Announcing my new blog and website

Dr. Kornel's new website and blog!

My blog 'Neurosurgery and Other Ruminations' has moved to its new home on the web: brainandspinesurgeon.com

BrainandSpineSurgeon.com is your source for breaking medical news, educational podcasts and my new blog home.

Get curated medical news updates. Watch my educational video series. Listen to past episodes of my radio show 'Back Talk Live.'  Follow my new blog. 

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Leave a comment on my new site and tell me what you think and want to hear about in the future.

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– Dr. Ezriel Kornel

Right-brain or left-brain, which are you?

The idea that there are right-brain individuals and left-brain individuals has been an accepted concept for many years.  Right-brain individuals are supposed to be more aware of their spatial environment, more emotionally tuned in and more creative.  There has been a generally held belief that these individuals function more with the right side of their brain.  Left-brain individuals are those who are more intellectual,  those for whom words and language are central to their being, those who think more than feel.  Of course, there are no absolutes, no individuals who are purely one or the other. What a research team at the University of Utah has proven as described in an article recently published in PLOS ONE is that individuals do not use one side of their brain preferentially over the other side. There are definitely many areas within the brain that associate most closely with other proximate areas on the same side.  However,  individuals use these functional zones about equally on both sides of the brain. So, what this says is simply that we use our brain in its totally.  What it does not say is how we use those areas in becoming the people we are. The more we learn of the brain the less we understand of its actual workings. If individuals do use both side of their brain about equally and we do know that there are important functions predominately on one side versus the other than why are some individuals more adept at complex intellectual problem solving and others more creative? Why are some people great at spatial relationships and others get lost in their own back yard?  Why are some people great with colors and others write beautiful music and others write sonnets and others perform mathematical wizardry?  Why are some great athletes and others trip over their feet?  These are still the great mysteries of the human brain.  They are what define us. Perhaps tomorrow someone will publish a study that explains it all but for now what we know is that we all tend to use both sides of our brain in being the unique individuals we are.

Time for a poem

Writing a poem #1

It has to be like alternating tightropes.
You're either balancing on the one of sorrow
Or on the one of elation
Hopping from one to the other
One misstep and you fall
Into that swamp of nothing really matters
Seems easier to balance on the tightrope of sorrow
Everyone standing so still and all
Harder to balance on the tightrope of elation
What with trying to bring everyone over
Makes it tough to gain a foothold

March 29, 2012
Ezriel Kornel

The BigBrain Project and the 3-D Brain Map

The BigBrain project has just been published in most the recent issue of the journal "Science". It is a major project carried out by a team of neuroscientists from different institutions that created a 3-D atlas of the brain in exquisite detail. It was created by painstakingly stacking thousands of very fine slices from the brain of a "neurologically normal" sixty-five year old female who had donated her brain for scientific research. This model allows anyone to view any portion of the brain in microscopic detail so as to understand the various cell to cell connections in each part of the brain and the differences in these connections among the various parts of the brain. It will give us a better understanding of how information is routed throughout the brain and by understanding the "normal" brain we can see how these connections differ in a pathological or "abnormal" brain. In a way, it is like understanding the internal wiring of a computer or how the parts of a car engine fit together to work as a whole. However, the brain, in its exquisite complexity, carries out many functions simultaneously. It informs us of all our sensory inputs such as the ambient temperature, the firmness of the ground on which we are walking, the sounds of the birds near by, all the sights we behold around us, the position of our limbs in space, the condition of our gut. At the same time it manages among many things, our respiration, our heart beat, our blood pressure, our internal fluid status and our biological clock. While doing all this it controls our muscles so that we can achieve coordinated, purposeful movement in response to our thoughts and our vocal cords and muscles of our hands so that we may express ourselves. And most remarkably of all, in the midst of all this it allows us to make sense of what is going on around us, recognize our relationship to the world around us, formulate thoughts by which we interact with the world and formulate thoughts in which we can plan what we will do in the next moments, minutes, hours, days, weeks or even years. While all this is occurring the brain generates emotions that permit us to feel our existence on this planet and in this universe and these feelings drive us to interact with the world in the ways of our choosing. Most remarkably, perhaps, while all this is going on it generates thoughts and feelings, generally inseparable from each other,in response to the thoughts and feelings expressed by others. There is nothing concrete or tangible about a thought or a feeling. We all know what they are but how difficult to truly define. Yet these thoughts/feelings are what human beings are all about. It is through the exchange of thought and feeling, spoken and unspoken, that we create bonds which lead to families and societies and the myriad consequences that result from these. The BigBrain project can not show us "thought/feeling." It may show us pathways that "thought/feeling" uses and where breakdowns in these pathways can lead to a wide array of problems. We may be able to better understand the relay stations that allow the brains many functions to work in concert. But this 3-D model can not show us how feeling and thought is generated and transformed. Perhaps we will discover where a song originates but it will not explain how a song originates. The answers to the most profound questions explaining how our brain makes us who we are lies in the biochemistry of the brain and the key is in the way the energy of the world outside of us interacts with the chemicals in our brain to generate further energy waves that create the most amazing interplay of energy, the dance of the human brain with universe in which it resides.

