Neurosurgery and other ruminations

2011-09-04T12:24:00.000-07:00

I read an article about the rap group Das Rascist today in New York magazine. Das Rascist is a group of three non-pure-white rappers who interject humor about race that is often intended to offend whites. Of course, it ends up working just the opposite and the group is gaining popularity. Their dilemna, is seems, is that they are striving to obliterate rascism, making race an inconsequential issue. Yet they are making a name for themselves by playing on rascism. So, it got me to thinking, is rascism passe? It is indeed becoming more difficult to identify those who are pure white, much to the anger of a few extemist psychopaths and sociopaths. But as "pure white" disappears, fear and anger will not. That is because there will always be "otherness" and it seems to be in the nature of humans to have to distinguish other from self. The more "other" someone appears to be, the more fear it evokes in some. So why is "other" so fear-inducing? It is because "other" challenges our sense of "self." Can an "other" devour us? Can we sustain our personal beliefs, our understanding of how we should behave, of how we should interact with others, who we allow ourselves to love, where we wish to live, how we wish to earn a living, if others approach all of these issues differently, especially if far differently? It is this fear that drives people to cruel acts, whether it is bullying a child in school or taken to the extreme, flying passenger-filled airplanes into occupied buildings. The question that has confounded humanity for millenia is how to erradicate this fear which leads to hatred and violence. The answer may be too simple for many to accept but it may be the answer, none-the-less, one that many great men and women have offered: to respect life above all else and to respect every individual's right to pursue their own happiness without infringing on other's equal right to the same. This is a challenge that requires understanding and compromise and above all, love. It is the foundation upon which every personal relationship is built and upon which this great country was built.

Flora and Fauna

2011-07-23T21:43:00.000-07:00

The cactus blossoms
From the parched desert earth
As the seedling stretches blue-ward
From the dank forest floor
In my hand I hold a tooth
Pushed out by the one behind it
A man must grow
Where he has been planted
His pain not penance
But a passing rain

Casey Anthony and Belief

2011-07-10T15:03:00.000-07:00

Apparently two thirds of Americans believe that Casey Anthony murdered her daughter. The jury did not believe this to be the case. That is because the jury understood that belief is not a basis on which to make decisions that profoundly affect another person's life. In order to make a judgement about another person, especially when it comes to imprisoning that person, restricting their freedom or even taking their life, belief is insufficient. Fact, or evidence is needed to make a determination as to the validity of a claim. As a matter of fact, no pun intended, this is what science is all about. People wish to believe a whole host of things especially when it is meant to make their life better in some way. When it remains purely personal, each individual can maintain their belief no matter how outlandish but when it comes to imposing it on others, we run into huge problems. The same is true in the healing arts. Lots of people offer remedies and treatments that they say is helpful and often may even try to benefit financially from offering these treatments but most often these are based on beliefs at best. Though it is true that experience may precede scientific proof and anecdotal experience may certainly be true for the one having the experience, offering it to others in a authoritative manner requires science and science is complicated and labor intensive and sometimes excruciatingly time-consuming but it will ultimately offer an answer that goes beyond belief. This is what, in effect, the Casey Anthony jury did in coming to it's verdict. It did not decide that she had not killed her daughter but rather that the evidence was not there to make a truthful determination that she had and it is what most of us would have concluded if we had gone through the same rigorous scientific process. It is a principle we should always apply to things that matter in our lives.

Osama Bin Laden Headshots

2011-05-02T11:52:00.000-07:00

Yesterday American Forces found and killed Osama Bin Laden. Of course, throughout the world there are always skeptics, those who doubt that he was really found and that it was really he who was shot and killed. Well, apparently there are photographs taken after he was shot in the head that show his face recognizably but also show the bullet wound through or close to his eye that reveals blood and brain oozing out of the wound. Officials now question whether it would be too disturbing to the public to see these images. Even after years of having seen individuals with open head injuries with brain exposed, I am always disturbed by the sight. However, in my opinion it is less disturbing than the videos of beheadings, than the sight of young soldiers with dismembered limbs and life-long disfigurements, than the sight of innocent people having to jump to their certain death out of burning, collapsing buildings. We were forced to witness horrific carnage on September 11, 2001 and beyond. Seeing the mortal wounds of the mastermind behind all this demonic terror is far less disturbing than that which was witnessed by many millions on September 11, 2001. Those who do not want to see the image of Osama Bin Laden's mortal wounds don't have to look at them but for those who doubt and those who need confirmation to be able to move on with their lives, seeing is believing.

Serena Branson and complex migraines

2011-02-20T09:10:00.000-08:00

It turns out that after two days of extensive testing, Serena Branson's aphasia was diagnoses as a complex migraine. What she has stated in an interview is that she had not been feeling well with a sense of tiredness and the onset of a headache before the speech disturbance began. That was a big clue. Never-the-less a full work-up needed to be done, including MRI of the brain, MRA (MR angiography, looking at the blood vessels) of the neck and the brain, EKG and echocardiogram as well as blood tests. When it was found that all of these tests were normal than the symptoms could be utilized to make the final diagnosis.

So how could a migraine cause the symptome of speech dysfunction? First, the phenomenon of migraines needs to be understood. Fundamentaly, the arteries in the brain constrict in the first phase (prodromal phase) and then dilated. Though the constriction may cause some headache, the dilation phase is generally what causes the severe headache. When the blood vessels dilate, there can be a reduction in blood flow to the area of the brain most affected. Depending on which area is affected, symptoms related to that area develop. This is referred to as an aura. If it occurs in the occipital area which has to do with vision, then the aura will included symptoms such as seeing spots, flashing lights, zigzags or moving lines, like blades of a fan. This usually lasts minutes but can last up to almost an hour. If it affects the prefrontal gyrus which controls movement then there may be problems with movement of a limb or with the face. When it effects Broca's area in the base of the posterior frontal lobe, then, though the individual may know what they want to say, they can not get it out coherently. This is exactly what happened with Serena Branson. Many other symptoms may also occur such as tingling, confusion, even hallucinations. Following this aura, the migraine headache usually ensues but it may not always occur so when it is only the aura which is the significant symptom, it may be difficult to diagnose until other causes of the neurologic dysfunction are excluded. Rarely, the vasospasm and reduction in bloodflow can be so severe that a stroke can occur. When auras occur regularly and can be temporarily disabling then medication can be used such as inderal to limit these troubling events.

