic. I remembered something I’d read somewhere: “That’s the thing about unhappiness. All it takes is for something worse to come along and you realize it was actually happiness after all.”

Instead of being emotional and fraudulently philosophical, it was time to recalibrate and see if this could be reversed. I asked the anaesthetist to bring up the blood pressure and we started a steroid infusion. I always pray when I’m in deep shit. Within 20 minutes, the signals reappeared, and my heart began to gently rise back into its normal position. Sometimes, sudden decompression of a chronically compressed cord can result in precipitous changes of perfusion (the passage of blood) to and within the spinal cord. This can be disastrous if not recognized and dealt with immediately. To my absolute delight, he woke up without any damage. He stated that he felt much better, and by the time he was discharged, he said he felt less ‘tight’ and more secure in his balance.

Imbalance while walking is not something that should be attributed to old age and left undiagnosed. Deficiency in Vitamin B12, especially in vegetarians or alcoholics, can afflict the spinal cord resulting in the same imbalance that a physical compression would. Diabetes damaging the nerves can cause one’s feet to burn and make them feel unsteady. A lumbar spine stenosis or even arthritic knees can make it difficult to walk. A disruption in the balance centres of the brain, certain brain tumours, or simply an excess accumulation of fluid in the brain can also make one’s gait unsteady. A detailed neurological examination is warranted before it can be attributed to old age; it would be negligent to miss out on corrective treatment for something that’s readily reversible.

Six months later, my patient walked into my clinic with his two sons, this time without holding their hands. He removed a crisp bundle of 2,000-rupee notes from his pocket and began to count them in front of me – effortlessly and cheerfully. Just when I thought (obviously in jest) that I would be at the receiving end of a few of those notes, he stuffed the stack back and gave me an empty but firm handshake. His grip was better than mine, and the power and function in his limbs were back to normal. And to me, that was priceless.

34 Comments on “The Surgical Imbalance
  • Mrs sunaina saraf says:

    Good morning sir
    Well done 👍
    Ultimately its the faith in almighty which helps u pull through rough times
    God bless!

    Regards
    Mrs sunaina N saraf

    Reply
  • Dr Atul Mashru says:

    Good job

    Reply
  • Dr Indu Bansal says:

    Superb and crisp piece of writing in common man’s words without any medical jargon. This is what makes you stand out apart. More power to u always.

    Reply
  • Gaurav Lalwani says:

    Wow Mazda. What an inspiring story. Tense but under the right care was treated in a timely fashion. Intuition and timely decisions is so critical and applies to every high pressure situation. You have the great gift of both.

    Reply
  • Supriya Correa says:

    Beautiful piece Maz! Another Sunday, another rollercoaster.
    As usual you give us punch-in-the-gut, heart-stopping moments…that desperate urge to skip reading and scroll down to what finally happens, vs enjoying the actual post. These should be part of book that you simply must write. Can’t wait for it to be out someday.

    Reply
  • Natwar Panchal says:

    Superb Dr. Informative to me atleast.

    Reply
  • Dr Sunil Dhiliwal says:

    Amazing as usual. Addition to your fan club. Heart touching articles always…

    Reply
  • Kashmira says:

    Dr Mazda,
    Your stories are inspiring, informative and engaging. The balance of humour and simplicity is par excellence.
    Thank you.

    Reply
  • Constance says:

    Beautiful encounter laced with anxiety filled moments. Thank you for helping your patients regain the ability to perform their simple Activities of Daily Living (ADLs). Certainly keeps us all sane in this insane world.

    Reply
  • CHANDAN R. Sanjana says:

    Oh wow Mazda. Like they say all is well that ends well. My heart truly skipped a beat reading this article and what happened during the surgery! I can imagine how terrifying it must be for the surgeon himself. This is where your skill as a surgeon comes into place. Bless you

    Reply
  • Tozar Heerjee says:

    Congrats Doc for literally giving the patient a new life.

    Reply
  • Dr Satyen Mehta says:

    Very well written Mazda. All these gamut of emotions is something we Spine surgeons go through everyday. Expressing these emotions in words requires a lot of skill which you obviously have in abundance. Keep it up!

    Reply
  • Dr L.N.Tripathy says:

    Another one of your surgeon’s nightmare write up! Well written and well.done as usual!

    Reply
  • Khyati says:

    “That’s the thing about unhappiness. All it takes is for something worse to come along and you realize it was actually happiness after all.”..loved the article and this quote.keep treating.keep writing.

