Trying to undo some of the damage Ben Carson has done to our profession. IamA Neurosurgeon AMA!

Do you think many people think Ben Carson is a bad pediatric neurosurgeon and he has done damage to the profession?

I think most people recognize that he's one of the best in the world and if one of my children needed brain surgery I would want him to perform the surgery. But he would be a terrible president and his ideas and beliefs are quite odd.

I'm sure he's helped far more people than he's hurt, although that increasingly may not be the case. Its kinda tongue-in-cheek about him hurting the profession. Neurosurgeons obviously have a reputation of being very smart and have a certain image, which is not always the case. Same is true about any profession, but now one of our own small community is on the national stage and his shortcomings are being dissected and naturally reflect upon all of us.

Has anything like the swamps of dagobah happened before?

We've had some smelly wound washouts, but nothing on that order. We did have a patient who had a terrible trauma and despite maximum decompression, the pressure in his head was too much and his brain came through the wound like toothpaste onto his head dressings. The room smelled like death, and his family was finally convinced to let them go.

his brain came through the wound like toothpaste

Dude...you said nothing on that order.

Well, its not like it got on anyone else!

:( What was the trauma? What does decompression mean?

Dont remember, some sort of traumatic brain injury, may have been hemorrhage. A decompression refers to decompressive craniectomy where we take off a portion of the skull to allow the brain room to swell so there wont be a high amount of pressure compressing the critical structures of the brain. The swelling and pressure in this patient was so bad that despite all treatments and medications, it swelled beyond the skull and through the stitches/staples holding the scalp together.

That sounds horrifically sad.

This may be quite a silly question but I've been curious about it so here goes. In cases of decompression when a portion of the skull is removed and stored in some later of tissue around the abdominal/thoracic area, does the body "interact" with that fragment and do things like harvest calcium?

Yes, that can happen. Sometimes resorption happens and the bone flap doesnt fit the cranial defect perfectly. Its typically not an issue and we can easily cover any open areas with titanium plating.

What's the weirdest thing that's happened to you during surgery?

I don't think I've ever really had a "weird" event during surgery. There have always been hairy moments where we've had aneurysms blow, or problems with their vital signs, or in any severe trauma case.

One weird incident I remember from med school:

It was the night of Halloween. Most people were out partying, but we had a big anatomy exam in a couple days. So my roommate and I decided for some reason to go study in the cadaver lab late at night, because it'd be nice and quiet and we could really study without distraction. So we're all alone in the basement of the med school surrounded by dissected dead bodies studying. Now, we had these sinks lining the room with automatic faucets. They never go off by themselves. Until that night. So we're just dissecting and studying, its completely silent in the huge cadaver lab, and suddenly clear across the room: FOOOOSSH! one of the faucets go off.

My roommate and I jump, stare at it and then each other and remark on how creepy that was. No big deal, we go back to studying. Then again, now to our left another faucet just goes off randomly! Now, we had both come down and studied in the evenings in the lab, and this had never happened. We we kept going, and faucets just kept going off and finally we had enough. We packed up and started to leave.

Now, as we walked down the hall away from the cadaver lab, we walked past a side room. This room was typically for an extra body or two that the anatomy teachers would work on for exams or teaching purposes. It was now midnight. We decide to go in just to take a peek. So we walk in, loudly talking and joking about the faucets and then stop dead. Inside is some tall skinny guy, with their backs turned to us, just dissecting away. No headphones or anything, but doesnt talk, doesnt turn around, just keeps on working. We never heard anyone come in the entire time. At this point, my roomie and I just stop dead and are thoroughly creeped out. We decided that its probably best to just slowly back away and go back home.

DId you guys ever find out who it was?

Nope. It wasnt one of our fellow medical students or any of the faculty. No clue who it was!

Ok, so what were the pyramids really built for?

Massive edifices of hubris.

My son, nine, was diagnosed with hydrocephalus this spring, and had ETV surgery to correct it. How common is it for something like this to be diagnosed at this age? It wasn't caused by trauma - I'm still questioning how and why. His surgeon used the word "cured" at his six month check, and I still can't quite believe it ever happened, let alone that he's cured.

Hydrocephalus is a concept that still isnt very well understood. There may be a whole host of reasons from congenital malformations to scarring caused by an infection or possibly even a tumor (obviously they would have checked for that in your son's case). Hydrocephalus is more commonly diagnosed in children and in the very elderly. An ETV procedure is more beneficial than a shunt in that no catheters or other foreign bodies need to be implanted into the body, but mind you, the ETV could still potentially close up and a second procedure may need to be performed.