Do we have the backbone to confront the problem of the aging spine?

We should all be happy that through advances in science, health-care and personal health management more and more Americans are living into their 80's and 90's and even reaching 100. The best news about this extension of life expectancy is that more and more of our "super" seniors continue to lead active life-styles. We have been very good at managing heart disease and vascular disease. Lung disease has significantly diminished as smoking has become much less common. Diabetes is more well-controlled and the treatment of cancers improves every day. What has not improved and, in fact, has yet to be addressed is degenerative disease of the spine. It is inevitable that everyone experiences some degeneration of the spine as we age. For many the degeneration can become severe with pain secondary to nerve compression and pain secondary to spinal deformity. These infirmities lead to profound life-style changes. Chronic pain leads to depression and limited mobility. No one wants to live their lives afflicted by pain, unable to participate in the normal activities of daily living, let alone unable to play sports, take walks with family and friends, go to the movies, go out for dinner or play with grandchildren . So as these individuals start to become intolerant of their pain and limitations they seek out help within our health-care system. There are certainly non-surgical approaches that can help, especially if treatment is instituted before the structural abnormalities become too severe. These include chiropractic, physical therapy, acupuncture, massage, Alexander training, injection therapy, and many more. All cost money and stress the finances of our health-care system but these treatments are relatively inexpensive and there are a large number of practitioners who offer these treatment. However, many individuals will require surgery to alleviate symptoms. This is were things become very confounding. Bigger, more complex surgeries have higher risks. Should "super" seniors be allowed to subject themselves to these increased risks which can add substantially to health-care costs when complications do occur? Furthermore, there are relatively few spine surgeons with the capability of performing complex spine procedures in the elderly. It will become more difficult for those who are prepared to go through extensive operations to even find a surgeon who can place them on their operative schedule. What greatly compounds this problem is that medicare payments for these procedures are exceedingly low. These operations also take many hours to perform. It will be very difficult to encourage surgeons to perform more of these procedures when they take up a large amount of their work time with very limited reimbursement. From a practical business point of view it is simply impractical and unaffordable. Those surgeons receiving a salary have little motivation to perform these extensive operations when they could in the same amount of surgical time be performing more operations with less risk, helping more individuals. So those suffering from severe spine problems may well need to find surgeons who do not participate in medicare and who will perform the surgery for an appropriate usual and customary fee. Even with a limited number of seniors able to proceed with a surgical option, the costs to the health-care system will be high. Do those controlling the health-care dollars want to spend them on seniors with bad backs? There is no question that the criteria for proceeding with this kind of surgery will be so extensive that few will ultimately be able to meet those criteria. What are possible solutions? First of all, individuals need, from an early age, to be taught how to take care of their spine, including exercise, body mechanics and weight control. We need to put money into research that can lead to treatments in the early stages of spinal disease such as stem cell injections to regenerate damaged discs. However, there will always be those who will fail all non-surgical treatments. For them, spine surgery may indeed be life-saving. New surgical techniques are being developed that are less risky. Minimal access spine surgery now is able to correct spine disorders with less trauma to the spine and surrounding tissues and less risk in general. Most importantly, the specific problem that is causing the pain and limitation needs to be identified and addressed with minimal access techniques. The entire spine does not need to be rebuilt. It doesn't matter what the spine looks like on an MRI or xray as long as the individual does not suffer from incapacitating pain and neurological dysfunction. More spine surgeons will be needed who are able to assess these problems accurately and perform these focused minimal access techniques. Finally, patients should be able to see surgeons who do not participate in medicare and receive the allowable medicare reimbursement that they can apply to their out-of-pocket costs, which currently is not allowed by federal law. Spine disorders in an aging population needs to be an issue that is carefully analyzed by our politicians, our health-care pundits and the medical community. We are currently very much behind the eight ball.

I say, tax the insomniacs!