Those who suffer from these symptoms should meet with a neurologist to find the right treatment including avoiding triggers such as certain foods or even odors or scents.

Serena Branson's Speech Arrest

2011-02-16T19:44:00.000-08:00

America witnessed a dramatic ezample of speech arrest or expressive aphasia when Serena Branson began speaking incoherently when reporting on the Grammies while on- air. According to news reports, her symptoms resolved within a few minutes at the most and she refused further medical assistance after the paramedics found her vital signs to be stable. There is great interest in knowing what could have caused a dramatic and sudden but thankfully brief loss of speech.

There are numerous possible causes of sudden aphasia that fully resolves. These include transient ischemic attacks, seizures, brain hemorrhages, low blood pressure, low blood sugar, multiple sclerosis and inflammatory conditions of the brain and blood vessels.

What comes to mind first is a transient ischemic attack (TIA). This is due to a brief reduction of blood flow to a portion of the brain but with resumption of adequate blood flow before damage to that area occurs. The reduction in blood flow can be due to a piece of "debris" breaking off a plaque in a narrowed, diseased artery in the neck or when there is such a high degree of narrowing of an artery in the neck or brain that briefly the blood flow through that artery is profoundly reduced. These events usually occur in individuals over the age of sixty. Another cause of TIA can be due to an abnormality in the heart such as an infection in the heart or an abnormal heart rhythm. In these instances a small piece of "debris" can be released from the heart into the blood stream and then into the brain. A TIA can also be caused by birth control pills, blood disorders and drugs such a cocaine. Inflammation of arteries, refered to as arteritis is another cause of TIAs.
TIAs are highly significant because they are often precurors of major strokes leading to permanent neurologic dysfunction. Therefore, it is important to diagnose the cause of a TIA and treat it appropriately and rapidly.

A focal seizure can present as a brief loss of neurologic dysfunction including a brief episode of aphasia as Serena Branson experienced. Again, there are numerous possible causes for the new onset of a seizure. A brain tumor, drug reaction, brain hemorrhage or low blood sugar are all possible causes of a focal seizure.

Even when someone recovers fully and feels well after an brief episode of aphasia, as apparently was the case with Serena Branson, the individual needs a full and careful medical evaluation. Not only do they need an MRI of the brain, which may, in fact, be normal but the arteries in the neck and the heart need to be fully evaluated. Additionally blood tests need to be performed. Without appropriate diagnosis and treatment, a permanent stroke could ensue or a minor hemorrhage in the brain could lead to a major hemorrhage. If a seizure has occured, a subsequent seizure might be more profound. The early stage of an infection such as encephalitis could become a life-threatening infection of the brain.

Certainly Ms. Branson will have a thorough medical evaluation and hopefully the cause of her episode of aphasia will be found to be readily treatable and she will not suffer future neurologic dysfunction.

Whiplash and Brain Injury, Part 1

2010-08-22T10:09:00.000-07:00

Whiplash can cause brain injuries
Part 1 of 2 Part blog

I am proud to be a co-author of an study published in the medical journal, Brain Injury that describes a change in the brain of a significant number of individuals who have suffered a whiplash injury.

Patients who have not suffered demonstrable injury to their spine often, over time, have been considered to have no clear cause of their symptoms. Many have been felt to have unsubstantiated injuries and that their symptoms were either psychological or for secondary/monetary gain.

In 95% of normal individuals, the cerebeller tonsils, a part of the brain that sits in the back of the skull and controls coordination, rests above the opening at the bottom of the skull (where the spinal cord passes from the brain into the spine). In 5% of individuals, these cerebeller tonsils can project through the opening (foramen magnum)--essentially meaning that part of the brain dips into the top part of the neck. This condition is know as cerebeller ectopia or Chiari malformation. This may cause multiple symptoms including headache, neck pain, numbness and weakness in arms and hands, weakness in legs and bladder dysfunction.

20% who have whiplash have Chiari malformation, study says.

This study has demonstrated that over 20% of individuals who experienced a whiplash injury have cerebeller tonsils below the foramen magnum when an MRI is performed with the individuals in the sitting position. Individuals who do not have a whiplash injury do not show a drop of the cerebeller tonsils in the sitting position.

It is uncertain whether this finding is a causative factor for any of the symptoms of the whiplash syndrome or if the same trauma that caused this brain injury can caused other, yet to be defined injuries that lead to the painful symptoms.
Further study is needed before we can say whether surgical intervention is warranted in these cases of cerebeller ectopia.

Speak to your doctor if you've had whiplash, or suffer from persistent headache, neck pain, numbness and weakness in arms and hands, weakness in legs and bladder dysfunction.

Cross-word

2010-08-08T20:38:00.001-07:00

Cross-word

After the craniotomy to remove the enormous
Blood clot in the brain of this octogenarian
The children remained in the waiting room,
Allowing their parents a moment of privacy.
As he remained unresponsive,
His wife approached his side and spoke to him,
“I have been doing the cross-word puzzle without you.
It’s a good thing it’s Monday.”
He awoke on Tuesday.
A blood-clot to his lungs killed him on Friday.
Sunday the cross-word puzzle was no doubt
Excruciatingly difficult
But she certainly completed it
For what else was she to do?

Ezriel Kornel
2/8/05

What it takes to be an excellent neurosurgeon

2010-08-01T10:41:00.000-07:00

I proctor pre-med students during winter and summer breaks and one of the students asked me an interesting question the other day, what does it take to be a good neurosurgeon? Well, first of all, you want, not a good neurosurgeon but an excellent one. So, what does it take to be an excellent neurosurgeon?