My uncle got hydrocephalus at age 3 from some sort of infection that gave him a very high fever. It didn't actually show up as anything obvious until he was a schizophrenic 25 year old who got in a bar fight and earned himself a head CT. What i've never understood is how he didn't have obvious symptoms such as headache, etc. Wouldn't a ton of pressure on the brain be really obvious? He unfortunately has slowly become more mentally and physically disabled over the years and lives in a nursing home, as they were unable to place a shunt.

Yeah, hydrocephalus is very interesting and still not fully understood. A lot of people can accommodate the hydrocephalus but develop relatively normally without symptoms. However, many of those patients later in life develop problems when they're elderly with cognitive and physical deficits. I'm very surprised that they were unable to place a shunt - thats virtually unheard of!

Could you fuck up a person just by one little wrong movement of your hand?

Yes. There are degrees obviously. Botching a surgery near the brainstem could kill someone. Mishaps in the spine could result in paralysis of a limb.

so every brain surgery is pretty risky, isn't? are you scared before entering the surgical room?

Nope. Obviously you have to treat every surgery as a serious endeavor and you can be daunted. But I've been well trained (and I'm sill undergoing training) and I have a knack for this kind of intricate surgery. If the situation does get too hairy, its never a shame to ask for help. I've seen some of the most experienced surgeons we have call for help from their colleagues and its absolutely crucial to have that kind of support around when doing these kinds of cases.

How often do you say the phrace: "Well, It's not actually brain surgery"?

I say, "Well, its not rocket science!"

Also, obligatory.

What was the toughest patient you had to deal with like?

I've told the story of the poor guy who's mother was basically brain dead of a massive stroke and wanted to donate his brain to her. I just couldnt convince him that wasnt an option.

I also had a rough Christmas a few years back where I had to tell two different families that their young family members (a 30-ish guy who died in a drunk driving incident & a 30ish woman who had a ruptured aneurysm) were dead.

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Obviously being fat/unhealthy is a big risk factor for such strokes and hemorrhages, as well as smoking. Younger, healthier people may be susceptible if they have a family history or genetic predisposition, but that is far rarer.

Why did you choose neurosurgery to specialize in? How much do you make (I assume I can ask this given that you are anonymous)?

Well I'm still a resident, so while I'm comfortable, I don't make nearly as much as a full practicing neurosurgeon. I make about $70K per year, and work about 75-90 hrs/week. A practicing neurosurgeon can expect to make about $400-500k/yr on average.

I chose neurosurgery for a whole host of reasons. I always wanted to do surgery. I love working with my hands, I love the fast paced nature and hard work of the field. There's nothing like being in the OR and seeing a sick patient's life saved. I had great mentors early on in college who took me under their wing and inspired me to go into the field. And, can't lie, there's always a little bit of ego boost that goes into it.

How realistic was Derek Shepherds portrayal of a neurosurgeon?

McDreamy right? I honestly havent seen much of it, but the show as a whole was completely unrealistic. General surgery residents don't just pop into neurosurgery cases. Completely separate residencies.

The most realistic medical TV shows I've seen were Scrubs and The Knick.

If I wrote you a long drawn out explanation of a problem I am having with my back that is in all likelihood a neuromuscular issue, would you be able to give me some advice on who to see and what the problem might be? I have bee suffering from extreme back pain for 15 years and my doctors do not have a good handle on what is causing the problem.

Can't hurt, PM me. Not meant to be actual medical advice, obviously. Let me know your location, I may be able to suggest an expert if I know any nearby.

Throughout your career, did you ever worry that you were going to burn out? If so, how'd you get past that?

What's your opinion on a single-payer healthcare system?

Yes, I did. The first couple of years of residency are very hard. You work long hours, deal with some very serious emergencies, and the field is so vast that trying to learn is like drinking out of a firehose. However, once you have mastered it, by the end of your junior residency, you are running the hospital. Literally. Your decisions affect the ER, the ICU, and OR recovery rooms, and you walk around with a swagger because you can handle anything that comes through that ER door.

Single payer healthcare. Thats a doozy. I feel like the villagers in the Frankenstein movie - I'm terrified of something I just dont understand. I'm glad that more patients are going to get access to healthcare. I want to help more patients, I want to do more surgery for people who need it and havent been able to get it. That said, I also want to be compensated for the time I've put it, the time I will put in, and for the degree of difficulty for the job. I hope you can understand that it kinda sticks in my craw, the prospect that plumbers to lawyers can set their prices for their work, but I have to accept whatever someone else decides to pay me. Imagine walking into Best Buy and saying, "eh, I don't really think that TV is work $500. Here's 50 bucks!" and walking out the door! Thats kinda how healthcare is.