The Supreme Court of the United States, in a decision written by Chief Justice Roberts has made it clear, if we were yet unaware, that Congress has the right to tax anything it sees fit to tax. Therefore, Congress may tax individuals who fail to purchase health insurance. These scoundrels who are avoiding purchasing health insurance clearly are harming society at large. As best as I understand it, insurance companies won't make enough money to keep sick people in their health plans unless more healthy people join the plans. I suppose the assumption is that people who choose not to buy health insurance are healthier as a group than those who buy insurance. So make the healthy ones pay up for the good of the sick. This is good for society in general, it seems. Well, we need to think about taxing others who are interfering with the general well-being of society. I say, tax the insomniacs (here referred to as "the awake.") Why do such a thing, you may ask. There are several good reasons too-awake members of society should be paying for their sleeplessness ("Sleepless in Seatle"? tax the bum.) First of all, it is a well-know medical fact that people are healthier if they sleep eight hours a night. So those who sleep less are less healthy which means they are sicker which means they use more health-care resources. These resources, as we have been told time and again, are extremely costly to our society. Does it not therefore make sense that these more "awake" individuals need to ante up to cover their less healthy life-style? Secondly, we all know that we can acheive more when we have more energy and that we have more energy the more rested we are. Clearly those with a good eight hours of sleep a night will have more energy thereby being more productive than those sleeping less than eight hours(the"awake") thus less energetic and less productive. Reduced productivity is harmful to society, it lowers our GDP and has lots of other bad consequences such as making the "sleepers" have to work harder and be more productive. It may even push the "sleepers" into the "awake." "The awake" clearly need to cover the cost of this reduction in productivity. Hence, the tax. Thirdly, the "sleepers" use precious few resources when asleep, far less electricity, far less heat and no gasoline at all (unless they are asleep at the wheel). The planet and society are well-served by those using less resources. This clearly reflects well on the "sleepers" and poorly on the "awake." We are paying a heavy price for the resources being used by the "awake."

Will you have your choice of doctors?

The face of medicine in the United States is about to change dramatically. For many years now, individuals have had choices regarding their healthcare insurance, they could choose an HMO plan or a plan that offered out-of-network benefits. The HMO plan requires subscribers to use contracted physicians who are "in plan" or else you have to pay the full doctor's fee yourself. With a PPO plan, one that offers out-of-network benefits you can choose to see a physician who does not contract with the insurance company. The insurance company will pay 70-80% of the usual customary fee for the doctor's services and you will be responsible for the 30-40% difference. You can always still use an "in network" physician to have 90-100% of the fee covered. You have the choice of paying a bit more for the opportunity to be cared for by a non-participating doctor who you may prefer. When insurance companies base their out-of-network reimbursements on usual and customary rates then not only do consumers have choice but physicians have a choice whether to be in-network or out-of-network. This means that insurance companies have to negotiate rates that some physicians will consider acceptable because those physicians otherwise can decide to stay out-of-network. This helps maintains a free market model in medicine, choices for the consumers and choices for the providers. This model is on the verge of changing profoundly. Health insurance companies want to peg out-of-network reimbursement to medicare rates. Physicians, especially surgeons and other proceduralists, can not remain in private practice with reimbursements based on 140-200% of medicare. Private practice physicians will go out-of-business and be forced to either leave medicine or become an employee of a large medical group or hospital. Only a small handful of physicians will remain in private practice and patients who choose to have these physicians care for them will have to pay the lion's share of that doctor's fee out-of-pocket. Those who can afford to do so will still have a choice, the remainder won't so this will immediately create a two-tier medical system. Once the majority of physicians are driven into large groups and hospitals that contract on behalf of the doctors, the insurance companies will ratchet down the reimbursements because physicians will have no option left but to accept whatever payment is offered. The large medical groups and hospitals will, of course, limit the number of physicians they employ to provide enough income for the physicians in their group. In order to make a marginally adequate income these health-care providers will have to see a very high volume of patients. This all translates into long waits for patients and very short visits. The quality you expect just won't be there. The coup de grace is that these clearly inferior insurance policies are still costing the consumers more, the insurance companies aren't lowering the cost of these plans, they are raising them. Make no mistake about it, the money that does not stay in your pocket or go to your health-care providers goes into the pockets of the executives of the health insurance companies and then to the company's shareholders. So if you care more about your investment then your health-care, buy stock in the health insurance companies. If you care more about your health-care, contact your legislators and insist that the private practice of medicine be allowed to flourish in the United States.