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Winter 2012

A Lot of Nerve

Date: February 1, 2012

A Lot of Nerve
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This time, the patient. When Marichi Capino was diagnosed with a spinal tumor, she turned to a familiar team to get her through.

Monitoring nerve function is crucial during surgery. Just ask Marichi Capino, who can speak both as medical specialist —and patient.

In early 2006, the problem started out so subtle and mild that it was easy to ignore: a twinge here and there in her left leg, some numbness and tingling when she sat too long. It must be sciatica, thought Maria Rosario Capino, known to her friends as Marichi. That would be the simplest solution.

But as time wore on, she started to suspect a more sinister cause. When, five years later, an MRI showed a tumor in her upper back clearly pressing on her spinal cord, Capino knew exactly what she was in for.

That’s because she’s one of 10 technicians at Hopkins Hospital in the intraoperative neurophysiological monitoring team (IOM), a group tasked with keeping an eye on how well patients’ nerves function during the complex, and often harrowing, neurosurgeries that take place in operating rooms across the hospital. The technologists protect patients by giving surgeons an early warning before that nerve function goes awry.

With the cause of her symptoms now diagnosed, Capino set down a path that she knows well from the other side. This time, she’d be the patient—and the doctors, nurses, anesthesiologists, and her own colleagues on the IOM team would be caring for her.

Capino joined the IOM team just a year before her symptoms started. After half a decade with Hopkins’ Child Life Department, where she met the psychosocial needs of school age medical-surgical patients and pediatric burn patients, the former pediatrician, originally from the Philippines, was ready for a change.

She knew nothing at all about intraoperative monitoring when she started her on-the-job training in 2005. The basic procedure is straightforward. Once a patient is under general anesthesia, but before surgery begins, the IOM technologist inserts a series of needles into different parts of the patient’s body. Trailing these needles are wires color-coded to different parts of the body—red for a specific muscle in the right arm, for example—so IOM technologists know exactly what they’re working with when they plug the opposite end of the wire into an amplifier, which in turn feeds into a computer.

Taking advantage of the natural way that nerves communicate—with bursts of electricity—one needle in a pair acts as a stimulating electrode and another acts as a recording electrode. To make sure a nerve pathway remains healthy and intact during surgeries, the IOM technologist periodically sends a stimulating current to the first electrode that is picked up milliseconds later by the second one.

The current is strong enough that “it feels like when you stick your finger in an outlet and get shocked,” Capino says. It’s powerful enough to make the stimulated part of the body twitch and jerk, so patients only receive stimulation at certain times during the surgery. For example, current usually doesn’t run while surgeons are making the first cuts. Though anesthesia renders patients blissfully unaware, says Capino, that current gives pivotal information to the IOM team member, who passes this on to the surgeons performing the procedure.

The brain, spinal cord, and all their associated nerves form a structure like a highway system in the body, explains Sergio Gutierrez, associate director of IOM and Capino’s immediate supervisor on the IOM team. When surgeons are working on or near these anatomical structures, he says, they can inadvertently cause the equivalent of a roadblock, disrupting the flow of electrical impulses from one part of the thoroughfare to another.

It might happen, for example, when the surgeon needs to slide a nerve or spinal cord out of the way to access a tumor, clip an aneurysm shut, or untwist a scoliosis patient’s misshapen spine. Any of these actions, he says, can decrease or completely stop the current flowing between electrodes, which shows up when technicians send periodic currents—information that the IOM technologist sees on the computer screen that registers the signals. 

A current dipping or dropping, seen in an absence or lowering of a series of squiggles on the computer screen, requires immediate action. When that current flow is compromised, so is the nerve, which could translate into either a temporary loss of function for patients—the best-case scenario—or a permanent disability, such as paralysis or loss of sensation.

“It’s challenging because you have to interpret these results in real time,” Gutierrez says. “This is not the kind of thing you can store in your computer, see it in two days after that, and interpret it then. If the surgery causes an injury, you have to identify it and inform the surgeon right away to solve the problem in the moment.”

Fixes might include temporarily stopping the surgical process to review whatever triggered the signal loss or giving the patient steroids or mannitol to reduce inflammation during or after the procedure. When nerve damage is unavoidable and permanent—a rare occurrence but, nevertheless, a real possibility with any neurosurgery—the surgeon is able to alert the patient and family so they can make plans to accommodate a disability.

