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Table of Contents    
NI FEATURE: THE PRESIDENTIAL ORATION - COMMENTARY
Year : 2016  |  Volume : 64  |  Issue : 2  |  Page : 208-214

The philosophy of 'middle path' in neurosurgery


Department of Neurosurgery, Gamma Knife and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication3-Mar-2016

Correspondence Address:
Bhawani Shanker Sharma
Department of Neurosurgery, Gamma Knife and JPN Apex Trauma Centre, Room No 720, Neurosurgery Office, CN Centre, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.177598

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How to cite this article:
Sharma BS. The philosophy of 'middle path' in neurosurgery. Neurol India 2016;64:208-14

How to cite this URL:
Sharma BS. The philosophy of 'middle path' in neurosurgery. Neurol India [serial online] 2016 [cited 2019 Aug 25];64:208-14. Available from: http://www.neurologyindia.com/text.asp?2016/64/2/208/177598


I was pondering for quite some time for an appropriate topic for the Presidential Oration of Neurological Society of India. I thought that it will be worthwhile to present the crux of my own experience of over 33 years in the field of Neurosurgery. The aims of the oration should be that it is not too ideological; it should not deviate from the ethical and evidence-based scientific principles; it should be capable of providing philosophical guidelines that may actually be applicable to life in general and and to neurosurgical practices in particular; and, most importantly, it should have the ability to reach out to the junior-most residents. The theme of this conference is 'From Controversies to Consensus.' As the 'middle path' is the best way to get consensus, I decided to choose this title as the topic of my talk.


  Philosophy of 'middle Path' Top


The concept of the 'middle path'[1],[2],[3],[4],[5],[6],[7],[8] was described by Lord Buddha as a 'route to enlightenment.' There are two ways of leading one's life.[1] At one extreme is the material way of life, believing that happiness comes from pleasure and comfort; at another extreme is the belief in a spiritual way of life, where one renounces the material world, relinquishes one's work and responsibilities and becomes a 'sannyasi'.[7]

The 'middle path' is leading a life that exists between these two extremes. The words portrays that one should not give up one's work and responsibilities but rather carry them out with utmost sincerity while using materialistic things in moderation at the same time. However, one should not run after or crave for these materialistic things.[7]

For example, when an attacker places a loaded gun on someone's head, ordinarily, there are two choices: At one extreme is to meekly accept the bullet from the attacker's gun and die. At the other extreme is to defend, overpower and kill the attacker. However, there exists another path, to negotiate with the attacker and convince him that he can do better than to commit a murder. Hence, the 'middle path' is not simply a trail in between two extreme courses of action. It is actually a different path that balances the two extreme view points and avoids errors, imperfections, blind alleys and pitfalls that extremism may lead to. It is similar to the concept of 'false dilemma'[9] in the Western philosophy and the philosophy of the 'golden mean' propounded by Aristotle.[6],[10] It is a path with the greatest clarity and is not even remotely related to a superficial understanding of the concepts or a biased view.[11]

It should not be confused with passivity or a kind of middle-of-the-road compromise.[12] It should also not be ascribed to be synonymous with the words 'mediocre, average, mean, intermediate, median or centre' and is far above and beyond these mundane concepts. It should also not be misunderstood as being equivocal about things in general. The 'middle path' implies applying to the best of one's ability, ongoing efforts in the broadest sense, and maintaining actions and attitudes that create happiness for self as well as for others.[12]

When applied to social life, the 'middle path' is a way to open one's mind and allow oneself to treat others with mutual respect, understanding, tolerance and love. It is based on building a strong foundation. When applied to personal life, it is a path of true freedom and optimal living that keeps one's stresses low and the satisfaction levels high, and is generally ascribed to having a positive attitude towards life. This is the optimum path for which the human body is designed. It is a healthy way to deal with the vicissitudes of daily life and helps to live life fully in the present without being swayed by the past or the future.[6] In other word, it is actually a path to progression and also balances the pressures and complexities of modern life. It is a path to purity, happiness and peace of mind.[8] It is safe and lasts longer. The 'midde path' philosophy is of universal significance and can be used in different contexts.[7]


  Neurosurgery Top


The neurosurgical training is rigorous and lasts for 6 (3+3) years. It is associated with long working hours and is associated with periods of inadequate sleep. It often forces the trainee to miss a meal, to bear the repeated coercion by mentors to work harder and way beyond one's capacity or inclination. Each trainee is often plagued by repeated thoughts of quitting his/her training at some stage.

