The wide-awake brain operation: Woman gives vital input while having tumour removed and gives a thumbs-up
21:06 GMT, 31 March 2012
21:06 GMT, 31 March 2012
Victoria Best smiles and gives a thumbs-up sign. It’s a simple gesture yet, in the circumstances, absolutely extraordinary because as she does so, consultant neurosurgeon Paul Grundy is removing a 4cm tumour from her brain.
Moments later, the 43-year-old mother of two from Bordon, Hampshire, chats enthusiastically about her granddaughter Connie, aged two, with a theatre nurse standing nearby – seemingly without a care.
Mr Grundy has pioneered the widespread use of awake surgery for brain tumours in Britain because he believes patient input is vital.
Positive sign: Victoria Gives surgeon Paul Grundy, centre, vital feedback during the operation
Of the 32 neuroscience centres in Britain, only four carry out awake brain surgery and only on up to ten cases annually. Mr Grundy’s team at Southampton General Hospital, however, performs more than 40 a year.
Awake surgery is being used increasingly for knee and hip-replacement operations, as well as in plastic surgery, because the recovery time is so short. Patients do not have to shake off the effects of heavy sedation and most can go home the same day.
In the case of brain surgery, there are other benefits too. Such operations are extraordinarily complex – doctors liken the procedure to ‘removing a spider from jelly’. Often the body of the tumour can be removed but a stray leg might be left behind.
Success is a balancing act. Although the aim is to remove as much of the tumour as possible, cutting away too much could cause irreversible brain damage.
If a patient is kept awake during the procedure, the surgeon can monitor their responses with a simple series of questions and directions. Which is where the thumbs-up comes in.
Mr Grundy explains: ‘The fact that a patient can tell me how they feel as I work allows me to see how much of the tumour I can get to and remove before triggering any potential long-term damage, such as paralysis. Ultimately, it means I can safely remove more of the tumour than if they were asleep.’
Victoria invited me to watch her operation, hoping her story will make the situation less daunting not only for patients about to undergo the procedure but also for the 4,700 people in the UK diagnosed with brain tumours every year.
Victoria becomes distressed as she feels a sensation in her left leg that she recognises as a prelude to a fit
But days before her operation at Southampton General in December last year, Victoria admitted: ‘I’m absolutely terrified at the thought of being awake during surgery.
‘My husband Andrew thinks it’s a big mistake because the idea of having any operation while you’re awake sounds horrifying, but, from our discussions with Mr Grundy, I know it’s the best chance of prolonging my life.’
The next time we meet, Victoria is waiting nervously in her hospital gown to be taken in to theatre. ‘If you’d told me when I started to have problems with my leg that I’d be doing this, I would have thought you were mad,’ she says.
Her symptoms began last year with a strange sensation in her foot. ‘I’d had tendonitis [inflammation of the tendon] in my right foot and assumed I had compensated by putting pressure on the left one,’ Victoria says.
‘My GP told me it was nothing to worry about, but by April I felt as if something was running up and down my left leg – a sensation that would come and go. I was tired all the time and felt very depressed, which isn’t like me at all.
‘The doctor gave me Prozac but within weeks my leg started twitching. Initially, it was thought to be a side effect of the antidepressants but my leg continued to get worse. My foot was turning inwards and eventually I could hardly walk.’
It wasn’t until last August, when Victoria had an epileptic fit and was rushed to Basingstoke and North Hampshire Hospital, that a scan revealed a tumour in the right frontal area of her brain.
‘I was blase at first, joking with Mr Grundy that I’d bring the tumour home in a pickle jar. Once the news sank in, my biggest fear wasn’t whether the tumour was cancerous but what might happen during the operation. Would I end up paralysed It was the fear of the unknown that scared me more,’ she says.
On the day of her surgery, Victoria looks surprisingly calm as she transfers herself from the trolley to the operating table.
She lies on her left side, with her neck on a cushioned rest to make her more comfortable during the two-hour operation.
Victoria Best before her operation to remove a brain tumour
Consultant anaesthetist Dr John Stubbing – one of the team who assists Mr Grundy – lightly sedates Victoria using a morphine-based pain-reliever and a mild anaesthetic. This helps calm her and prevent any pain as local anaesthetic is injected into her scalp around the area where the skull will be removed.
By running a pen-size neuro-navigation system over Victoria’s head, Mr Grundy produces an intricate 3D image on a screen. From this, he can map out exactly where he needs to open the skull and operate.