Not every hospital offers IOM (it’s generally available only at larger surgical centers) and not every hospital that has IOM has its own dedicated team, explains IOM director Eva Ritzl. Often, hospitals rely on outside companies to supply IOM technologists; this doesn’t lend itself to strong relationships with the hospital’s own surgical team or specialized expertise on any of the procedures that hospital performs, she says. In contrast, Hopkins maintains a dedicated IOM team (most have MDs); not only do technologists know all the surgical teams well, but they are also well-versed on the unusual and complicated neurosurgeries performed only here, to the tune of sometimes 10 or more per day.

Most of Hopkins’ neurosurgeons fully recognize the value of IOM; they lean heavily on information delivered by their IOM technologist to know just how far to push a particular surgical technique without damaging nerves. The information also allows surgeons to get through a harrowing surgery knowing a patient’s nerve function remains intact. But few patients or their families are ever aware that the IOM team is involved in their care, Ritzl points out. In the operating room, the technologists often fade into the background, she says, rarely earning the credit they deserve.

“We rarely get any recognition,” she says, “even though what we do is incredibly important for protecting patients’ safety.”

The job certainly isn’t for the timid or shy. Gutierrez points out that IOM technologists need to be ready to speak up at any moment, even though they might not be delivering good news. The job gets even more challenging with the nature of Hopkins’ often intricate procedures that require lengthy stays in the operating room.

“If you don’t like stress,” he says, “this is not for you.”

But Capino readily excelled at the job. After joining the IOM team, she quickly caught on to the wires’ color codes, how to place the patterns of electrodes for each type of procedure, and what the signals on the screen signified. Highly meticulous, she arrived early every morning to review the particulars of each surgical case on the lineup. She developed strong relationships with each member of the neurosurgery faculty and IOM team—which made her diagnosis—and its aftermath—all the more challenging.

In 2011, having literally limped along with the pain, numbness, and tingling in her left leg for nearly five years, Capino had decided in June to get another opinion. An avid golfer, she suspected that the forceful twist of swinging clubs might have herniated one of her disks. She went first to a sports medicine doctor at another local hospital, who ordered an MRI of the lower part of her spine.

Nothing glaring showed up in the spine section targeted by the MRI. But the doctor spotted a shadow in a snippet of the spine at the top of the image. “Possible tumor,” he wrote in his report.

Scared, Capino requested a second MRI of just that upper section of her spine. When the results came in, they showed an obvious tumor, about the size of a marble, between her 11th and 12th thoracic vertebrae. The tumor wasn’t huge, but neither was the space it was wedged in. It was already pressing precariously on Capino’s spinal cord, causing all of her symptoms. And unless it was removed right away, she knew, the ever-growing tumor could have far worse consequences.

“I see it every day,” she says, thinking back on patients she’s monitored through their own surgeries to remove spine tumors. “I could see myself having loss of function, long- term disability, or even paralysis. It was a rude awakening because I knew that I [would soon] be the one on the operating table.”

Capino realized that time was of the essence. So she immediately began to plan. Spending every day in the operating room with neurosurgeons and their colleagues, performing procedures in line with the one she would soon have, had given her a unique perspective on who she wanted on her own team. Topping the list was Hopkins’ George Jallo, a neurosurgeon who often handles pediatric cases but has a strong expertise in conditions that affect the spine.

Soon after she received her second set of MRI results—and after she called the radiology company to double-check that they were definitely hers—Capino sent an email to Jallo telling him that she had a spinal cord tumor and asking him if he’d be willing to be the surgeon.

“I said okay, but I didn’t realize right away that she was the patient,” Jallo recalls. “I thought she was asking about a friend or family member.”

Jallo pulled up Capino’s records within Hopkins’ computerized record system and took his own look at the MRI. A closer examination showed that the tumor was crammed into the intradural space, a fluid-filled area between the spinal cord and a tough membrane that covers it. The tight squeeze was irritating Capino’s spinal cord, shoving it to the side and causing it to swell.

“We really needed to get it out sooner rather than later,” Jallo remembers thinking.