The first thing that is crucial and without which the rest would not matter, is judgment. A neurosurgeon needs to be able to establish a diagnosis and then determine when surgery is necessary, when it is not and what other treatment options are available. Once that is established they need to decide what operation is best for each individual patient and their particular condition. It is also of great importance and a matter of judgment that a surgeon be confident in their decision and in their capability in performing a particular procedure. They should be willing to confer with colleagues to help with decision-making and should be able to turn to other colleagues to assist with surgery. Should another colleague have greater expertise in a particular operation, the excellent neurosurgeon should refer the patient to that physician.

Secondly, the neurosurgeon needs to have the surgical skills to be able to perform these operations. Generally, well-trained neurosurgeons who have completed an accredited training program and have become board-certified possess the requisite skills. But, in truth, just as some professional musicians are greater virtuosos then others, the same applies to surgeons. It is a strange gift that skilled surgeons possess, just as certain musicians, artists, mathematicians and writers are more gifted. In fact, I believe everyone has a gift, they just need to recognize where that gift lies, acknowledge it and express it.

Thirdly, an excellent neurosurgeon needs to have great confidence without manifesting a huge ego. They need to know that they can do the job. Anxiety in surgery can interfere with the best results. However, a big ego will prevent anyone from obtaining advice from others and will make them incapable of listening to constructive criticism. They are less likely to learn from their mistakes (and everyone makes mistakes at one time or other, being human after all and not divine.)

Being patient is another skill that neurosurgeons need to possess. If they make a decision too quickly they may perform unnecessary or even dangerous surgery. Sometimes patience allows a problem to manifest or resolve itself in a different manner. With prudent waiting surgery may not be necessary or a different procedure may be deemed appropriate.

Respect and compassion for their patients is another quality that an excellent neurosurgeon should possess. When this is present, a good bed-side manner is always manifest. This needs no further amplification.

Finally, an excellent neurosurgeon must have love and passion for their work. Nobody wants a neurosurgeon who is eager to get you out of the door, or rush to leave their side when lying in a hospital bed or to rush to get through the day. Though neurosurgeons have a life outside of the operating room with families, friends and other interests they should always feel a deep gratification when performing their work. When they are in the operating room all their attention and focus should be on the surgery they are performing.

When all these qualities are evident, you are most likely to experience the best results possible and the quickest and most complete resolution of your illness.

Quiet Hero

2010-07-28T21:22:00.001-07:00

Rita Cosby was my special guest on BackTalkLive this past Sunday. Though the show deviated a bit from its usual format, I found what Rita had to share with us about her Dad and his experiences in WWII to be profoundly significant. Of course, since my father, like hers, was from Poland and experienced the horrors of the Nazi invasion, we felt an immediate bond. However, her father and mine had very different experiences. While my father at sixteen fled his small town with his uncle towards Russia and survived in a labor camp there, Rita's father, living in Warsaw joined the underground as a resistance fighter. His story is fascinating and among other things, reveals how people can tolerate great pain when they have a higher, meaningful goal. However, the long-term effects of that pain can lead to psychological problems later in life. I found the book "Quiet Hero, Secrets of my Father's Past" hard to put down, enlightening about a very dark time in the world's history (not so long ago) and profoundly moving. It is beautifully written in a very engaging manner. I urge you to pick up a copy of this book right away. I have no doubt you will find it to be an important addition to your library.

barcelona and england

2010-07-17T20:38:00.000-07:00

The photo album of a great vacation.

Back from vacation with a poem for you

2010-07-17T18:44:00.000-07:00

I returned this week from a wonderful vacation. Away for two weeks, it has been years since I took that long a vacation and it really allows one to shed all the stress of work and life at home. My first visit to Barcelona and I found it delightful and fascinating. I was very taken by the genius of Gaudi. We visited the Costa Brava for a few days and it was a dramatic landscape with twisting mountain roads down to the Mediterranean. Off we went to London and a run from Piccadilly Circus through Green Park and into Hyde Park on a beautiful Sunday, what a delight. We were joined by our three daughters, two of their friends, my mother and my mother-in-law. Surrounded by females I felt quite the fortunate fellow (yes,even with my mother-in-law, whose company I enjoy immensely). The highlight, however, for all of us was a stay for one full week at Fairlight Hall near Hastings. Designed by the designer of Hyde Park in 1850, Fairlight Hall is a magnificent 70 acre estate with gardens, meadows, fields and forests, all sitting majestically above the sea. The home, based on Battle Abbey is a fairy-tale castle. Our hosts, the Kowskis, were generous and gracious. We ate breakfast in the courtyard with the peacocks, visited the lamas, alpacas and sheep and picked fresh vegetables, fruits and flowers from the extraordinary gardens, designed and managed by Tony, the head gardner. We were constantly guided by the dogs of Fairlight Hall, the gang leader, Storm was always by our side with ball in mouth. The flowers and dogs remind me of a poem I wrote about ten years ago. I would like to share it with you.

Does a Rose Recognizes its Roseness

Does a rose recognize its roseness?
Does it delight in its own perfume,
In the velvety softness of its petals,
In the iridescence of its coloration?
Does it recoil from the barb of its thorns?

The dog seems certainly to know itself
Content in its licking
Happy to run with abandon
After whatever draws his attention
Showing no reluctance in seeking an affectionate hand

And how am I to know if I am the rose
Thinking I had for so long been the dog
Perhaps both, perhaps neither
Perhaps all possible things

Ezriel Kornel
October 10, 1999

More "you don't have to be a brain surgeon to know that..."

2010-06-12T13:56:00.000-07:00

You shouldn't drive on "empty."

Even with a cell-phone, it's, at a minimum, a waste of your time sitting on the side of the highway with traffic whizzing by while you wait for your gas delivery. A few moments spent doing something seemingly trivial will prevent us from having to spend what may seem an eternity doing something we truly don't enjoy.

