Surgeons Cut a Giant Tumor Out of My Head. Is There a Better Way? | Hacker News Reader

Surgeons Cut a Giant Tumor Out of My Head. Is There a Better Way?

bloomberg.com

129 pointsmelling71 comments

Back in '96, I had a pretty serious craniotomy.

Took me a couple of months to learn to walk and chew gum at the same time, but I was pretty much 100% recovered, in five years.

One of best days of my life, was when my neurosurgeon said "I never want to see you again."

They did it the old-fashioned way. Scalpel and Black-and-Decker circular saw.

A family member of mine had to go through something similar, the old-fashioned way. I've never felt more scared for someone else than on that day.

Brain plasticity is amazing.

So long as they are young!

That's a myth. Brain plasticity was never properly studied beyond 26 years of age.

nope, neurons are fully regenerable including into old age.

Is it actually a black and decker? It isn’t some sort of special FDA approved medical saw? Is that even a thing?

A friend is a neurosurgeon and they use some special saw that stops as soon as there's no hard tissue providing resistance. So you press it hard into the skull, and when it's done chewing through the bone, it immediately stops.

Apparently the scariest bit for the junior doctors to learn to use, somehow.

That is known as the perforator drill bit - https://www.reddit.com/r/toolgifs/comments/z2zikm/cranial_pe...

Used to make burr holes so that the dura can be stripped away from the skull using the Penfield 3 instrument.

Then what's used is what's known as the B1 with footplate to create the bone flap - https://www.researchgate.net/publication/323134344_Exposure_...

Here is an example of the drill system - Midas Rex MR8 - https://www.ebay.com/itm/125960633809

Here's a video of a surgeon performing the pterional craniotomy, probably the most common craniotomy for things like aneurysms, - https://www.neurosurgicalatlas.com/volumes/cranial-approache...

Same or very similar stuff is used to cut plaster casts for broken bones. You see that small circle rotating next to your veins in legs and there is suddenly some tension in the room. Especially when saw seems to keep stopping when cutting through plaster for no good reason, causing some confusion for the doctor and making him lean more heavily into it.

Afterwards they realize that harder resin casing was layered with soft fabric by previous orthopedic surgeon in previous hospital, so the thing actually worked as intended (but if you keep pressing power button and leaning into it it will keep cutting). Talking about hospital equipment in Switzerland, 2 weeks ago after a nasty paraglider crash landing.

Cast saws are different, they don't affect skin as demonstrated by this youtuber with a high speed camera:

https://youtube.com/watch?v=Bx1AiQdMQro

edit: though actually I googled the skull saws which I wasn't familiar with and they might work on a similar principle, found someone talking about using them in autopsies anyway.

That's strange. Cast saws don't need to stop like that; they can't cut skin even running at full speed. Your grey matter is not as tough as your skin and you wouldn't want to touch it with even a gentle power tool, though, so it makes sense that brain-surgery saws would be different.

I'm forever grateful to the doc who actually pressed the running sawblade into his hand to prove that it's harmless, instead of just saying "don't worry, it's safe" while going to town on my leg with a power tool.

You mean the bonesaw-through-the-chest scene in Reanimator was not accurate?

What would the difference be in your mind?

As long as the blade is suitable for cutting bone and it's all sterilized, what would make it medical grade over carpenter grade?

My Dad was the manager of a tool store for decades. He has had a lot of knee problems and he has a funny story about his knee surgeon coming into the store looking for a drill bit to drill out a stripped screw. He jokingly asked if the stripped screw was in someone's knee, and sure enough it was.

My woodworking equipment has a certain amount of jitter and give. It seems to have precision to about 1-1.5mm. I imagine medical grade machine cutting would have higher precision?

Probably, but when you're watching these surgeries as a layman for the first time it's surprising how much fumbling around they seem to do. I have a few pieces of metal inside me so took more of an interest at some point, and even those surgeons admit their job is mostly carpentry on hard mode.

My grandfather was an orthopod and an amateur carpenter. The skills really do transfer.