I like the tough life and thrive on challenges. I chose neurosurgery because it was challenging and different. The inherent concept of 'hating to lose' makes us neurosurgeons, a breed apart. We all realize that neurosurgery is a stressful sub-speciality and the consequences of small errors may lead to death or disability.[13] Despite the prolonged efforts, and despite the elegant and masterly surgery performed, sometimes our patient may not do well. The patient satisfaction levels are low because of a wide gap in the scientific advances propagated in the media or falsely perceived by the patient and his family, and the actual treatment available. A classical example is that of stem cell technology touted as the holy grail of every form of treatment, especially for incurable diseases.[14],[15] Similarly, there is an undue emphasis on the projected benefits of surgery by the endoscopic or laser technique.


  Stress in Neurosurgery Top


Operating on one's relative/colleague/friend is stressful. Also, there is an acute and additional stress of an intraoperative aneurysmal rupture, brain swelling as well as other introperative mishaps. Too much stress may lead to a poor performance [Figure 1].[16] A study of the ambulatory pulse and blood pressure recordings performed in our department showed an abnormally elevated stress response in neurosurgeons during surgery that is far greater than that induced by a vigorous exercise.[17]
Figure 1: Inverted 'U' shaped curve showing the relationship of stress and performance. The best results are achieved with an optimum stress

Click here to view


In this scenario, the concept of 'middle path' is to temporarily detach onself from the situation. This reduces the stress levels and improves perfomance. At the same time, in times of intraoperative stress, requesting your colleague of equal competence to scrub up with you is a great stress-buster. A team effort will bring down the stress levels and will allow a more rational judgement.

The 'middle path' promotes balance, diversity and moderation.[18] It is a path between excess and deficiency. Gladwell described an inverted U-shaped curve that shows that having more stress is not always better. Initially, stress can be utilized to bring about more efficient services, but later it become disadvantageous as one passes the threshold. This Yerkes-Dodson law/inverted U curve/bell-shaped curve denotes that, when levels of stress become too high, performance decreases.[16],[19],[20] At a high level of stress, the cost overweighs the benefits.[6] There is a point along the line after which the positive effects turn into negative ones.[6],[19] An example of this is the inverse relationship that often exists between emotional well-being and income, happiness and longevity, class size and academic achievement, alcohol consumption and health, and, crime level and punishment.[6]

The fundamental issues in neurosurgical practice are two. First is developing clinical judgement and decision making; and, second is mastering surgical skills. During decision-making, one should consider the diseased and not the disease. The expectation of benefit must outweigh the risk of surgery, and therapeutic alternatives, for example, radiosurgery, should always be given due consideration. The outcome should be better than that of natural history of the disease, and approaches should be adopted that are best for the patient and not necessarily what is best for the tumor/surgeon. During the surgical planning, due provisions must be made for the many contingencies that may occur. Cognitive bias, overconfidence, fatigue and lack of emotional equanimity may cause errors in decision-making, which may result in morbidity or mortality.[13],[21] Decisions should be based on scientific evidence and recommendations, algorithms, personal experience, intellectual exchange (a team decision) and comes with knowledge, experience and wisdom.