Speaking up for Israel

2010-06-09T20:55:00.001-07:00

Rational people must read this and help spread this type of rational analysis:

Subject: Spanish Politician castigates US and Israel bashers.

Pilar Rahola

Pilar Rahola is a Spanish politician, journalist and activist and member of the far left. Her articles are published in Spain and throughout some of the most important newspapers in Latin America .
"Why don't we see demonstrations against Islamic dictatorships in London , Paris , Barcelona ?
Or demonstrations against the Burmese dictatorship?
Why aren't there demonstrations against the enslavement of millions of women who live without any legal protection?
Why aren't there demonstrations against the use of children as human bombs?
Why has there been no leadership in support of the victims of Islamic dictatorship in Sudan ?
Why is there never any outrage against the acts of terrorism committed against Israel ?
Why is there no outcry by the European left against Islamic fanaticism?
Why don't they defend Israel 's right to exist?
Why confuse support of the Palestinian cause with the defense of Palestinian terrorism?
And finally, the million dollar question: Why is the left in Europe and around the world obsessed with the two most solid democracies, the United States and Israel, and not with the worst dictatorships on the planet? The two most solid democracies, who have suffered the bloodiest attacks of terrorism, and the left doesn't care.
And then, to the concept of freedom. In every pro Palestinian European forum, I hear the left yelling with fervor: "We want freedom for the people!"
Not true. They are never concerned with freedom for the people of Syria , or Yemen , or Iran , or Sudan , or other such nations. And they are never preoccupied when Hammas destroys freedom for the Palestinians. They are only concerned with using the concept of Palestinian freedom as a weapon against Israeli freedom. The resulting consequence of these ideological pathologies is the manipulation of the press.
The international press does major damage when reporting on the question of the Israeli-Palestinian issue. On this topic they don't inform, they propagandize.
When reporting about Israel , the majority of journalists forget the reporter code of ethics. And so, any Israeli act of self-defense becomes a massacre, and any confrontation, genocide. So many stupid things have been written about Israel , that there aren't any accusations left to level against her.
At the same time, this press never discusses Syrian and Iranian interference in propagating violence against Israel ; the indoctrination of children and the corruption of the Palestinians. And when reporting about victims, every Palestinian casualty is reported as tragedy and every Israeli victim is camouflaged, hidden or reported about with disdain.
And let me add on the topic of the Spanish left. Many are the examples that illustrate the anti-Americanism and anti-Israeli sentiments that define the Spanish left. For example, one of the leftist parties in Spain has just expelled one of its members for creating a pro-Israel website. I quote from the expulsion document: "Our friends are the people of Iran , Libya and Venezuela , oppressed by imperialism, and not a Nazi state like Israel ."
In another example, the socialist mayor of Campozuelos changed Shoah Day, commemorating the victims of the Holocaust, with Palestinian Nabka Day, which mourns the establishment of the State of Israel, thus showing contempt for the six million European Jews murdered in the Holocaust.
Or in my native city of Barcelona , the city council decided to commemorate the 60th anniversary of the creation of the State of Israel, by having a week of solidarity with the Palestinian people. Thus, they invited Leila Khaled, a noted terrorist from the 70's and current leader of the Popular Front for the Liberation of Palestine, a terrorist organization so described by the European Union, which promotes the use of bombs against Israel .
This politically correct way of thinking has even polluted the speeches of president Zapatero. His foreign policy falls within the lunatic left, and on issues of the Middle East , he is unequivocally pro Arab. I can assure you that in private, Zapatero places on Israel the blame for the conflict in the Middle East , and the policies of foreign minister Moratinos reflect this. The fact that Zapatero chose to wear a kafiah in the midst of the Lebanon conflict is no coincidence; it is a symbol.
Spain has suffered the worst terrorist attack in Europe and it is in the crosshairs of every Islamic terrorist organization. As I wrote before, they kill us with cell phones hooked to satellites connected to the Middle Ages.And yet the Spanish left is the most anti Israeli in the world.
And then it says it is anti Israeli because of solidarity. This is the madness I want to denounce in this conference.
Conclusion:
I am not Jewish. Ideologically I am left and by profession a journalist. Why am I not anti- Israeli like my colleagues? Because as a non-Jew I have the historical responsibility to fight against Jewish hatred and currently against the hatred for their historic homeland, Israel . To fight against anti-Semitism is not the duty of the Jews, it is the duty of the non-Jews.
As a journalist it is my duty to search for the truth beyond prejudice, lies and manipulations. The truth about Israel is not told. As a person from the left who loves progress, I am obligated to defend liberty, culture, civic education for children, coexistence and the laws that the Tablets of the Covenant made into universal principles.
Principles that Islamic fundamentalism systematically destroys. That is to say that as a non-Jew, journalist and lefty, I have a triple moral duty with Israel , because if Israel is destroyed, liberty, modernity and culture will be destroyed too.

More of "You Don't Have to be a Brain Surgeon to Know That..."

2010-05-29T20:14:00.000-07:00

Here's the next item:
After opening, refrigerate products that say "refrigerate after opening."

Following simple instructions can lead to the successful avoidance of major aggravations down the line. Going to the kitchen cabinet and opening pasta sauce only to find a science experiment is not conducive to a hearty appetite (and scraping off the mold does not make it safer for consumption.)