Next time you go under ask your surgeon to take pictures and videos. Very interesting to see inside your body!

I even kept the metal rods they had in my leg in between surgeries that would otherwise be thrown out!

A friend of mine got a hip replacement, and asked for the old hip.

They refused to give it to him. They said it was "medical waste," and they weren't allowed to deal with it, except in whatever federal manner was required.

It would need to be survive an autoclave, for one thing. It would need to be possible to actually clean it, not shed bits of paint and plastic into the patient's skull, material compatibility with antiseptics, etc.

If I thought about it for a few minutes, I'm sure I could create a long list of requirements for a suitable saw.

> what would make it medical grade over carpenter grade?

In my experience, about $50000.

As long as it survives an autoclave and doesn't leave behind any debris in the site, it seems fine.

You will have a very hard time sterilizing a carpenter grade saw.

Nah… that was a joke.

But their tools look surprisingly like standard hardware.

Lot more pricey, though.

'x grade' stuff is usually just about testing & certification, it's not that it is actually necessarily any different from the 'standard' model.

Wow. Genuinely grateful you got through it so well.

So am I. It was a ... tense ... time of my life.

A counterpoint on focused ultrasound for essential tremor - just because you don’t penetrate the brain with a physical object doesn’t mean you don’t have side effects - as usual, benefits come with risks

https://jamanetwork.com/journals/jamaneurology/fullarticle/2...

This article isn't accessible so it's hard to see what you mean. Do you have a link to the full thing?

Found a similar previous one https://movementdisorders.onlinelibrary.wiley.com/doi/10.100... where out of 10 patients, 7 had issues:

> Tremor significantly improved in all patients. Seven experienced mild adverse effects, including 2 with transient gait impairment and a fall, 1 with dysarthria and dysphagia, and 1 with mild dysphagia persisting at 3 months.

Also can't access the full pdf either though.

> The key is knowing exactly where to aim. While the MRI machine took readings, Elias ran a test at a low intensity to see if he could gently heat up the spot on Doby’s thalamus he was targeting. Satisfied with the result, he then proceeded to blast an area millimeters wide with 6,000 joules of focused sound energy for a few seconds. A graph on his monitor showed the temperature jumping to about 60C (140F). Everything around it stayed at a normal 37C. Other than a brief sensation of heat inside his head, Doby said he didn’t feel a thing. Elias repeated the process three more times, checking the tremor after each. By the fourth, it was gone.

Leaving it at "knowing where to aim" is severely underselling the problem, because then the next step is how to aim.

Back in 2003 when I still studied physics I attended a talk back by a Dutch biomedical researcher who worked on shock wave lithotripsy - a procedure where ultrasound is used to break kidney stones. So same idea as this, except kidney stone

So what he pointed out was that the human body is not a medium of uniform density, so the way the sound waves propagate is hard to calculate.

Worse, the human body tends to move, even when the patient is under anesthetics. Even if you sedate someone enough to lie perfectly still, the heartbeat means blood vessels grow and shrink, breathing causes miniscule motions that can throw off the ultrasound beams.

Maybe this is specific to kidney stones though, maybe kidneys are just a lot more "floppy" organs and maybe kidney stones move a lot. Maybe the brain is a lot more "stable" in the skull. And I suppose the method of destruction is different (kidney stones need to be shattered by ultrasound waves, whereas this method uses heat), so that might also be an influence.

I'm not being critical of this technology btw, just trying to point out that the engineering problems involved are likely a lot more interesting than that this article is suggesting.

[0] https://en.wikipedia.org/wiki/Lithotripsy

In radiation therapy, respiratory gating is a common method to deal with the problem of breathing movement: https://www.oncolink.org/cancer-treatment/radiation/support/...

I was not aware of respiratory gating being used in SWL. So, I did a brief search and saw that the efficacy of gating had definitely changed over the years:

https://pubmed.ncbi.nlm.nih.gov/7858616/ (1994)

https://pubmed.ncbi.nlm.nih.gov/22471349/ (2012)

https://pubmed.ncbi.nlm.nih.gov/38515108/ (2024)

So, it looks like that engineering problem has been worked on a lot since that talk in 2003.