I believe NPR recently did a series on healthcare costs thats well worth checking out.

Thank you for your responses!

I have one more question, if I may. My father's a doctor. He's been doing it for 25 years. He enjoys practicing medicine, but hates the administrative entanglements, and I think he's depressed. I've suggested that he see a therapist, but he's stated a concern about having that follow him around in the profession (I also think he's an old-school traditional guy who doesn't want to talk about his feelings). Through various books and articles, I've read numerous times about doctors and residents jumping off hospital roofs and/or developing drug/alcohol addictions. I don't worry that my father is going to be one of these people, but I do wonder how much of a stigma there is in the medical field about professionals seeking help with their mental health. Can you comment on that?

Jeez. Thats heavy. Its said that an entire medical school class (~400 doctors) are lost to suicide every year. It runs very prevalent in physicians and there are more and more articles like this on medical blogs. I've been lucky. I have a great working environment, co-workers and mentors that I enjoy working with, a very understanding spouse, and close family support. Not everyone has that kind of support system.

With that said, I'm safely protected in residency still. Its very different when you're the one in charge and having to deal with insurance issues, endless paperwork, badly designed electronic medical record systems, difficult patients, overloaded schedules, and possible lawsuits.

Do you have any thoughts on the Blue Brain Project which aims to create a synthetic brain by the year 2023?

My institution is doing a lot of work on brain connectivity and neural networks. Good luck and more power to the Swiss!

Where do you stand on marijuana and the brain and do you consider it a medicine?

There has been lot of fascinating new research on cannabinoid receptors and its effect on pain. I don't necessarily consider smoking marijuana a medicine per se, but I do think can further research should be undertaken to see if we can derive effective medicines from it.

Hey, uh...done any work with hemangiomas inside the vertebral body?

No. I have treated other kinds of tumors, though.

Quick question: I have an EMG and nerve conduction study tomorrow. I had vertebroplasty in 2006 for a massive hemangioma that grew in an uncommon and aggressive manner inside T9.

1) because my pain never went down post-vertebroplasty (even though it was successful) and I am still in agony any time I am weight-bearing (even simply standing up is unbearable) to the point where I need methadone to not jump off a bridge and have had to go on disability, what could've happened or be happening to still be causing such severe bone pain and muscle spasms?

2) is an EMG and nerve speed conduction study going to involve 1000 needles poked in my back muscles? Can I get a bit of dilauded or would that interfere with the test?

(That was more like 4 questions, but I appreciate any feedback. Especially if you know of an expert in hemangiomas in the USA. I lost my career, job, marriage, home, life, everything, starting at age 28, from that hemangioma.)

Oh, one more: 3) I just found out I have a second hemangioma, located inside T2. Is it likely that it will do what the T9 hemangioma did and aggressively grow?

Hemangiomas are typically benign and shouldnt really cause much pain. If they have caused a compression fracture (I assume thats why you had the vertebroplasty), they can be painful. I gotta say, its pretty hard for me to advise you without seeing your images or being able to do a good neurologic and physical exam, so I can't in good conscience go and speculate.

EMGs will involve some needles, definitely not 1000s or them, and they're very small, fine, and sharp; and they should not hurt.

I sympathize with you. Back pain can be extremely debilitating, and obviously can affect peoples' lives in big ways. Its one of the hardest aspects of being a spine surgeon, and doing the right surgery (or not operating at all) is rarely easy. You may have a genetic condition that predisposes you to excessive growth of your hemangiomas. Your spinal surgeon and/or pain doctor may want to do tests to look into that.

What's your opinion on the fact/myth that humans only use 10% of their brain? Has research been done on the same?

Also, do you have more videos like this one?

You use all parts of the brain, if you didnt you'd be dead or paralyzed.

The American Association of Neurological Surgeons has a very nice Youtube channel.

I agree with you. Tell me if I'm wrong, but hasn't it been discovered that different parts of the brain have different functions, like the frontal lobe controlling (among other things) motor control? Therefore, if a part of the brain wasn't being used, there would be a very observable change in the person.

Yes, there is localization of certain functions. For example the motor cortex of your right brain controls the left side of your body. Language function is localized to parts of your left frontal and temporal lobes. Vision is localized to the occipital lobes at the back of the brain. But those areas of the brain dont just shut down. If your right motor cortex just shut off, you'd collapse. If your frontal lobes shut off, you may lose consciousness, etc.