Bono's Back Surgery

2010-05-26T21:11:00.000-07:00

U2 front-man, Bono, suffered a herniated lumbar disc and underwent surgery to remove the extruded disc fragment, according to his German neurosurgeons. This is a common operation but is not done emergently unless nerves in the spine are severely compressed leading to either profound muscle weakness such as a complete foot drop or abrupt bladder and bowel dysfunction accompanied by weakness and numbness in both legs. The later is know as cauda equina syndrome. When one of these two conditions occurs, emergent surgery is recommended to prevent permanent nerve damage. A full recovery is generally expected. When the primary symptom is pain and mild weakness of a muscle as well as some numbness is present, then non-surgical treatment is generally initiated first. This is the more common scenario and with time, the herniated disc generally shrinks and can be resorbed, resulting in resolution of symptoms without surgery. When symptoms do not resolve or when the situation is emergent, than a procedure called a discectomy is performed. This can be done via a "standard" laminectomy in which an approximately three inch incisicion is made in the center of the lower back, muscle is stripped off the spine, a portion of the spine know as the lamina is removed to enter the spine and then the disc fragment is removed. This can also be performed via a microdiscectomy in which the incision is smaller and the amount of bone removal is less and a microscope is used to visualize the inside of the spinal canal and the disc fragment. The procedure I prefer is even less invasive, what is refered to as an endoscopic microdiscectomy. With this technique a two centimeter (less than half inch) incision is made and a tube is passed to the spine without needing to dissect muscle off the spine. A few slivers of lamina are removed, if any, and the spinal canal is able to be visualized through the tube using high-power magnification. The fragment is then visualized and removed. The operation is performed under general anesthesia and the patient is able to go home the same day. Patients are walking the same day, begin therapy within a week and can resume the majority of their normal life-style activities within four to six weeks. The surgery is highly effective in resolving the symptoms and has a success rate of over 95%. A herniated disc can reherniate and this occurs between 10 and 20% of the time. Learning proper back care and maintaining good core muscle strength helps reduce the incidence of reherniation. This is the link to the video of this type of operation: http://www.youtube.com/watch?v=YV_EZgnCwTs.

You Don't Have to be a Brain Surgeon to Know That...

2010-05-22T17:01:00.001-07:00

This is the beginning of a new feature in which I hope many will participate. As a brain surgeon, the phrase "you don't have to be a brain surgeon to know that..." has particular resonance for me. The second half of the statement is generally something that it is assumed any fool should know. The implication of the first part of the statement is that there are things that are so esoteric or complex only an individual blessed with a prodigious intellect could comprehend them. Well, when it comes to brain surgeons, the truth of the matter is that though we do study and train for years, rigorously, a great deal of what we need to know on a day to day basis is a matter of common-sense. The majority of the knowledge we utilize daily is knowledge that most people possess. What is truly remarkable is how often we human beings forget the simple truths that are so often fundamental to our well-being and success. Why people do not utilize the knowledge they possess is an interesting question to which I don't have the answer. Perhaps part of the answer lies in people's unwillingness to expend the mental energy required to understand the basics of a sitiuatuion they may find themselves in. When one does make a effort one often finds that the solution to a predicament often follows or better yet, keeps a person from falling into a predicament in the first place. Ultimaletly, with less predicaments, we have more time for contentment and pleasure in life.

So, in an effort to provide some simple insight I will begin cataloging some of those things that all should know but all tend to disregard at one time or another. I would be delighted if you would send in your items which you feel should be included in such a list.

My first entry is: If you are going to be far from a toilet for a while and you think you have to go, go.

Uncomfortable, embarrassing, all-consuming, and, oh yeah, very uncomfortable are some of the words that come to mind when you really have to go to the bathroom and one is not available. It is truly amazing how often we find ourselves in this situation even after our parents have warned us. Just think about it again for a moment before you get into a car for a ride that will take longer than fifteen minutes.

Extraforaminal Endoscopic Lumbar Microdiscectomy

2010-05-14T13:21:00.000-07:00

Click on this link to see the video of an endoscopic lumbar microdiscectomy I performed: http://www.youtube.com/watch?v=YV_EZgnCwTs. Hope you find it interesting. Please share your thoughts with me.

Doctors opt out of Medicare

2010-05-11T06:24:00.000-07:00

Here is the youtube link to the piece I did for CNNMoney. http://www.youtube.com/watch?v=428iqTWiFVY I would greatly appreciate your comments (thoughtfully articulated.)

BackTalkLive

2010-05-10T20:53:00.000-07:00

I'm so happy to announce that this blog is now linked to BackTalkonAir.com, the website for my radio show, BackTalkLive. The website will shortly become BackTalkLive.com as soon as the domain transfer is completed. Please listen into the radio show on WOR710am on Sunday nights at 7:30 PM. You can get it as a streaming podcast on WOR710.com. I would love to hear your thoughts about the show. This past Sunday, Dr. Vijay Vad was our guest. He, along with Richard "Mr.Chipwich" Lamotta developed a terrific analgesic cream that really does work (not a magic potion), The MDsystem. Please check out their website, TheMDsystem.com. Dr. Vad, a sports medicine doctor at Hospital for Special Surgery will be on "The View" this week.

another crisis

2010-04-27T20:18:00.000-07:00

I get the feeling we are in crisis. It seems to me we are having a crisis over the number of crises we are dealing with now. Let's list some of the crises we have been dealing with in the past two years: the war in Iraq, the war in Afghanistan, extremism in Pakistan, the nuclear aspirations of Iran, the Democrats riding rough-sod over the Republicans, the Republicans neutering the Democrats, the mortgage crisis, the collapse of banks, the collapse of the US car industry, the collapse of the US economy, the collapse of the world economy, the earthquake in Haiti, earthquakes in Chile and China, attempted airliner bombings, an American-Islamic psychiatrist turned terrorist, the breakup of a terrorist group that planned to attack NYC subways, illegal aliens, drug wars spilling across the border, Israel expanding settlements in East Jerusalem and, of course, Health Care. Certainly you can add a few more to the list. Even Canada got in there with an unsafe luge track at the Olympics. So will the real crisis please stand up. It has to be the economy, stupid. It always is. The more the economy deteriorates, the less people have, the more disgruntled they become and the more social unrest exists and then comes governmental change. That has to be avoided at all costs. So what does the government do? It creates more crises which divert attention from the situation at hand and makes people feel that something important requires immediate attention and management, that something has to change and so we can all can stand on the side of right and support those who will resolve the crisis. Voile, suddenly it is imperative that we resolve the "health-care crisis." It becomes the most important piece of legislation in four decades. That out of the way, even though the banking system has been shorn up and the economy seems to be getting its legs back under it, the government has to go after Goldman-Sachs and the other bad boys and girls of Wall Street. Who wouldn't want to do battle against a bunch of egg-head do-nothings who steal our money and drive around in Ferraris while talking on platinum cell-phones? Come on now. When are we going to get around to appreciating that we are still here, that our economy is again growing, that we are now aware of global warming and have all started doing our own green thing, that we can still travel freely to most places in the world, that we have an outstanding health-care system that allows us to live to a much greater age, that we can still vote politicians out of office, that Sara Palin can still see Russia from her kitchen window, that we can still change laws without it always being about "life and death" issues, that we can love whom we wish to love. So perhaps we can take a step back from the brink of disaster, take a deep breath, smile and resolve the biggest crisis, who is going to be the Biggest Loser?

