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TECHNOLOGY REVIEW JULY / AUGUST
surgeon orders an MRI. There are a couple of potential pit-
falls here. One is that the patient (especially an NPH patient
with memory problems) may forget to tell her neurosurgeon
about the scan. Furthermore, the radiologist may not realize
that the shunt is programmable or that an MRI can change
the setting. I have seen patients whose settings had been o -
kilter for more than a year following an MRI scan.
Ideally, when a patient with a programmable shunt sus-
ceptible to this problem undergoes an MRI scan, imaging of
the shunt valve is ordered for the same day, so that the valve's
setting can be confirmed. These images then have to be read
by a radiologist or neurosurgeon who is familiar with that
particular shunt. If the setting is o , then the neurosurgeon
needs to reset the valve and perhaps even send the patient
back for repeat imaging.
A more advanced programmer uses a built-in ultrasound to
confirm a valve's setting without requiring separate imaging.
But this introduces two new problems. The first is that some
patients complain about getting ultrasound gel on their heads
and hair. Second, the programmer is so sensitive and tempera-
mental that it may not work in rooms with either too much
noise or too much electrical equipment. This pretty much
describes most doctors' o ces. In my first experience with
the new programmer, I tried close to a dozen times to adjust
the valve setting before I gave up, used the old programmer,
and sent the patient o for fluoroscopic imaging.
Meanwhile, a competing manufacturer has designed an
altogether di erent programmable shunt that is advertised as
MRI compatible. Not only that, but its programmer is almost
pocket-sized, whereas the programmer for the old shunt is
housed in a heavy, unwieldy, briefcase-like container. When
I heard about this new shunt, I jumped at the opportunity to
try it. It seemed almost too good to be true: no need to worry
that MRI scans would change the settings, no need to bother
with fluoroscopy, and no need to lug a heavy programmer. My
first few cases with the new shunt went fine from the surgi-
cal standpoint. But it turned out that despite what I had been
led to believe, MRI compatibility cannot be guaranteed. As I
learned from a representative of the company that made the
competing shunt I'd just forsaken, the fine print reveals that
follow-up imaging of the new valve after an MRI is still o -
cially recommended. Conclusion? Again, I can't win.
I once spoke with a freelance writer who was observing his first
operation in preparation for a piece on brain surgery. In the
crowded operating room, he watched a nurse as she struggled
to push a surgical microscope into position, trying her best to
move the heavy and unwieldy base amid the tangle of cords
and tubes draped across the floor. I asked what he thought of
the operation so far, expecting him to say something about
the wonder of the human brain. Instead, he said that he had
worked on a ship once, and that a ship's deck would never see
such a tangle of ropes.
A young surgeon relishes such tangly cases---tough, com-
plex, time-consuming, high-tech. While the operation is in
progress, the room might be crammed with people---two
surgeons plus a surgical assistant, two or three nurses, one
anesthesiologist, one or two neuromonitoring technicians
(who usually sit quietly in a corner), a "cell-saver" technician
(to run the machine that cleans and recirculates lost blood),
one or two industry reps who stand back and field questions
from sta about their equipment, and perhaps a radiology
technician if fluoroscopy is being performed. The size of the
crowd can be almost comical. More and more trays of surgical
instruments are brought in as the surgeon encounters tricky
conditions or unusual anatomy.
I've found, though, that as surgeons get older, they appre-
ciate the simpler cases more and more. Some of the happiest
senior surgeons I know have reduced their practices to just a
few nice cases---the ones that require the least support sta , the
least technology, and the least clutter in the operating room.
The other day, while I was doing a quick carpal-tunnel opera-
tion using only a few simple instruments, I had two thoughts.
I've found that as surgeons get older, they appreciate the simpler
cases more and more. The other day, while I was doing a quick
carpal-tunnel operation using only a few simple instruments,
I had two thoughts. The first was that this procedure is one of my
favorites. The second was that I must be getting old.
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