But those areas of the brain dont just shut down.

so are those areas then on "lower" activity? Some sort of "idling cycle"?

Pretty much, there's a lot we dont know.

Does taking more than the prescribed amount of drugs such as adderall effect the brain in bad ways?

I dont know; I don't work with those kinds of patients, nor have I ever prescribed/used those kinds of medication.

I'm a young lad aspiring to become a NeuroPsychologist. Had a bunch of people tell me any number of bachelor degrees to go for as there doesn't seem to be a clear and agreed upon path. What I do know is that I have 10 years of schooling left to figure it out. Any tips on going about this process?

Also any tips/stories/general information on residency and fellowships is appreciated.

Thank you much for doing the AMA! Your answers have been a joy to read and very informative.

Neuropsychology is a separate track from neurosurgery, which is typically through medical school. My favorite college professor was a neuropsychologist and I still keep in touch with the guy. As far as I know, you'll need to go to graduate school and get a degree in clinical psychology and specialize in neuropsychology. More power to you. Its a fascinating field with a lot of new science behind it and we neurosurgeons work closely with them as we rehab patients and even do awake brain operations with them!

Have you seen a patient with a lobotomy or other destrucive brain operation? Could you also give some info on their behavior based on experience or your knowledge?

Yes, but its typically been to remove a tumor or a region that causes epilepsy. It doesnt have normal function and so typically doesnt cause them many deficits. The era of lobotomies to fix psychiatric disorders and leaving patients all fucked up are long over.

Have you ever wanted to cause pain/kill any one of your patients or their family members? Can you wear T-Shirts to work, rather than suits (obviously not during surgery)?

No. We've had some fucked up people come in, and as much as I'd like to think that I'd be some vigilante badass, my job is to treat patients. Its not in me to inflict pain like that, but I havent exactly come across child molesters or murderers or anything like that.

We are strongly encouraged to come to work in professional attire. Usually I wear a button-down shirt and khakis and immediately change into scrubs. Why wear anything other than scrubs? They're like wearing pajamas at work!

I'm 32. Should I stop smoking?

Yes. Many neurosurgeons don't electively operate on smokers - it increases the risks of surgery and impairs healing. It also puts you at risk for strokes and hemorrhages. People who keep smoking in some ways walk around with a bomb in their head.

What about pot smokers? Do you notice any different look to a smokers brain verses a non smokers brain? Same for heavy drinkers?

Dunno about pot smokers. People who drink alcohol excessively often have degeneration and smaller brains, which leaves them susceptible to having their brains rattle around in their heads more often, leading to a higher propensity to bleed when they fall. Which happens quite often to alcoholics...

Does a smaller brain correlate to lower intelligence?

I'm asking because two of my chemistry professors are functioning alcoholics but smart as hell.

No, a naturally smaller brain does not correlate to lower intelligence. This has been shown in numerous studies, and anecdotally, I have a relatively small head (I've bought "youth sized" baseball caps to get one that fits well) but I don't think its affected my intelligence.

Alcohol in excess may lead to neuronal cell death and repeated injury which leads to a smaller brain - that could affect intelligence.

As someone who is 16 and wanting to become a surgeon and considering neurosurgery/science, is there any advice you can give for studying and getting into the profession?

Study hard and get good grades. You've got a LOOOOOOONG road ahead of you!

You don't happen to work in NY, I suppose?

Mayhaps.

And thus, mayhaps a young pre-Med redditor by the username of ezzy13 gets his first neurosurgeon shadowing experience?

PM me

How long have you been a neurosurgeon?

Why did you decide to become a neurosurgeon?

How long does a normal surgery last?

How steady do you have to keep your hands and what do you do to keep them that steady?

Been watching cases and doing research, studying and preparing to do neurosurgery since college and through med school. Was fascinated by the anatomy and function of the brain and spine and the complexity of the cases involved. Love working with my hands and really wanted to be a surgeon all my life.

Surgeries vary in length depending on complexity of case - removing simple blood clots or simple spine operations can be done in less than an hour. Removing complex brain tumors or doing a big spinal operation may take 12 hours or more.

Your hands don't always have to be steady, especially for spine cases where your movements don't necessarily need to be so fine. For brain operations, yes they do have to be stable. I don't really do anything for them, I happen to have decently stable hands. I try not to drink coffee right before operating.

What are some examples of the stuff that Ben Carson has done to mess up your profession?