Passage of Health-Care Reform Bill

2010-03-22T20:29:00.000-07:00

Well, to no one's surprise, the very flawed bill was passed. President Obama did prove he is a strong president, for better or worse. I am convinced that unless there are substantial changes made to this legislation, it will have very negative financial reprecussions, impede access to care and reduce quality of care. More people will have access to insurance but not more access to health-care. Even many democrats agree this is a very imperfect bill. Our strength is in the living, ever-changing democracy that we are proud to call our own. But it does take great strength to shift the direction of this great ship. When we have strong convictions, we must not give up on achieving our goals. We can still, in the end, have a health-care system that provides the highest quality of care at affordable cost to all the citizens of this country. We must remain proud of our health-care sytem, the greatest of all our public services.

My Poem of the week

2010-03-13T21:04:00.000-08:00

Late April Afternoon

The green, green grass
Softens my expanse of yard
And I do see it green, green
Though I’m a color-blind bastard of unwanted birth
At least from my father’s recounting
The setting sun so soft and warm
This late April afternoon
A Brahms piano waltz
Dances me to the precipice of clarity
The residua of a decaying carcass
Barely breaching my olfactory groves
So close to my beloved amygdala
I remember nothing
I recall everything
So green, green, green

Ezriel Kornel
April 28, 2009

Are the health insurance companies' profits too high

2010-03-09T20:55:00.000-08:00

President Obama is right about one thing in his plan for health-care reform: insurance companies need more controls placed on them. Insurance companies are middle-men. They don't diagnose illness and they don't treat illness. Some offer incentives to stay healthy but mostly they decide how to spend your money. What they prefer to do is not spend it at all and use it to make a profit and distribute your money to the shareholders.They make money when you are healthy and they make money when you are ill by denying services that your doctor requests in order to make you healthy again. Somehow they think they know better than the doctor if a treatment plan may work or not. So why not restrict the profits of insurance companies since they are only "managers" of your money? Why not do what is done with utility companies, allow only limited profits. somewhere in the neighborhood of 1-2%. More money would go to providing health care and less into redistributing the money that you paid to obtain good health-care.

Tort Reform

2010-03-06T19:57:00.000-08:00

I could go on and on about the topic of medical tort reform but in a brief essay I can say what needs to be heard . In New York, all neurosurgeons who have been in practice for more than two years have been sued for malpractice. The average number of suits is just shy of one a year. So a neurosurgeon in private practice for twenty years can expect to be sued almost twenty times. If each suit suggests that bad doctoring has been going on, one must therefore assume that all neurosurgeons in New York are performing substandard care on a regular basis. The only other explanation is that doctors are being sued, not because they are providing substandard care, but because patients think that they should sue when an outcome is not perfect (and believe it or not, some just lie about it.) Who tells them it's appropriate to sue? Why the lawyers, of course. They know that the harassment of a suit pushes many doctors to settle rather than have to spend years worrying about a case and weeks to months in court when they should be taking care of patients. Lawyers are happy when doctors settle because it's far less work for them. Don't forget that in an effort to minimize suits, doctors are told to order countless tests so that no lawyer can say that perhaps "the one test" that wasn't performed may have lead to a different outcome. Even more unsettling, doctors perform invasive procedures and even operations because they fear that if they do not do "everything" some lawyer will say they did not do enough. All doctors know this to be true. No one is of the opinion that patients who are the victims of substandard care should not be compensated. We need a system that accomplishes this goal justly and fairly and appropriately. We can use the money wasted on paying into the legal system and use it instead to provide health-care to more of our citizens.

2010-03-04T19:51:00.000-08:00

Poem of the Day

The Pronouncement

His still, angular form
Lies upon the bed
Clad only in the hospital gown
And his socks

When he pulled them onto
His feet this morning
He could never have conceived
That they would offer
Far more tangible evidence
That he once was
A breathing man

Than that
Still, angular form
Which once
Contained him

Ezriel Kornel

Medicare editorial from BackTalkLive

2010-03-03T19:02:00.000-08:00

Just as I was preparing my editorial on medicare, CNN asked me for an interview about my perspective on medicare. What did I tell them? It's a SHAM because it doesn't pay doctors who want to practice quality medicine enough to stay in practice. So how can they stay in practice? From the income private insurance pays. This means that medicare is a subsidized insurance program, like a charity. Primary care doctors either have a patient mill with a squad of physician extenders such as nurse practitioners and physician assitants (most are very competent) working for them or they can't make a living. That's why so often you don't even get to see your doctor or if you're lucky, maybe for five minutes and that's after waiting for an appointment for a ridiculous amount of time. I, a surgeon, opted out of medicare because I didn't want to support a sham. It doesn't come close to even covering my costs so I want my patients to know the truth. I ask them if they can pay a reasonable fee, I never want them to go broke but I want to at least cover my expenses. If they can't pay anything and are determined to have me perform their surgery, I will do my best to work something out. Not all doctors are prepared to do this, they just can't carry the losses. If my only reimbursement was medicare based, I would have to perform over 500 operations before I saw a penny of it myself. None-the-less I always give the best of myself no matter whether my over 65 patients can pay or not. Most of my patients do choose to pay because they want to feel good about selecting the doctor of their choice. With medicare further cutting payments, more doctors will be forced to opt out and patients will all have to pay more out of pocket or receive second class medical care.