Examples

  • Petro-clival meningioma totally excised via routine suboccipital retromastoid approach [Figure 2]
  • A 25-year, unmarried lady presented with failing vision. After clinical and radiological examination, she was advised transcranial surgery but the patient wanted endonasal surgery. The risk of developing anosmia and the 5% risk of cerebrospinal fluid leak was emphasized but she still insisted on undergoing the endonasal approach. I reviewed her clinical picture, computed tomography (CT) and magnetic resonance imaging (MRI) again. The lesion was small, with a well-pneumatized sphenoid sinus and the presence of an adequate transplanum transtuberculum corridor. The indications were appropriate and safe. The lesion was, therefore, excised via an extended, endoscopic endonasal approach with an excellent outcome [Figure 3].
Figure 2: A petro-clival meningioma totally excised via the routine suboccipital retromastoid approach with the combined use of a microscope and endoscope. (a) Preoperative contrast axial MRI showing a large petroclival meningioma; (b) Postoperative CT scan showing complete excision

Click here to view
Figure 3: Complete excision of a tuberculum selle meningioma using the extended endoscopic endonasal approach. Preoperative MRI with sagittal (a) and coronal (b) images showing the tuberculum selle meningioma. Preoperative contrast axial CT scan (c) and postoperative CT scan (d) showing complete excision

Click here to view



  Qualities of a Neurosurgeon Top


No single personality type or trait describes all neurosurgeons but certain basic personal qualities are required. The neurosurgeon must have commitment, passion, sincerity and dedication. He should also possess professionalism, that is, the ability to work well within a group/system/team. At one extreme, indecisiveness makes one seem as 'spineless,' having no stature or dignity; while at the other extreme is 'arrogance,' with the person not bothering about his colleagues which makes him/her unadjustable in the team. Both of these extremes constitute an abnormal behaviour. Having a flexible/adjustable personality makes one fit as a teammate which is an essential prerequisite for a successful neurosurgeon.[22],[23],[24],[25],[26]

Another important quality is in knowing when to stop. Do not aim for perfection in trying to remove all fragments of the tumor stuck to vital neurovascular structures. Successful neurosurgeons, when faced with tough intraoperative decisions, consistently do a risk–benefit analysis during surgery that includes the decision to either remove every last bit of the tumor or to leave some behind in order to minimize the risk of neurological deficits.[23] A neurosurgeon should be quick in decision making, should know his limitations, should be efficient while performing under pressure and should know how to get out or stay away from trouble. The neurosurgeon must learn to operate with naked eyes, loupes, a microscope and/or an endoscope. The hallmarks of a neurosurgeon are: Manual dexterity, hand-eye coordination, three-dimensional orientation, spatial perception and tactile memory, that is, the ability to return one's hand exactly to the same place in the operative field where it was, before it was moved.[23]

He also needs to have the ability to maintain longer periods of concentration as neurosurgical operations are often of a long duration. Most importantly, 95% of the intraoperative complications occur in the last five minutes. Hence, the surgeon cannot afford to let his guard down even for a moment.[23]

A neurosurgeon should always be optimistic. Life and death decisions are part of his daily routine and he can either cure, buy time or improve the quality of life. Extra life gained by surgery, and spent in misery in the hospital on chemotherapy and radiotherapy, may be of lesser imortance to the patient whose main focus may be on maximizing his quality of life. Considering the 'middle path' philosophy during resection of tumors like a glioblastoma multiforme (GBM) of a deep/eloquent area, partial resection may be acceptable to preserve the postoperstive quality of life of the patient.[27],[28]

Great neurosurgeons believe in the 'do no harm' philosophy and have a balance of confidence and empathy for their patients.[23],[24] They always possess critical thinking and are incessantly exploring the possibility that there must be some better way of doing the same thing.[23] They always keeps pace with the technical advancements and newer surgical skills. The judicious adoption of new skills and technology with proper indications is beneficial for the patients. For example, the 'distraction compression extension reduction (DCER)' technique in atlanto-axial dislocation (AAD) and basilar invagination (BI) is quite effective and eliminates the need for a traditional transoral surgery in many patients [Figure 4].[29]
Figure 4: The DCER technique: (a) Preoperative sagittal MRI and (b) sagittal CT scan showing the chronically displaced type II odontoid fracture with significant cord compression. (c) Postoperative sagittal CT scan and (d) craniovertebral junction radiographs showing a good reduction with fusion