Its a bad joke.

How much do we know about how the human brain functions so far?

Tons of research going on right now into that. I don't think we know exactly how much we know or don't know about brain connectivity, neural networks, and how it relates to function.

Late to the party but where do you see the biggest advancements in TBI care coming in the next decade or so? We seem so far behind.

I recently wrote a review on pharmacological treatments for Traumatic Brain Injury. We've made big strides in operative treatments and critical care and we've saved many lives. But the past 40 years worth of research to find a drug or therapy to improve outcomes for TBI have been an unequivocal failure. That said, there is a lot of promising research out there.

And the same thing can be said about glioblastoma - the most common form of brain cancer. We've only really improved life expectancy by about 6 months despite a ton of new kinds of therapy. Thats why we're doing so much research and desperately need more funding to treat both TBI and brain cancer.

Is Dr. Carson a genuinely good surgeon? I was wondering considering that his political career is down the toilet...

Beats me. I never saw him operate. By the accounts I've heard he was nothing special, but that was from his fellow pediatric neurosurgeons / competitors.

How important was chemistry in studying medicine? And what did you think about Carson's chemistry angel story?

I can't say that I use it on a regular basis in my clinical job. But i use some of the techniques and chemistry knowledge in the research lab.

What's your favorite DS9 episode?

Thats a hard one. Probably "In the Cards." Its a fun campy episode, and it just kinda really shows the great chemistry the cast had, which I think really set it apart from the other Star Trek series.

You are my favorite neurosurgeon now.

Ha! Take that Carson!

I have a radiculopathy c5-c6, that doctors are suggesting a fusion on. I'm not really thrilled with a fusion, and would prefer a replacement disc. Surgeon I spoke to said he didn't want to do a replacement because I have bony outgrowths both in and out of the vertebrae, and because (I'm slightly extrapolating here) he's only done about 15 replacements vs countless fusions.

Here's the few other medically relevant issues: I have tics. Since forever. Mostly they manifest as rapid tics which cause me to forcefully move my head forward and chin down. I suspect that it's the cause of the c5/c6 issue. I'm not going to be stopping ticking, and suspect that the discs above and below will be rapidly impacted.

My c3-c4 is bad, but not horrible. No real symptoms yet.

I'm going for a second opinion, but, would love to hear your thoughts on this.

40 year old male, non smoker. Otherwise generally healthy, but am type II diabetic (controlled with oral meds).

What's your thoughts on this?

You should absolutely go for a second opinion with someone who has experience with artificial discs., if only so you can be comfortable that you're doing the right thing. Disc replacement is a relatively new procedure - I've personally performed only about 2 or 3 myself at a very busy spine center- with limited indications. Most spine surgeons are familiar with fusions - they are safe, very effective, and typically durable. If you have bony outgrowths they may be bad enough to require removing the entire vertebral body, however, and disc replacement surgery likely wont be possible and you will need to have a fusion. Id have to see your scans to say for sure. Your tic issues complicate matters. If your tic is really bad, it could effect your healing and may require you to be in a hard collar for a long time after surgery.

Are you religious or are any of your colleagues crazy wackadoodles or evangelicals like Ben Carson? How does this affect your/their work? Do you find it conflicts with the science part of neurosurgery?

Its not something we discuss very often, but as far as I can tell, very few of my colleagues are all that religious - some of the jewish ones keep kosher and will take off for the high holidays.

How much of a role do RN's / NP's play in your OR?

There are special OR RNs that will act as circulating nurses, and some scrub in to during the surgery and will organize and hand us the appropriate tools. They don't really assist in the surgery itself, but they're crucial to doing the operation efficiently and getting the right tools at the right time.

I'm an undergraduate applying to med school this summer. Any quick advice on the daunting prospect of medical school?

It gets harder and harder. You have to check all the boxes and have excellent grades, test scores, extracurrics, essays, letters, and research. And on top of that, you have to ace your interviews.

Best thing is to do your research on the school you're interviewing at. If you have a particular interest, find out who at that school is involved in that specialty and their activities. Mention special curriculum quirks or resources that make the school unique. If you have any previous experiences that make you unique emphasize that and talk about how you can contribute to the school and the student body.

I know you can't give medical advice. I'm looking for a more general answer, but I am going to give the details to explain why I'm asking.

At what point are lifestyle changes just not going to cut it as a viable alternative to surgeries on the back? (Obviously, they should still be made, but when does a person who is seriously changing all of their bad habits have to really consider surgery?)

