Case 2 : Spinal Cord Tumor

 

Archer was a 65-year-old family man with a strong sense of faith.  He lived his life honestly with a devout sense of responsibility to his family and his work.  He was well respected in his community, in particular for his charity.  Unfortunately, his family noticed that he was having difficulty walking.  He was tripping and seemed to lose his balance frequently.  He was losing strength in his hands, his handwriting deteriorated significantly.  He used to like going out for walks, but now had difficulty even make it to the bathroom.  He felt stiff and began to notice numbness in his extremities. 

 

Archer sought the help of his family physician who referred him on to a neurologist.  An MRI was performed demonstrating a malignant spinal cord tumor involving the upper cervical spine extending into the lower brainstem.  The spinal tumor was inside the spinal cord.  He saw a local neurosurgeon who immediately recognized the gravity of the situation and the need for specialized attention.  Archer was advised that his condition was terminal and to consult with a neurosurgeon with more specialized skills for second opinion.

 

Archer was devastated with this news.  His family tried to console him, but Archer retreated deeper into his faith and sought the guidance of his Lord.  He spent many days praying and found his peace with God.  At the same time, his family searched for a physician with an answer.

Archer’s son was in medical school and he immediately began researching neurosurgeons in Houston.  They talked to many people in the community and were advised to see Dr. Ajay Bindal.  His entire family accompanied him to my office.  I could see the anxiety on everyone's face.  Interestingly, Archer appeared unusually very calm.

 

I reviewed Archer's films, took his history, and examined him.  Archer had classic radiographic findings for a malignant tumor of the spinal cord that extended into his brainstem.  These findings were confirmed by the radiologist who was very confident of the likely diagnosis.  This tumor was damaging his spinal cord nervous tissue, resulting in his difficulty with control of his arms and legs.  I explained this to him and his family. 

"So what can we do?"  asked Archer.

 

I advised Archer that excision of the tumor was unlikely and that this was a malignant tumor.  In order to biopsy it, we would have to open the spinal cord at its most dangerous point near the brainstem and that it was very likely that he would suffer further neurologic loss of function and even death with the operation.  He could lose control of his ability to breathe and require a ventilator.  He could be “locked-in” i.e.  awake, but unable to move his arms or legs.  I had suggested the option of simply letting the tumor take its course and enjoying what little time he had.

“So, how much time do you think I have?”  retorted Archer.

 

“Oh, probably three months to a year,” I responded.

 

“No...  That's not true.  You see, I have prayed.  I believe in God and I have faith that I'm going to live many more years.” Archer spoke.

 

“Well, science says otherwise.” I responded.  I always felt it was important to be blunt and direct with patients so that they don't get false expectations.

 

Despite our disagreement on how long Archer would live, he agreed to proceed with surgery.  He was taken to the operating room on October 24, 2000.  I opened the back of his skull and upper cervical spine exposing the brainstem and upper cervical spinal cord.  Using the most advanced of operating room techniques including microscope, lasers, monitoring devices, and micro-dissecting tools, I opened the spinal cord and exposed the tumor.  I proceeded to biopsy the tumor and sent a specimen to the pathologist.  The pathologist indicated that the biopsy had the appearance of a more benign slower growing tumor, but that this was nearly impossible as there were only a few reported cases in the literature of such a tumor in this location.  Pathologic diagnosis from biopsies done at the time of surgery are often incorrect and when an unexpected result is obtained, clinical judgment is required.

 

I was still convinced that the lesion was likely malignant, but held the possibility that perhaps it was slower growing, given the biopsy result.  I thought to myself,  “Perhaps I can take out more tumor and cure him of this disease.”  I proceeded to chase the tumor further into the brainstem.  I couldn't help but think of Archer's expectation that he was going to live many more years.

 

As I removed more tumor, I began to doubt myself as to whether this was the right course of action.  The enemy of “good enough” is “better yet” and I would hate to cause harm seeking a better result.  I continued to remove more tumor but thoughts crossed my mind “Ajay, what are you doing?”  It was as if my hands were compelled to remove the tumor in order to achieve Archer's expectation of long survival.  After it was all done, I realized that the tumor had been completely excised.  It then struck me, “What if Archer’s brainstem was damaged and he was locked-in?”

 

After the operation was over I went to the recovery room to examine Archer.  I was relieved to find that Archer had no new significant neurologic deficit.  He spent many weeks in the hospital, requiring rehabilitation and made a remarkable recovery.  He still had difficulty walking, though it was improved.  His final pathology came back an intra-spinal cervical medullary schwanoma.  Indeed, there are only a few reported cases in the literature of this diagnosis, which is a slow-growing tumor.  Despite slower growth, the tumor would continue to grow and still cause neurologic dysfunction and death over time.

 

Archer returned three months later to my office with an MRI scan for my review.  He appeared as cheerful and fulfilled as ever.  His family was anxious for the results.  To my amazement, the MRI scan showed no evidence of any residual tumor.

“So Dr. Bindal, how long do you now think I'm going to live?”

 

“Well, Archer, it seems you were right.  You are going to live a long, long time.”

 

“Dr. Bindal, I want to give you this token to keep in your office as a reminder never to lose faith.”

 

He handed me a gift that I still keep in my office to this date.

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