Collateral Damage

A 30 year old woman presents with a history of progressive neck and back pain, followed by weakness, numbness, and tingling in her arms and legs. Eventually, a diagnosis of a spinal tumor is made. The intradural cervical (as in neck location, not reproductive organ) mass has grown quite large and may be a metastasis from an unknown primary cancer, though no obvious source is found. She undergoes an all-day cervical-thoracic laminectomy for removal of the tumor.

The anesthesia for this case has interesting aspects. The mass has grown so large that the patient cannot extend her neck; the steroids to shrink the tumor cause a Cushingoid body habitus and a rudely-named "buffalo hump"; edema in her face has made her tongue swell. All these factors make her a difficult airway, but using a video laryngoscope, we are able to intubate her smoothly. I did not want to write about this case because of the anesthesia, though, but because of what happens surgically. In order to resect the tumor, the surgeons cannot help but enter the dorsal columns and adjacent tissue.

Those of us who remember our basic neuroanatomy from medical school remember that the dorsal columns carry sensory information. Intraoperative neurologic testing confirms that the patient loses her somatosensory evoked potentials. When the patient wakes up from the surgery, she will not have feeling in her arms and legs. Even more concerning, the tumor is quite close to the motor pathways and despite the surgeons' care, neuromonitoring shows a decreased signal for one of the arms.

At the end of the surgery, which we consider successful, the patient's symptoms will be worse than when we started. True, the tumor is all out, but the collateral damage is not insignificant. It will take months to years for her to regain sensation and strength, if at all. She will no longer be able to work, and her life will be permanently changed.

For most surgeries, patients come out better than they started. Although there may be perioperative pain and discomfort, we hope patients eventually will be able to do more, have less pain, be healthier, live longer, stay happier. When I have a case in which this is not the outcome, it really strikes me. "First, do no harm" is a mantra that simplifies clinical situations too much. We weigh risks and benefits, and sometimes have to sacrifice one thing for another.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.