The patient is scared.
He’s in the preoperative room at Roger Williams Hospital, about to have a major back operation. The surgery will be next to the spinal cord and his mind will linger on the risks. Could a slip cause paralysis? Failure leaves him in chronic pain?
Now 57, with three young adult children, he has a history of it. In his twenties and thirties, a bad disc flared up several times a year, so he bent down on pain medication. Finally it broke. That was when he had his first operation 20 years earlier, a discectomy, to remove the bulging material.
He was fine, the episodes stopped, but in the time since then his body had grown scar tissue around the area, and the pain had returned a year earlier. Now there was also a stenosis, the narrowing of the bony opening where his spinal nerves came out to his right leg.
First, the patient tried epidural steroids injected at a Warwick clinic for fluoroscopic pain management. The first shots helped for a few months, but not much later. The pain became excruciating at times, like the spikes of a train drawn in from his back to his lower leg. It even affected his gait, his foot sank a little with every step because signals to the elevator muscle had been hit.
He finally found himself faced with the need to treat it surgically.
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A doctor friend advised him to find someone with a balance between caution and courage – the reluctance to avoid too many interventions, but the confidence to be courageous when necessary.
The patient chose Dr. Prakash Sampath, a Providence neurosurgeon with an exceptional reputation, outgoing and athletic, who played squash in his spare time.
That day of surgery, in his 40s, Sampath arrives at the hospital at 7 a.m. from his Lincoln home and then sits down to review the patient’s pictures. Worried about what he sees, he makes a dramatic decision.
Minutes later he enters the preparation room in a blue coat and asks how the patient is feeling.
Nervous, says the man as he lies in a Johnny with an IV in his arm.
Now Sampath tells him the new strategy.
At first he wanted to do a laminectomy on his own, a serious procedure that pressed the bones onto the spinal nerves. But he decided he had to do more.
“Mark,” he says to the patient, “I’ve watched these films carefully and I think it would be better for you to do the more definitive operation.”
This means a fusion in which the two vertebrae above and below the defective intervertebral disc are cemented together to form a unit, using rods, screws and bone grafts to stabilize the spine.
The patient understands what Sampath is not surprised at. He is unhappy, demoralized, can barely walk and worries that he will have to live like this.
Sampath leaves to get ready, and soon the patient is being wheeled down the hall to the operating room, where a team of half a dozen are waiting.
Soon the anesthetist begins pushing propofol through the patient’s infusion.
“You’re going to sleep now, Mark,” says Sampath. “See you in recovery.”
As soon as the patient lies under the floor with an inserted breathing tube, the team gently pats him up to his stomach on a “Jackson table” that specializes in avoiding weighted pressure points that could cause injury or increase surgical bleeding.
The patient’s back is dabbed with a dark antiseptic. Sampath will check the problem area with a new x-ray and fluoroscopy and mark the exact spot that is penetrating on the skin.
He pauses and looks around the room.
He then asks for a scalpel and begins cutting in the direction of the spine.
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A neurosurgeon’s path to Roger Williams Hospital
Prakash Sampath grew up outside London, the son of a computer scientist who immigrated there from India in the 1960s. Sampath went to boarding school in the UK, then his father moved the family to the United States to work in the space program.
Sampath graduated from Johns Hopkins in Baltimore with a bachelor’s degree in biomedical engineering. He then spent several years doing neurological research and then went on to medical school at Columbia University.
He was fascinated by neurosurgery as a specialty; the brain and spine still had many unknowns and he liked this challenge.
After a long fellowship in neuro-oncology with Johns Hopkins, Sampath was recruited by Lifespan in 2000 to lead the Rhode Island Hospital’s brain tumor program. In 2006, he became the Chief Physician of Neurosurgery at Roger Williams Medical Center, but his talents were so in demand that he was hired again in 2020 to also practice at Brown / Lifespan Neurosurgery, dividing his responsibilities among the institutions.
Performing spinal surgery to relieve chronic back pain from a Rhode Islander
Hunched over the patient, Sampath cuts through the skin and fascia and etches to stop the bleeding. In larger patients, it can take up to an hour to penetrate the adipose tissue, but it is quick. He then uses a retractor to pull the lower back muscles back four inches to expose the bony spine.
The protective lamina protrude like overhanging arches to protect, but in this case Sampath can see that they are part of the problem, a stenosis that compresses the spinal nerves that exit to the right leg. To make matters worse, a broken intervertebral disc also pinches the nerves on the left side. Sampath can see degenerative arthritis. Scar tissue too.
There is work to be done here.
He would operate near the spinal cord, one of the most dangerous parts of the body for a surgeon, along with the brain, but Sampath is calm. He’d spent seven years in post-medical training, and rooms like this are essentially his office. There he performs 8 to 10 spinal and brain surgeries per week, with the brain work usually associated with cancerous tumors.
Spine surgery: cutting bones, ligaments and scar tissue
Spinal surgery, like many orthopedic jobs, is like delicate carpentry work with similar tools.
Sampath asks for a rongeur, a forceps-like instrument that is used to remove bone, albeit carefully. In this case it is for the laminectomy.
Half a centimeter at a time, Sampath begins to bite off the vertebral arch – the lamina. But it’s complex, and soon enough he calls for a medical drill, punch, chisel and drill, chooses finer instruments as he cuts deeper, gets closer.
Then he is there and can see the spinal nerves. He managed to cut away the bone and ligament that hit it.
But even in this case something else is pressing the nerves.
“Wow,” Sampath thinks, “that’s a lot of scar tissue.” It’s baked on and sticky. No wonder this guy is in pain, he thinks.
This is now the hardest moment to remove the bad tissue from the spinal nerves in order to loosen them. Using craters resembling tiny spoons and surgical scissors, it takes half an hour, millimeter by millimeter, to dissect and shave the scar tissue without being damaged.
It’s finally clean; the nerves freed and mobile again. Sampath knows what a difference it will make. It is the most satisfying part of his job – healing patients who have deeply debilitating ailments.
But neurosurgery often involves many stages; there is still work to be done here.
The patient needed so many bones, ligaments, discs, and facet joints that the spine was destabilized.
As Sampath knew in advance, he would have to do a merger.
First, he gently taps a hard, synthetic spacer where the problematic bone and intervertebral disc were. Then they mill the bone removed by the patient himself directly in the operating room, mix it with other material and pack it back into the operating site as natural cement.
Then, in a moment of real carpentry, Sampath drills two large little finger-sized titanium screws to attach small sticks for extra support. The hardware will be there forever.
They are finally done.
Sampath closes and sews the spot.
A short time later he is operated on again. This was only part of his day.
But what a difference it made to the patient.
I am writing this now because the operation took place about a decade ago.
Since then I have no more pain or restrictions.
I suspect it is unusual for patients to tell a surgeon years later how much they have changed their lives.
With this article I want to thank Dr. Prakash Sampath.