New Orleans Saints

2010-02-08T12:08:00.000-08:00

Who knows in what fortunes and misfortunes God chooses to intervene but yesterday he/she must have felt compelled to support the Saints in their efforts to bring forth a miracle. The city of New Orleans, a city of great tenacity in the face of great adversity, will be uplifted by this miracle and we should all celebrate, even those from Indianapolis, the efforts of strong and determined people to acheive their loftiest goals.

Helping in Haiti

2010-02-01T20:06:00.000-08:00

My partner and I volunteered immediately after the earthquake to offer our expertise in Haiti. We tried to do so through multiple organizations as well as the White House. We were placed on a list but I am certain that there were many physicians throughout the world who also volunteered to provide assistance. The problems, of course, were many. Getting to Haiti was at first a major challenge and planes with doctors could not even land. Furthermore, there were no facilities initially for providing medical care for the seriously injured. The first physicians to arrive were those who already had disaster management experience. Sadly, any patients requiring neurosurgery due to head injuries would have had to receive attention within hours. Certainly, individuals with spine injuries may still require stabilization procedures and many are being transfered to the USS Comfort or to Miami. We know, however, over the coming months and probably for next couple of years there will be individuals in Haiti who suffer injuries and illnesses that require neurosurgical intervention. I hope that all who have offered their expertise in the acute phase of this disaster will be willing to help as future needs arise.

Poem of the Day

2010-01-31T16:08:00.000-08:00

Two Cats and Me

There are two Cats in my room and Me
One is a small, gray and white ceramic cat
Fiddling atop a round, yellow box
For tiny mementos
The other is a great big gray one
Just now lying in the doggie bed licking his paw
Sometimes he lies on top of me when I lie in bed
Purring as I stroke his chin and chest and
That spot just behind his ear
The three of us
Sharing this room

Ezriel Kornel

1/30/10

Insurance companies once again trying to increase profits on the backs of consumers

2010-01-31T13:32:00.000-08:00

Well, the health insurance companies in New York have a new trick up their sleeves. Until very recently, insurance companies have been paying doctors who are "out-of-network" fees that are based on usual and customary rates (UCR). They usually pay 70 to 80% of these UCR and the patient is responsible for the difference between what the doctor charges and what the insurance company pays. The insurance companies used to determine UCR based on numbers established by a company they themselves set up. Attorney General Andrew Cuomo felt this was not appropriate or fair to the consumers because there was a conflict of interest and because the UCRs they set were lower than the actual UCRs as determined by analyzing true physician's fees. Under this old scheme patients had to pay more out of pocket. With the new methodology, insurance companies will have to pay more and consumers less. So the insurance companies decided to pull a switcheroo and stop basing reimbursements on UCR . They have been sending letters out to their subscribers telling them that they will now make payments based on medicare rates, the maximum pay-out being 140% of medicare fees. Medicare fees are woefully inadequate especially for reimbursement of surgical procedures. There is no way that physicians, especially surgeons can lower their fees to a fee anywhere close to 140% of medicare. Therefore, the consumer will now be out-of-pocket for far, far greater an amount then they had been with a UCR based fee.
If the insurance companies think that by pulling this switcheroo they will be able to force more doctors "in network" they are mistaken. Groups such as ours, will, in fact have to close the office doors if reimbursements are based on Medicare rates. We have far too great an over-head to be able to cover this over-head and still make an adequate living.
So, some physicians will move or retire and those left will have to try to maintain fees adequate to provide the revenue they require, leaving the patient to pay more out-of-pocket. The only way this miserable scenario can be avoided is for consumers to inform their insurance companies and their elected officials that this is unacceptable.
Both the insurance companies and the government want to change the way health-care is delivered, each for their own purposes and in the end, it seems, to the detriment of most patients.

Ignorance is bliss---not

2009-08-16T19:39:00.000-07:00

Oh, how loudly people are screaming (the pundit Palin once again expressing opinions without comprehension of the facts) that now the government wants to decide who lives and who dies. First, its "the government wants to provide health-care to one and all" and suddenly its "the government wants to withhold health-care from the old and sick." Well, it reminds me of the old joke about the Ignorantans vs the Jesuits but its a long joke and I won't repeat it now. Suffice it to say that there are complex and appropriate arguments on both sides of the health-care debate but ranting against the one unequivocally appropriate and important provision in the health-care bill brought forth by the House is an accolade to ignorance. There are governments that believe they have the right to determine how money is spent when they are giving away "free stuff." Both Great Britain and the state of Oregon, for example, have made decisions not to treat certain illnesses that have an extremely low likelyhood of recovery. But this is not what our legislature has in mind, it wants to educate people, a seemingly radical idea. Who wants to remain ignorant about what treatment options we have when we get really sick and are likely to pass on to the next world? The answer should be "no one." Someone may want to be on a ventilator with IV's and catheters and multiple medications if it allows them a few more hours of life even if they are comatose. Another person may choose to have no treatment and even withhold nurishment if they are in a condition that will not allow them to live a life which allows them a measure of independence along with normal cognition and communication. Both have the right to their exit strategy but unless they know how to communicate their wishes to the health-care system, they will all be kept alive to the very end and sometimes even beyound. The bottom line is when an individual understands their choices, expresses those choices clearly to someone else and then identifies that person to their health-care provider than there is a high likelyhood that their wishes will be honored. This empowers the individual and is that not the core of conservative ideology? We have the added benefit of not having to waste large sums of money on unwanted treatments. Is this a case of everyone wins? Yup, it sure is.