I have had chronic pain for the last ten years (I'm 26.) It's just recently started affecting my nerves, mobility, stability, etc. I just quit smoking and drinking alcohol. I'm overweight, and very slowly losing weight and generally just trying to make better health choices. My GP seems to think I can completely avoid surgery by just making lifestyle changes. I have a follow up with the orthopedic center soon, and since the "threat of surgery" has been looming over my head ever since a neurosurgeon mentioned it when I was 17, I just assume this is going to come back up. (I want to do anything possible to not have surgery. I'm terrified of the thought.)

(These are the dx on my chart: Lumbosacral Spondylosis Without Myelopathy; Spinal stenosis of lumbar region without neurogenic claudication; Acquired spondylolisthesis) And something I was told over the phone this past week after my Nerve Conduction Study/EMG was bilateral nerve impingement (I think).

Again, not looking for you to comment on my specific situation, just a general "In these types of situations, xyz would be when I'd seriously start considering surgery..." if you wouldn't mind.

Well, losing weight and stopping smoking/drinking goes a long way. Core strengthening exercises like planks will help as well. Avoid twisting and bending movements with situps and crunches or with weights. Its interesting, if you see really little kids, they pick up objects from the ground by bending at the knees and standing up. We adults seemed to have forgotten that and typically isolate our backs and that causes a lot of problems.

http://www.dailymail.co.uk/health/article-2834646/Advice-bend-knees-straight-lift-flawed-scientists-claim.html

Interesting study. There has been a real shift in the past decade in spine treatment. We take a much closer look at spinal curves and angles and instead of just focusing on the area of concern - lumbar or cervical - we look at global alignment. Everyone's skeletons are slightly different and different amounts of correction are needed even if their area of concern is similar.

A few comments on the paper, the scientific abstract can be found here. This studied volunteers who were pain free and this may not hold true in patients who have pain. They did not list the average age studied, the variation of age, and the highest age studied was 65. The vast majority of patients who have bad back pain are 65 and older. Their main conclusion seems to be that volunteers who were instructed to do a lifting motion different from their preferred motion struggled. They concluded that this may be due to a difference in their spinal curvature, or it could simply be because they've built up habits and struggled with a new motion. One final concern is that this abstract was presented approximately a year ago, and was probably concluded well before then. Supposedly it won an award at a conference. Yet it hasn't been published in a peer-reviewed journal with more information presented. That suggests that there may be flaws with the study that were not mentioned.

Like with all things, a one-size-fits-all mentality doesnt work for everyone, but we're not going to give everyone an MRI and suggest the optimal individual lifting strategy. Until then, I'd advise people to exercise, don't get overweight, strengthen their core, and lift with their legs.

Can you tell me if you do any work in aplasia cutis on the skull, and if there's anything 's parent should be in the lookout for? My son is 4 and was born with a small, dime-sized spot on the crown of his skull. He's never been treated for it, it healed quickly from birth to the coloring of the surrounding scalp, and his doctor has said if it "gets larger", they'll send him to a dermatologist.

We don't go to go the doctor that often, so I'm not sure what to look out for in the meantime. He recently began touching it when he was ill, and said it hurt. It very well could have been a headache, because he hasn't said anything else about it or touched it since.

I'm just curious if there are neurological issues that are affected by aplasia cutis, and if there is anything I should be checking on a regular basis.

Thank you for the AMA! It's been very informative so far!

So long as it doesnt communicate with the bone underneath or is associated with other congenital anomalies it shouldnt be an issue.

Do you see many patients with a subdural hematoma caused by coumadin? That is what happened to me. Then I read that people on coumdin have a 2% chance of developing a brain bleed per year. Is that accurate?

Oh yeah, all the time. I joke when I'm on call that all the old folks take an extra dose and start tottering around just so they can fall, get bleeds, and come in for me to operate on them!

Neurosurgeons hate blood thinners. Obviously as a whole, they're beneficial for people who have heart problems, but they have a risk of causing significant brain bleeds. And when that happens, it delays surgery because we have to reverse the effects of the blood thinner before we can operate, otherwise it'd be a bloodbath in the OR. And it still has a risk of causing further bleeding after the operation. We need to have more sophisticated medicines that are both cardio-protective, but can be easily inactivated in case of emergency.

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Its more likely that someone in poor health and in their 80s had a natural but severe brain bleed due to their being on Coumadin. Its far more likely than an intentional overdose (which I was totally joking about, earlier!) and then falling down. The only way to know is to do an autopsy and postmortem tests.