Interesting. Maybe part of the solution is better predicting and controlling the motion inside the human body. I could imagine using a method to guarantee a particular organ be at a certain place at a certain moment: perhaps by accelerating the body a certain way to shove the organ into a position for a moment. Or maybe by injecting microscopic machines to surround and hold an area still. Someone will figure it out.

I once had to have a Heart MRI, which was fascinating because movement normally messes up an MRI. For the heart, they attach a pulse monitor and the MRI machine pauses its movement for a split second each time the heart beats.

Science needs more cadavers! Bring out ya dead

The FDA approved histotripsy mentioned in the article to treat liver tumors is available at NYU Langone.

https://nyulangone.org/news/nyu-langone-cancer-specialists-u...

I'm a bit confused on the use of word non-invasive in this context.

I was under the impression that non-invasive meant no cutting of tissue. Even if ultrasound separated the cancerous tissue from the healthy tissue - how would the surgeons get it out of the head without cutting into the skull? I also thought some surgeons used diluted hydrogen peroxide irrigation for removing potential neoplastic cancerous tissues post excision?

Either sonic or photonic attacks from every direction at once, resonating at the tumour site.

You'll also need to bolster the immune system to aid in recovery.

> You'll also need to bolster the immune system to aid in recovery.

This eats the brain

How?

I guess they're referring to the brain (and, by extension, the eyes!) being an "immunoprivileged zone" [1]... the brain-blood-barrier makes a lot of "everyday" stuff for the rest of the body pretty complex affairs for everything CNS related.

[1] https://en.wikipedia.org/wiki/Immune_privilege

Your link says the brain proper got the Pluto treatment.

Wait, what???

Where on earth did you hear that?

Source?

Anything immunotherapy in cancer treatment is extremely targeted. Early trials with new drugs include people getting cooked to death as the immune system and in particular the wrong interleukins get over-stimulated. 'Bolstering of the immune system' sounds good, but in general the immune system is a fine balance between doing the job against pathogen/cancer but not well that it is erring on being nonspecific and attacking self, i.e. autoimmunity. Unless otherwise noted, non-specific 'bolstering' in a tissue like the brain is likely not a good thing.

https://www.imdb.com/title/tt0087469/

I wonder how is it different than radiosurgery? Machines like Cyberknife, Gammaknife also treat brain tumours in non invasive way

I wouldn't call radiation non invasive, it ages the surrounding brain tissue a lot.

For people with faster growing tumors like GBM the tumor will usually kill them before the side effects of radiation hit.

But for people with slower growing tumors like oligodendroglioma, the side effects of radiation can force them to quit their job and go on disability, years before they actually die of the cancer.

The better we get at treating these tumors and extending patients' lives, the more important it will be to avoid radiation as long as possible to ensure that extra quantity of life also has quality.

In medicine/surgery, 'invasive' is a bit of a term of art, meaning that implements physically enter the body. 'keyhole surgery' (a small incision with a scope and tiny tooling pushed through) for example is often described as 'minimally invasive'.

Yes. Even placing stents during cardiac catheterization (PCIs or angioplasty) is 'minimally invasive' because typically access is achieved by the femoral artery and snaked up (the femoral comes "direct" from the heart, for all intents).

Yes, you blow up vessels with a balloon and leave a metal sheath in them, but as you say, minimally invasive, because you didn't crack the chest to do it.

I didn't realize how aggressive GBM could be until watching this video: https://www.youtube.com/watch?v=VSLPq010Q-o

That much growth in 4 months is eye watering.

> The better we get at treating these tumors and extending patients' lives, the more important it will be to avoid radiation as long as possible to ensure that extra quantity of life also has quality.

This is a good point.

Radiosurgery has it's limits and also horrible side effects esp in CNS tumors. If the tumor can be accessed without damaging too much healthy tissue and it's a histological type that has clean borders you are probably better off cutting it out.

Should have asked this question beforehand?

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