More Riffs on Health-Care

2009-07-30T19:22:00.000-07:00

Everyone is talking about the need for change in the health-care system but the system is constantly changing. It is a huge enterprise responsive to many factors ranging from economics to new scientific discoveries and developments to new illnesses making sudden appearances to changes in personal views on life and death. Some changes have been taking place with relatively little notice from the public. One big shift is the movement by many hospitals to employ hospitalists to care for hospitalized patients. Hospitalists are physicians trained in internal medicine with particular focus on the needs of hospitalized patients. These, of course, tend to be the sickest individuals and require the most time and attention. What this means for you, the "customer" is that your primary care provider will care for you when you are well , have a relatively minor illness or when you have illnesses that are chronic and generally not severe. When you get really sick and have to be hospitalized your primary care provider, most often your "family doctor," will not be the one caring for you. Someone who probably has never met you before and who has a number of sick patients to care for will be in charge of your medical management. On the positive side, you will be taken care of by someone who keeps up-to-date on the management of serious illnesses and who is being paid to take the time to care for you. They are not in a rush to get back to the office to get through a busy office schedule. They are responsible to the hospital and also responsible for providing information about your condition to your primary care provider. Therefore, their management is closely scrutinized and if they do not meet the high standards generally set, they have to find another job. On the down side, the medical professional who knows you best and who you feel most comfortable with is not the one who will be taking care of you when you are at your most vulnerable and want to know that the person caring for you knows you well and cares deeply about your well-being. The truth is that most primary care physicians would like to take care of you when you are really sick in the hospital but they just can not afford to do so. The system has dictated that in order to be able to stay in business and make a living (and we are not talking about a fortune) primary care providers need to see many patients in a day. There is just not enough compensation for the time physicians spend in the hospital caring of one,two or three hospitalized patients. Taking care of two hospitalized patients can easily take a couple of hours and in that time the doctor could see six or more patients in the office. The hospital is able to bill for the services of the hospitalists they employ and pay these physicians a reasonable salary. Of course, the large teaching hospitals utilize residents as hospitalists and they have been a source of cheap labor for many years but as residency work hours are restricted, hospitals have to employ more expensive health-care providers including physician extenders such as physician's assistants and nurse practitioners. As sicker individuals are being cared for by hospital-employed personnel, primary care physicians spend more of their time providing well care and managing chronic illnesses. Much of this type of medical management can be handled by physician extenders who command lower salaries than physicians. By expanding on this army of health-care providers and leaving physicians to oversee these health-care providers and directly manage the care of more complex problems that specialists generally manage we can hold down the number of primary care physicians needed and keep health-care costs from rising further. If we want the highest quality of care for the money, we will want more specialists and more physician extenders, not more primary care doctors. This is how I see it , from my perch.

The Future of Medicine as Perceived by a Working Neurosurgeon

2009-07-12T13:27:00.000-07:00

Health-care reform has taken center stage in the national political debate in America. In truth, it has been center stage for years. I recall when I completed my residency in neurosurgery in Washington, D.C. in 1984 the talk was all about the escalating and out-of-control health-care costs. Government had to control medicare costs, limiting expenditures with the assistance and complicity of physicians. The government gained support of physicians by a monetery redistribution, taking money form "proceduralists" who were the minority and giving more to "cognitive" specialists, physicians in the majority. In other words, they took money from surgeons and gave more to internists, general practioners and the like. In the end, of course, everyone got less. The "cognitive" specialists had to see many more patients to make ends meet and the "proceduralists" could never make enough with the reimbursements the government provides. In the end, private insurance had to subsidize the medicare system to keep "proceduralists" in the medicare program. Surgeons, unless they are employed by a hospital, make their living from private insurance reimbursement. If the government begins to provide a medicare-type insurance policy to the currently uninsured at reimbursement rates similar to medicare rates, "proceduralists" will drop like flies. They will simply be unable to remain in business. The truth is that we already have a shortage of "proceduralists" and we will have a major crisis in access to care if the number of "proceduralists" drops further. As the population grows and ages, more people require craniotomies for subdural evacuations, hip and knee replacements, laminectomies, thoracotomies, abdominal operations, prostectomies, organ transplants, mastectomies, colonoscopies, arterial stenting procedures, etc, etc.. Though much is being spoken of primary care shortages, the solution lies not in more primary care physicians but in more physicians extenders. It does not make fiscal sense to pay highly trained physicians to provide well-patient care. In truth, one physician can oversee several nurse practioners and physician assistants. These physician extenders can provide care for many routine medical problems ranging from colds to diabetes management. More complex disorders which require more expertise and more time can then be managed by internists and medical specialists such as cardiologists, neurologists, endocrinologists, oncologists and the list keeps expanding because medicine keeps becoming more complex as more is learned about each medical disorder and treatments become more refined and diverse. It has become nearly impossible for one physician to know all the crucial management issues for every medical disorder. Furthermore, individuals are becoming more involved in their health-care and as information becomes more abundant on the internet, the majority of Americans will be playing a significant role in their health-care. In fact, patients may be required to become more active in "doctoring" themselves. It will improve the quality of health-care and save a substantial amount of money. Patients will be required to fill out forms on-line that ask questions about their medical history and symptoms of illness. Based on these answers a differential diagnosis will be generated. Patients can then review these diagnoses to understand more about their illness and also review possible treatments. When they then go to their health-care provider a differential diagnosis will already have been generated saving the health professional a considerable amount of time. It will also reduce errors of diagnosis and treatment because the health-care provider can choose a treatment course based on the recommendations the program generates. If the treatment plan does not match an option, the health professional will need to provide a justification/explanation for why they have choosen this particular approach over another. The patient can review the treatment plan to whatever depth they wish in order to feel comfortable with the plan that has been recommended. In the end, the quality will have been maximized. This type of program could be created now (and probably is being created by some clever health-care organization) and patients who are willing to complete it before seeing their health-care provider should be offered a discount since they are saving their health-care professional and the health-care system time and, as they say, time is money. More ruminations on health-care to come.