Have you been sued? Have you lost the suit?

No, and hopefully I never have to find out how thats like. One of my mentors recently ended a lawsuit trial that went his way. He took a week off from surgery around the time of verdict because he didnt want to be mentally affected while operating.

Do you know people who worked with Dr. Carson? Was he a good surgeon?

I haven't spoken with anyone who trained at Hopkins specifically about Dr. Carson. According to some of my pediatric neurosurgeon colleagues, he wasnt as good of a surgeon as he purports himself to be. However, that may just be sour grapes.

If a dying person wanted to donate their brain to science how could you make best use of it?

Pretend that ethics doesn't restrict your options

You know, I never thought about that! However, I think these days, living brains are more important to neuroscience. We want to study brain function and connectivity, which you just can't do with deceased patients. And if you were "dying", you'd probably want to spend your days with your family and not in a hospital with tests being run on you!

I'd suggest donating your body to a medical school.

Have ever had a patient with an Arteriovenous malformation? If so, what was it like? How did it affect them?

AVMs can be very bad. They're often silent lesions that people have their entire lives and one they they pop and can cause a massive brain bleed. Depending on where it is, it can be devastating if not treated. Worst AVM patients I've had were the pregnant or recently post-partum patients. Blood pressure issues are big in pregnancy, and so they're susceptible to those kinds of hemorrhages. Those are tough, sad cases.

Is it possible that the idea behind treppaning being beneficial could be true? Apparently some folks believe it improves blood flow to the brain and promotes increased mental well-being.

Also, what do you think about synesthesia (i find it fascinating and wish I had the sound to colors variety). Do you think it is caused by a difference in anatomy? Do you know any professionals with it?

I've never heard of people getting trepanned without having some underlying pathology. I would hope that no neurosurgeon would do that, because thats a bunch of quackery right there!

I don't think we know exactly what underlies synesthesia. Its extremely rare, and is definitely caused by variances in neural connectivity. There's a lot of research going on in neural networks and connectivity, so maybe one day we'll know!

I'm a student in biomedical sciences. As I understand it,there are several regions in the brain, that have different functions but very few, if any, structural differences. For an example, how are you sure that you are operating on the prefrontal and not the precentral part of the frontal lobe?

We have intraoperative neuro-navigation. Think of it as GPS for your brain. We know exactly where we are in 3D space and it correlates to the MRI or CT scan. However, a lot of the time we estimate. We say "OK, the tumor/blood clot is about 4cm above the ear and 10 cm behind the eye. We do our operation there and we find the tumor/clot and take it out.

I have epilepsy and am going in for a 5 day video EEG on Thursday. It is in my left frontal lobe, next to my language centre. Have you performed this type of surgery? Would you advise it? What are the risks?

Is it just an EEG with scalp electrodes? Most places have a protocol for epilepsy.

If there is a clear focus on the EEG and an anatomical anomaly in the same area on MRI, then that is the place to target for surgery. Many times, however, the seizure focus can't be localized on either imaging or on the EEG. In that instance, we will do a surgery where we place electrodes on top of and into the brain, and then you'll stay in the hospital for a week or two and we record your seizures to localize in 3D space where they're coming from.

If you need surgery there are a couple ways to do them. You can have open surgery, where they will do a sizable operation to remove the affected part of your brain thats causing the seizure. Many centers, including my own, are using a new therapy called Laser Interstitial ThermoTherapy (LITT). It is a catheter thinner than a coffee straw that is placed in the seizure focus through a tiny hole made in the skull, and we then stick you in an MRI and using lasers, we burn away the area causing seizures. Its a much smaller and well tolerated procedure, but its still very new and the long-term durability of the procedure are still unknown. However, it seems to work very well, at least in our experience.

In your case, being next to your language center, you have to be very careful. Make sure you go to an experienced epilepsy group that works as a team with neurologists, neurospsychologists, and neurosurgeons, and that they explain everything to you in detail. Most large university hospitals are the best place for these kinds of treatments.

Hey, thanks for this AMA. Can you tell us about your research on brain tumours without doxing yourself?

Much of my research involves improving the delivery of chemotherapeutic drugs to brain tumors. In the lab we are testing nanoparticles to open up the blood/brain barrier to improve drug penetrance into brain tumors. I am also a co-investigator for clinical trials involving intra-arterial drug delivery to brain tumors

Cool, thanks for your response do they still use the chemo "wafers" or is that now outdated tech? What do you think of immunotherapy for brain tumours, does the BBB make this challenging?