Click here to view



  Mentoring Top


Working for extended hours is unsafe. The concentration and efficiency goes down. Overfatigued residents, who have sleep deprivation and have been working for long hours are unsafe and have the potential to affect patient care. However, working 80 hours per week may not be enough for neurosurgery.[30] Dr Burr requested for an increase in working hours. The Accrediation Council for Graduate Medical Education (ACGME) in USA, approved for a 10% increase in the duration of working hours for residents from 80 to 88 hours a week.[2] Such requests are granted for a handful of the programmes such as neurosurgery owing to the prolonged surgeries, the complex anatomy, the critically ill patients and the lesser number of residents in this field.[30]

Convincing the residents about the importance of becoming more involved in the surgical and patient care by placing a little bit of extra effort can yield dispropotionately better results both for the patient's well-being as well as the resident's learning.

Aging decently is an art. Always train your colleagues. Teaching is learning twice. Inculcate discipline and work culture and develop mutual trust and respect. Always take care of your colleagues' interests and give them credit from time to time. One should develop the right combination of personal and team excellence.

Be a good team leader. A leader is the first among equals.[31] One should continue to learn. The moment you stop learning, you are dead professionally. Learn from failure and successes, learn from mistakes of predecessors and institute a behaviour that prevents repetition of these mistakes. Once in a while, introspect and analyse your own results and learn. Do not compete but seek inspiration from and learn from people who are better than you in that particular skill or surgery.

Encourage and foster younger colleagues to take up areas with lesser conflict as described in the 'blue ocean strategy,' that is moving from the red ocean of fierce competition to a blue ocean area that is unexplored till date.[32]

Developing mentor – disciple relationship is necessary, which is a shared pledge to work together.[33] Each successive person should expand on the vision of his predecessor. The diversity of people should be fostered and encouraged.[33] The mentor–disciple relationship is like a 'needle and thread' relationship, where the mentor (needle) leads the way and the disciple (thread) follows the mentor holding everything together to create a long-lasting impact. It is the deep connection between the mentor and disciple that leads to the development of the organization.[34]

Clinical examples of the 'middle path' philosophy applied to neurosurgery

  • The 'middle path' regime for treatment of spinal tuberculosis in the 1970s by Tuli:[35],[36] In the management of spinal tuberculosis, at one extreme is the thought that the non-operative (conservative) management is unjustifiable in all cases because of a slow response time. The disease may progress and cause deficits. At the other extreme is to perfom surgical extirpation of the abscess-bone-granulation tissue, which allows for a speedy recovery but seems to be unnecessary in a lot of cases. The 'middle path' is when surgery is performed only if there is no improvement using conservative treatment, or if the patients develops progressive neurological deficits or has a symptomatic prevertebral abscess [Figure 5] and [Figure 6]
  • Management of a giant, complex paraclinoid segment internal carotid artery aneurysm: At the one extreme, a direct clipping of the aneurysm may lead to cranial nerve morbidity; at the other extreme is treatment by the indirect method of gradual internal carotid artery ligation,[37] which can lead to a delayed stroke. The middle path is the internal carotid artery ligation with an external carotid-internal carotid artery bypass, a technique that has a lesser morbidity and decreases the risk of developing a delayed stroke
  • Management of anterior circulation aneurysms: At the one extreme, aneurysms may be always coiled; at the other extreme, they may always be clipped utilizing a pterional craniotomy. However, an optimum solution in unruptured, simple aneurysms, unsuitable for coiling, may be to treat them with a minimally invasive, supra-orbital key hole approach and endoscope controlled clipping [Video 1][38],[39]
  • Management of colloid cyst of the third ventricle: One extreme is to always insist on performing pure endoscopic surgery and the other extreme is to always insist on advocating an open craniotomy and microscopic excision.[40],[41] The 'middle path' is to start a pure endoscopic approach via a small trephine craniotomy rather than a burr-hole. Another channel may be used to hold the cyst wall. If this fails, an endoscopic-controlled excision may be performed via a tubular retractor or the procedure may be converted to a microscopic excision. The bottom line is to achieve total/near total excision of the wall of the cyst and not just the cyst aspiration.[41]
  • Management of skull base tumors:[42],[43],[44] In the late 1990's, radical procedures were in vogue in various Congresses and the skull base surgeons were the heroes of those days. The other extreme approach is to try the minimally invasive/endoscopic surgery through tiny/natural orifices in every case.