After meeting with Capino and going over the details, Jallo set a surgical date just weeks away. Capino remembers those weeks being some of her saddest. The 46-year-old was filled with worry about the procedure and the possible consequences she might have to deal with for the rest of her life. And she was concerned about how being a patient might change her relationship with her IOM colleagues.

Not only would they have to face the stress of caring for one of their own, but the particulars of the surgery might make future interactions awkward with her team members: Based on the tumor’s location, Capino would be face down and naked. Patients sometimes urinate or defecate during surgery because of the effects of anesthesia. “You’re really in all your glory during this kind of surgery,” she says.

Not knowing how or what to tell her colleagues, Capino tested the water with a neurology fellow, showing her the MRI image but not telling her whose it was.

“She said, ‘Oh my God, is that patient walking?’” Capino recalls. Not incredibly reassured by that reaction, she slowly started spreading the word to the IOM team once her name was listed on the patient roster for upcoming surgeries.

“People were pretty scared for her—clearly, this was something major,” remembers Ritzl. “But at the same time, I think [we] felt confident because we know what to do so that we’re able to protect her during surgery.”

As Capino’s team members absorbed the news, they quickly realized that one of them would need to be the technologist on her surgery. Understandably, Gutierrez says, few were eager to be chosen for this task. The IOM technicians are like a family, he says, and few medical practitioners jump at the chance of treating their own family members.

But the choice was Capino’s. After selecting Jallo and her anesthesiologist, Lauren Berkow, she chose her IOM technologist: Charles Lule, a stickler for details and a ferocious advocate for patients. Capino says she knew Lule would be a terrific asset to her case.

On the day of Capino's surgery, a Friday in July 2011, she showed up early in the morning, only to face a nerve-racking wait because beds in the surgical suite were full. Sitting with her best friend, Lauren, in the waiting room, she kept remembering how she and her colleagues had often seen other patients trailing into the same room, looking nervous while they waited for their names to be called.

“I couldn’t stop saying, ‘I can’t believe this is me,’” Capino says.

After changing into a hospital gown and stockings—a standard precaution to prevent blood clots in the legs during surgery—she greeted a stream of visitors who came to see her in the pre-op area: aunts who had flown in from Dallas, a cousin who snapped photos and helped lighten the mood, colleagues from around the hospital.

The wait seemed interminable, but eventually her anesthesiologist came in to put her to sleep before she was wheeled into the operating room. There, her surgical team sprang into action. Jallo’s special team of nurses and scrub technician bustled around the room, placing blue drapes around the sterile areas and arranging all the tools that Jallo and his colleagues would need for the procedure. Berkow monitored Capino to make sure she remained well sedated. And Lule placed all the necessary electrode needles to keep track of Capino’s nerve function during surgery.

A few minutes before Jallo made the first incisions, Lule started nerve stimulations to generate and record pre-incision baseline signals. Although his colleague was the one on the table, Lule recalls that the atmosphere in the room was matter-of-fact.

“For me,” he says, “it was like any other day.”

As Lule kept his eyes on the screen evaluating the acquired signals, Gutierrez periodically stopped by to take a peek, and Ritzl watched the signals remotely from her own office. Throughout the smooth and quick surgery—lasting just 90 minutes, from beginning to end—never once did Capino’s signals vary from the norm.

As Jallo lifted the tumor from the incision in Capino’s back, Gutierrez started clapping. Others in the room quickly joined in. The tense atmosphere immediately switched to one of immense relief, with smiles all around, he recalls.

When Capino woke up in the recovery room, still groggy from anesthesia, she found Ritzl sitting on the end of her bed. Ritzl could tell her with confidence that, from the perspective of her nerves, she’d be just fine. After all, that’s what the signals said. There would be no danger of Capino’s greatest fears: no loss of function or paralysis. In fact, according to Jallo, Capino would be back playing golf six weeks later—a prediction that proved accurate.

Now nearly a year past her surgery, Capino says that she has a new appreciation for what her patients go through—both those who have tumors the same as or less serious than her own, and those facing even more dangerous scenarios. Her own experience helps her relate better to them, and also to the unique level of care available at her own workplace, including the services of the colleagues she sees every day.

“I really appreciate life more and more each day,” she says. *

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