Using a marker pen, he draws an outline of the area of skull he will remove – about an 8cm-wide square – and shaves a strip of Victoria’s shoulder-length hair just a couple of centimetres from her crown, to allow him access.
As soon as the drilling starts, Victoria’s sedation stops. Dr Stubbing explains: ‘It takes about ten minutes for the anaesthetic to get out of the system so she is awake enough for Mr Grundy to do the procedures he needs to assess how much of the tumour he can remove.’
Victoria admits to feeling a sudden pressure in her head during drilling – which is much quieter than at the dentist – yet she still manages to give me a wave as I sit at the end of the operating table watching the scene unfold.
Her blood pressure and oxygen levels are monitored constantly and anticonvulsants are fed into her hand from a drip because the probe being used by Mr Grundy to get to the tumour can provoke seizures as it is moved around.
As the probe touches key areas around the tumour, Victoria tells Mr Grundy when she can feel pins and needles, if there is any sensation in her left leg and foot, and when she feels any discomfort. At one point, she says there is an ache over her right eye and she moves her hand as if to brush away the pain. Mr Grundy moves the probe and the discomfort is gone.
Having exposed the accessible area of tumour, he then uses an ultrasonic cutter to remove it. There is little blood, as the high-tech device seals the blood vessels as it cuts.
All seems to be going well until an hour into the operation. Victoria becomes distressed as she feels a sensation in her left leg that she recognises as a prelude to a fit. Mr Grundy’s assistants irrigate the brain with ice-cold water, helping to stop the seizure, and the operation continues. Within 15 minutes, however, she is having more prolonged convulsions.
To me it looks no more serious than a slight twitching in her left leg, but the tension in the room is palpable and Victoria begins to cry, fearing she’s going to have a full-blown epileptic fit.
A general anaesthetic trolley is kept in the theatre at all times in case of emergency, but it remains untouched.
After some calming words from a nurse and Dr Stubbing, Victoria begins to relax. It’s only later that Mr Grundy admits the six-minute episode put him and his team under pressure as the brain began to swell. But once the cold water takes effect, they can continue with the operation and, despite her distress, Victoria is still able to smile and talk. She is given light sedation to help calm her again.
As the surgery nears completion at 1pm, Mr Grundy ensures there is no bleeding in the brain before his assistant screws back into place the removed section of Victoria’s skull and staples the scalp membrane together.
Victoria says later that it was only as the staples went in – and the local anaesthetic in her scalp must have worn off – that she felt any real discomfort, and then only for a matter of minutes.
An hour and a half later, I speak to Victoria on the ward. Astonishingly, she is as chatty and alert as she had been at 7.30am when she arrived at hospital.
She showed no sign of what she had just been through – in fact, she seemed so unaffected I had to confirm with her husband, a landscape gardener, that I hadn’t dreamt the whole operation. That same night, after a CT scan to ensure there was no collection of blood in the brain, Victoria was allowed home.
Despite his pioneering work, Mr Grundy admits: ‘Unfortunately, there are very few brain tumours we can actually cure. Even if we completely removed the tumour, they always regrow because the cancer cells are scattered around the brain. To try to stop regrowth, you’d have to remove an area up to 2cm beyond the tumour itself and that would mean going into other important areas of the brain that could potentially cause irreparable damage to the patient.
‘The long-term outcome for patients depends on the type and grade of the tumour. There is no cure and average life expectancy with treatment is seven years, but the more of the tumour we remove, the better the outcome.
‘If I can’t remove at least 80 per cent of a tumour, I wouldn’t operate because surgery wouldn’t be effective.’
Unfortunately, news from Victoria’s operation isn’t all that she hoped for. Results from a biopsy reveal that her tumour is a grade three (grade one is the least aggressive form, while grade four is most aggressive).
It meant that after the operation she had to have chemotherapy tablets (Temodal) over a five-day period, followed by 23 days off. She then visited her oncologist for blood tests before starting the same procedure again.
Victoria expects to continue with this for the next eight months. She also takes epilepsy drugs, while anti-sickness tablets lessen any side effects of the chemotherapy.
‘Mr Grundy always told me that he couldn’t cure me, that he could only try to slow the growth of the tumour,’ she says. ‘I could live for five months, I could live for five years or more – specialists can only give me an average.
‘It was a blow but I try to be optimistic. I want to see my children married and settled and I love spending time with my beautiful granddaughter and my husband. It’s my family that keeps me going.’