Yes, they are used in certain circumstances. New similar kinds with radioactive "wafers" are used as well.

What is the rarest brain tumor you have ever seen? How big was the largest?

My husband died after surgery to resect a ~5cm hemangiopericytoma, so I'm curious as to how rare that is. Thanks for the AMA!

Hemangiopericytomas are pretty rare and they can be pretty bloody and complicated. I'm sorry to hear about your husband, fortunately post operative deaths are rare for tumors. The biggest was an absolutely enormous and irregular meningioma. The rarest was a supratentorial neurenteric cyst. Only about 20-30 have been written about and we contributed about 3 more.

Have you separated conjoined twins?

No, craniopagus twins (twins connected at the head) are exceedingly rare. I've only ever seen one at the Mutter Museum.

Is Ben Carson on Oxy?

Just a small little fantheory I have

I don't know, I've never personally met that man. I have also never seen anyone speak the way he does to an audience.

What are your thoughts about the recent blood brain barrier breach and how does this change your line of work?

My research is all about BBB disruption for glioblastoma so this is big news! Personally, I think that ultrasound to disrupt the BBB can be improved by selectively catheterizing the blood vessels near the tumor, releasing the microbubbles there, and then using the US. Then, you can immediately infuse your chemo to that area and my idea is that you an even possibly inflate a balloon in the artery for brief flow arrest to improve saturation of the tumor.

My institution is likely getting a focused ultrasound machine soon and we'll be doing trials with it much like the Toronto guys. We're also doing some fascinating work on nanoparticles for both BBB disruption and drug delivery. Couple this with all the new virus and vaccine research against glioblastoma, I think this coming decade we may actually be able to make real improvements in glioblastoma survival!

Thanks for doing this. What kind of research do you do? Do you think an MD/PhD student interested in maintaining an active basic/translational lab should even consider neurosurgery as a specialty?

I have no aversion to hard work, I love neuroscience, and I want to be a surgeon, but I also want to continue research in tissue engineering and stem cell biology for the rest of my career. Do you think it is possible to do 50/50 research/neurosurgery (less? more?) at an academic institution? What is the minimum hours/week you would need to maintain your skills? What if you sub-specialize (into something like spine or neuro-oncology)?

Thats a great question. I do research on improving chemotherepeutic delivery to penetrate brain tumors to better target the cancer stem cell niche. It involves tiny surgeries on mice and some cell culture work. I'm not the biggest fan of basic/translational work and I much prefer clinical research - I'm also a co-investigator for a number of glioblastoma clinical trials.

I do think its possible to maintain a 50/50 research based practice. There are plenty of academic neurosurgeons who do so. Its all at academic institutions and you have to find the right place for you. I think the minimum hours per/wk to maintain your skills is indivualized so I dont know. I say you'd need to spend at least 2-3 days in the OR/Seeing patients.

Remember, by the time you're a practicing neurosurgeon, you're likely going to be running the lab not running gels. You'll have students and post-docs and likely even a PI working with you to do the daily lab work while you're busy raising funding, supervising and mentoring the labworkers, and managing the lab. You'd likely subspecialize into whatever field your research is in.

Have you ever seen rare spinal abnormalities like diastematomyelia? If so what are some long term complications even for high functioning patients?

Yes. Some patients may have lingering neurologic issues - which can be serious - like bowel or bladder issues. Other patients with long untreated diastematomyelia may have scoliosis which may also require surgery.

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Like most of life, the answer is more nuanced - I'm liberal on many issues and conservative on others.

What kind of damage has Ben Carson done to your profession? Do you think too many under qualified blacks are admitted to medical school because of affirmative action?

You tell me, do you think less of neurosurgeons because of Ben Carson? I'm really just joking, no one's not going to a neurosurgeon because of Ben Carson. But it does tarnish the image of the all-knowing, hyper competent neurosurgeon though; which obviously is not a reality.

You ask a really loaded second question. Some of the most ridiculously intelligent and gifted physicians and neurosurgeons I've met have been black. I think affirmative action policies are an easy way out that many colleges and grad schools take because it takes a huge amount of effort to truly critically look at every applicant and consider their merits and life stories. You can't interview everyone in-depth, and so they use this as an easier means of capturing people who could potentially develop into superstars but may go overlooked. I don't necessarily agree with it though, because it leaves too many qualified applicants out and I've seen under-qualified people who made it in flame out. I don't have a good alternative though.

Have you ever witnessed a hemispherectomy?

I've performed one. They just dont happen to be very common at my institution.