    Reply
  • Navzer Irani says:

    The first life was God’s and the second spell was given by you. Combination of prayers and skills always work as the Creator works through you.

    Reply
  • LeahG. says:

    Thank you Dr Mazda for yet another beautiful piece of “infotainment” or “ edutainment “, written to be understood by ordinary people! A smile, a giggle, a laugh and a tear are always guaranteed for me whenever I read your writing! What a blessing!

    May God continue to bless you for using your big brain and big heart to be a blessing to your patients!

    Reply
  • Anuradha Karnik says:

    The challenges that you face in the OT and how you have to overcome them speedily is amazing and very well expressed by you in your article. Well done and good luck

    Reply
  • SANOBER IRANI says:

    Well done Mazda , you made his life worth living again.you truly are an angel in disguise in reversing his psychological age …. If not his biological one . We are truly blessed to have you in our lives ‼️‼️

    Reply
  • Vipul Shah says:

    Hello Dear Mazda Sir……..

    So much up & down during the procedure is unbelievable & lot of tension what happens next in OT……..

    We ordinary people feels of reading a suspense Nivel piece by my CHETAN BHAGAT …….

    👍👌

    Reply
  • Monica says:

    Every clever DOCTOR who puts his heart above all else is thrice blessed. He is divine.
    May your tribe grow!
    May your words flow.
    Many guru-blessings, Mazda.
    PS: Your OT experience was terrifying yet electrifying.
    Your conclusion subtly amusing!
    Keep going……..👍❤️

    Reply
  • Rita singh says:

    I wish we had more doctors like u.many a times I wish I lived in Bombay to b able to b near a doctor of ur intelligence and dedication.May God give u the power to heal the pains of more and more mankind.The narration as usual is most interesting.

    Reply
  • Aspi Aibara... says:

    For a layman’s point of reading ..U started with a slow engine…Later it became interesting .. until the sudden brakes of decompression of spinal cord ..etc etc .. That 20 minutes that u must have taken out must be a foot in mouth …
    Loved the article .. simple ..crisp ..& to the point …Felt as if I was operating on a patient..
    GOD BLESS YOU….

    Reply
  • Dinesh Shikotra says:

    Dr Mazda, Awesome way you tackled the challenge faced on the operation table. Love your faith in Almighty when you said ‘I always pray when I’m in deep shit’. Amazing Doc, You have magic fingers. God Bless You !!!

    Reply
  • Vineeta Rao says:

    You have such amusing encounters with your patients! You gently infuse useful medical information, humor, suspense, philosophy in your stories and make them so entertaining ! Always looking for your next one .

    Reply
  • Mahashweta Biswas says:

    Congratulations on your quick thinking during the surgery which saved his life & he is able to walk now

    All the best for all your future surgeries

    Reply
  • Brij Bhushan Chachra says:

    Hi – your honesty and sincerity is evident in the way you write and express. Thank you and great to have surgeons like yourself around! God bless!

    Reply
  • Cyrus says:

    Enjoyed reading this! As always unpretentious and to the point.
    If I may, just curious as to why a sudden perfusion would do that? Is it the change in bp affecting the nerves and then why would raising the bp help?

    Reply
  • Dr Shivkumar V Falvi says:

    Very well written like a taut detective story with ups n downs. Honestly giving response like an ordinary person. Also enumerating very succinctly all possible causes behind such problem. I congratulate u in ur wonderful achievement to bring out a happy ending to ur case.

    Reply
  • ADI ENGINEER says:

    Doc, By now we have read so many episodes of your insightful surgical experiences that we run out of vocabulary to complement you on your literary and surgical skills. A neoro sugeon should definitely have nerves of steel. However the bit about not taking imbalance lightly is an eye opener. Keep up the good work.
    Adi Engineer

    Reply
  • Vinod Ahuja says:

    A beautifully crafted and fluently written article that is profound and sharply perspective. Thanks .

    Reply
  • Dr Vilasini Choudhary says:

    One of the best article I have ever read. Very informative with simple but interesting language.

    Reply
  • Di says:

    Wow! Well done during the operation! Amazing work as always… beautiful article n lovely ending that is priceless… when i read the line “i always pray when am in deep shit”, my response me too! Lol.. With ur flair for writing u can become best seller author with million copies sold.. make it ur retirement plan 😉

    Reply
  • Atman Daftary says:

    Enjoyed reading your sunday write ups

    Reply
  • Atman Daftary says:

    Enjoy reading your sunday write ups

    Reply

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