Exciting Progress

This week there was exciting news published in the New England Journal of Medicine about the potential benefits of intrauterine surgery on a fetus with spina bifida (see also Spina Bifida Association).  In the past, similar approaches have resulted in unacceptable risks to the mother and complications of the pregnancy.  With advances in technology and technique, these risks have been limited and in fact no additional risk to the mothers were found.  Dramatic positive results included (full text at NEJM link above):

• The first primary outcome, fetal or neonatal death or the need for a cerebrospinal fluid shunt by the age of 12 months, occurred in 68% of infants in the prenatal-surgery group and in 98% in the postnatal-surgery group (relative risk, 0.70; 97.7% confidence interval [CI], 0.58 to 0.84; P<0.001) 
• The second primary outcome — a score derived from the Bayley Mental Development Index and the difference between the functional and the anatomical level of the lesion at 30 months — was significantly better in the prenatal-surgery group than in the postnatal-surgery group (P=0.007). 
• In post hoc analyses, infants in the prenatal-surgery group were more likely to have a level of function that was two or more levels better than expected according to the anatomical level (32% vs. 12%, P=0.005) and less likely to have a level of function that was two or more levels worse than the expected level (13% vs. 28%, P=0.03) than were infants in the postnatal-surgery group. 

The New York Times hailed the research as opening the door to the great potential for fetal surgery.  Many days I have happy to be a neurosurgeon, some days I feel GREAT to be a neurosurgeon.  Reading the results of this study, as someone who has spent many hours with these patients and their families, I am thrilled!

The Social History

A  49 year old woman came to my office last week with 5 years of debilitating headaches.  Her neurological evaluation included an MRI which  revealed a pineal region cyst.  After several years getting interval MRIs focusing on this benign cyst until she took her care into her hands and sought the opinion of a neurosurgeon.  I looked through her extensive catalogue of MRIs and could confidently reassure her that this cyst was not a worry and not the source of her headaches.  She was relieved but asked the expected question, "Then what is causing my headaches?"  I think I know but before I answer let me divert for a moment...
Pain-in its many forms and expressions-is probably the greatest challenge for physicians.  You can't see it or touch it, there are no tests that reliably predict it or measure it (there are scales that are used but they remain completely subjective), and it is always a "symptom" rather than a diagnosis (think appendicitis as diagnosis/right lower abdominal pain as symptom OR brain tumor as diagnosis/headaches as symptom).  Despite all this, pain is always real-one might complain more than another or let it interfere with life more but anyone who comes to my office complaining of pain IS REALLY experiencing pain.  Because pain is the end product expression of many factors and modulations-both physical and psychological.  And to date, science has failed us miserably in understanding the real mechanics of pain.  Sure I could enumerate molecular knowledge about receptors, agonists, antagonists, signal transduction and the like but in the end, it wouldn't get any of us closer to understanding how and why patients suffer, how stress can bring on a headache or aggravate back pain, or how a wedding can temporarily halt longstanding cancer pain (as just a few examples of a myriad of pain enigmas).

Early in my career, I learned an invaluable lesson from an enormously gifted and talented plastic surgeon (who I count as both friend and mentor), Dr. Jane Petro.  We were jointly running a peripheral nerve clinic and had to evaluate a patient with RSD (Reflex Sympathetic Dystrophy as it was known then, now referred to as Complex Regional Pain Syndrone-CRPS).  After the patient left, she engaged the team in a discussion of a striking paper that demonstrated the very high correlation of RSD with abuse (both child and spousal abuse) (References below).  The clear implication was that our life events clearly impact our response to injury and disease in ways that remain unknown to us.  But while we may not understand the mechanism, it is evident that all health care providers have to more closely attend to understanding the lives of our patients in order to administer to their medical needs.
Which brings me to the Social History-probably the most under-rated component of a patient's history (beyond the perfunctory smoking, alcohol, and drug history).  Despite the pressures and my role as a sub-specialist, I always ask a few questions about home, employment and background.  At the least, I know a few things about my patient and it helps me view them as people (fathers, sisters, colleagues, etc.).  And sometimes the information turns out to be critical for successful outcomes or interventions.  For example, I recently performed a spinal fusion on a woman who was clearly in a threatening marriage and based on that information, I made sure she went to rehab post-op, even though she was likely medically well enough to go directly home.
So how does this all relate to my headache patient? Well, by just asking one simple question, she revealed a recent divorce after several years of a nasty separation.  Clearly, her headaches were temporally related to the onset of marital strife.   Trust me, this woman truly suffers from terrible headaches-they are real and life-altering, neither imagined nor exaggerated.  How? I don't know. Why headaches and not some other complaint? I don't know.  What is the best intervention now for this woman? I don't know.
But I do know, taking the Social History remains a critical component of understanding and providing the best care to our patients.

References:
Abuse-related injury and symptoms of posttraumatic stress disorder as mechanisms of chronic pain in survivors of intimate partner violence. - Wuest J - Pain Med - 01-MAY-2009; 10(4): 739-47

Prevalence of interpersonal abuse in primary care patients prescribed opioids for chronic pain. - Balousek S - J Gen Intern Med - 01-SEP-2007; 22(9): 1268-73

Sexual and physical abuse in women with fibromyalgia syndrome: a test of the trauma hypothesis. - Ciccone DS - Clin J Pain - 01-SEP-2005; 21(5): 378-86

Psychologic factors in the development of complex regional pain syndrome: history, myth, and evidence. - Feliu MH -Clin J Pain - 01-MAR-2010; 26(3): 258-63

Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st ed.; CHAPTER 82 - Domestic Violence

Katz: Comprehensive Gynecology, 5th ed.; Chapter 10 - Rape, Incest, and Domestic Violence

Patient Wisdom

Sometimes my patients utter wisdom that I feel blessed to share with others.  Here is a recent representation from just one day in the office:

• As to my children, I don't worry about the first 10 years (of their lives), it is the second 10 I lose sleep over.
• Parental wisdom comes in waves.  At first children think their parents the wisest humans in the world.  Then there comes a time when they know absolutely nothing.  This may last for 10 years or more.  Then the next generation arrives and suddenly the parents regain their rightful place as all knowing and wonderful.
• You may have been taking care of these types of patients for years but I have been dealing with my mother for more than 40-I think I know her well.
• If you ask the wrong question, you may get an answer you don't need nor want.
• I realize there is a price to pay for everything.
• I can only ask that you do your best and that you are honest.  No one is perfect.

Everyday, my patients share themselves with me.  I am eternally honored by their trust and the wisdom they share with me-it has enriched my life.