  • The 'middle path' is that of controlled agression via an optimal (minimal incision to achieve maximal efficacy) surgical approach and maximum safe resection with the optimal use of endoscopy and radiosurgery. The 'middle path' helps the surgeon to get to the optimal position during surgery in a quicker time. It encourages the surgeon to accept the suggestions of colleagues or to incorporate the advances in surgical techniques in his/her repertoire.[44]
  • Sizeable intracerebral hematoma: This can be treated either conservatively or by an open craniotomy and evacuation. The 'middle path' is an endoscopic-controlled removal through the minimally invasive techniques.[45] It reduces the chances of a possible neurological deterioration in the ensuing days, enhances recovery, reduces hospitalization and prevents the development of hydrocephalus.[45]
Figure 5: Successful management of Pott's spine with medical treatment. (a) T2-weighted sagittal MRI showing a T1-Pott's spine with soft tissue compression without bony deformity before starting the antituberculous therapy; (b) T2 weighted sagittal MRI, 6 month after administering the anti-tuberculous medication, showing the resolving disease with relief of cord compression

Click here to view
Figure 6: The patient with Pott's spine with paraparesis requiring surgical intervention. (a) T2 weighted sagittal MRI showing T2 Pott's spine with significant cord compression and deformity along with cord signal changes. (b) T2 weighted sagittal MRI of the same patient showing canal compromise. (c) Postoperative CT and radiograph (d) after T2 corpectomy and posterior fusion

Click here to view


Balance in life

Life is energy flowing in a particular direction that is determined by one's intentions and priorities. Many people direct their energy excessively in one area, ignoring all other aspects of life. This can prove to be unproductive and leads to an imbalance in life. If life is out of balance in one area, it will soon be out of balance in other areas as well (like a domino effect).[46],[47]

Neurosurgeons face a duanting challenge in balancing their family and professional life. Life is not only about work. There is more to life. When “not on duty”, find some time to socialize, entertain, relax and exercise. This practice recharges and rejuvenates one's inner self and improves efficiency. Always pursue a hobby, for example, playing music, cycling or participating in a game. This acts as a great stress reliever.[48]

In summary, neurosurgery is a delicate, difficult, challenging, and stressful subspecialty. Clinical decision-making, teaching, mentoring, and a continuous updating and learning of new skills are essential components of a neurosurgeon's professional life. Adoption of the 'middle path' philosophy in neurosurgery culminates in a perfect combination of personal and team excellence and safeguards the vital interests of all concerned. It is a genuine philosophical concept and not an analytical one. An analogy would be the 'keyhole' concept in neurosurgery where the approach is optimized to one's needs. It is not a quantitative measure but rather a conscious path that should be determined based on individual circumstances and needs. It investigates and penetrates to the core of the problem and situations with an unbiased attitude; it, therefore, facilitates decision-making and provides practical solutions to moral and professional problems. The 'middle path' of surgical approach for a maximal safe resection with minimal invasiveness is, likewise, quite relevant in neurosurgery.


  Conclusion Top


The 'middle path' is a pathway of moderation and perfect balance. Fine tuning of three areas that includes health, family and profession, creates harmony and a perfect balance in life. Living a balanced life produces a sense of completeness and a deep inner peace.

Acknowledgement

I extend my gratitude to Professor PS Chandra and Dr. Dattaraj Sawarkar for their help in the preparation of this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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