图片来源:DALL· E 3
Imagine this scene: you wake up from your sleep and find yourself lying in the operating room, the doctor next to you is talking softly, and the clanging sound of medical equipment colliding can be heard from the top of your head. You recall that you were undergoing a craniotomy, so you savor it and try to get a sense of what the surgeon is doing in your brain. At this point, the nurse next to you hands you a guitar and says, "Please start your performance." ”
I don't know how you feel, is it panic, disgust or shock? Actually, this scene is not from a science fiction movie, but a real story that happened in a medical setting. In December 2023, American professional guitarist Christian Nolen underwent such an operation.
Nolen having surgery while playing the guitar (Image Credit: @WSVN-TV via YouTube)
Rock 'n' roll operating room
During one of the performances, Nolan was bumped. He didn't care at the time, but soon some problems arose. Nolan lost sensation on the left side of his body, he couldn't control the area above his waist, and his face began to sag. As a professional guitarist, not being able to move your left hand means the end of your musical career. A worried Nolan came to the hospital, and after a series of tests, doctors found a glioma in the right frontal lobe of his brain, which was the culprit that caused him to develop various symptoms.
The medical team at the University of Miami's Leonard M. Miller School of Medicine told Nolan that he had to undergo surgery as soon as possible to remove most of the tumor. On the one hand, this will alleviate his current symptoms, but on the other hand, the treatment options for different tumor conditions are very different, and the doctor will need to obtain the pathology results of the biopsy sample before arranging follow-up treatment.
As a result, the surgery date was scheduled for 10 days later. To Nolan's surprise, the doctor made a strange request to him: Can you do the surgery while awake and play the guitar while the tumor is removed?
Faced with Nolan's confusion, the medical team told him that this was because craniotomy was a very dangerous thing, especially since his tumor was very close to the key functional areas of the brain, and the slightest carelessness could cause damage to important abilities. If Nolan undergoes surgery while unconscious, it can be difficult for doctors to tell if the area under the scalpel is affected. So they wanted Nolan to play the guitar while undergoing the surgery, so doctors could monitor the impact of the surgery on his dexterity in real time, making sure the tumor was removed as much as possible without harming critical areas.
Awake craniotomy requires teamwork (Image Credit: Acta Neurochirurgica)
The doctor also assured Nolan that during the procedure, he would not feel any pain and would be very comfortable. After listening to this explanation, Nolan still felt very unreal, as if scenes from TV and movies really appeared in his life. However, in order to save his left hand, Nolan accepted the offer, even if there was still a trace of fear and anxiety in his heart.
On December 18, 2023, the operation began. Under the influence of the anesthetic, Nolan soon fell into a coma. I don't know how long he slept, but he vaguely felt that someone was waking him up, as if something from his mouth (actually an endotracheal tube) had been removed. Nolan opened his eyes in a daze, trying to sit up and look around. Suddenly, a hand stopped him. That's when Nolan realized that he was undergoing a craniotomy.
Before the surgery, the medical team had told Nolan in detail about the procedure and what to expect, so he followed the doctor's instructions and began to control his breathing and stay calm. The nurse handed Nolan the guitar and told him he was ready to play. Nolan chose to play his daily repertoire, which included works by two American metal bands, the Deftones and the System of a Down.
Deftones乐队（图片来源：benjgibbs, CC BY 2.0, via Wikimedia Commons）
With Nolan's guitar to the sound of the operation, the operation went smoothly. However, because the tumor is directly connected to the area of Nolan's brain that controls hand movement, when doctors began to remove the deepest part of the tumor, it was obvious that Nolen's hand was functioning abnormally. Fortunately, the highly skilled doctors did not injure the area and were able to remove the tumor intact while preserving the function of Nolan's hand. Nolan then fell asleep under the effect of the anesthetic, and the operation lasted two hours.
The day after the surgery, Nolan returned to his home. While Nolan's first few weeks were difficult to comply with the doctor's post-operative demands, he was over and back to the gym and picked up the guitar he had almost lost. Soon, Nolen's left hand function improved dramatically, and he passed the dexterity test, just waiting for the pathological results of the tumor tissue and receiving further treatment.
Awake craniotomy
The craniotomy that Nolen undergoes while staying awake is called awake craniotomy. In fact, this type of surgery is not new. As early as 1886, the British scientist Victor Horsley performed an awake craniotomy on an epilepsy patient. Because the electrocortical imaging is required to accurately locate the patient's lesion during the operation, and the anesthetic drug will directly affect the electrical activity of the nervous system, it is more conducive to the localization and resection of the epileptic lesion that the patient remains awake.
Subsequently, awake craniotomy was increasingly used to remove tumors in key brain regions, including the motor cortex in the prefrontal gyrus, the sensory cortex in the postcentral gyrus, and the language cortex. Not only are they directly related to critical patient functions, but they are also difficult to image. Therefore, by observing and monitoring the performance of awake patients during surgery, doctors can be assisted to avoid injury to important areas more directly.
In addition, another benefit of awake craniotomy is that less anesthetic is used, which can reduce the cost of postoperative intensive care and reduce neurological deficits. Moreover, patients will recover faster and have better results after surgery. Typically, a longer hospital stay means more postoperative complications, and as a result, patients who undergo an awake craniotomy have a longer postoperative survival than a regular craniotomy.
These surgeries are increasingly being performed, such as Sylvester Comprehensive Cancer Center in the United States, where Nolen operates, for example, performing more than 200 such surgeries a year, an average of several a week. In March 2007, the First Affiliated Hospital of Henan Xinxiang Medical College in mainland China cooperated with doctors from Toronto General Hospital in Canada to complete the first awake craniotomy in China.
Frisch playing the violin during surgery (Image Credit: @MayoClinic via YouTube)
However, even then, it is not routine to have the patient play a musical instrument during an awake craniotomy. Doctors usually talk to the patient during the procedure, ask the patient to complete some simple verbal tasks (such as word comprehension), and sometimes ask the patient to sing. In 2017, violinist Roger Frisch was also asked to play the violin during surgery due to essential tremor. However, unlike Nolan's removal of the brain tumor, Frisch underwent surgery to implant electrodes in the brain region of interest. Now, with the flip of a switch, the electrodes send out electrical impulses at specific locations in Friesch's brain, altering brain activity and allowing him to play fluently.
You may wonder if it doesn't hurt to remove a brain tumor while awake? In fact, although it is called "awake craniotomy", the patient is not awake the whole time. In the very first stages of surgery, the skull is nailed, scalp cuts, and bone flaps and dura removed, so this stage usually leaves the patient in a coma under anesthesia. In the stage of removing a brain tumor, because the brain itself does not have pain receptors, the patient only feels the pressure or vibration of the surgical procedure (imagine the process of wisdom tooth extraction). At the same time, the muscles, skin, and dura of the patient's head are under anesthesia throughout the procedure, so there is no pain.
However, not all patients are suitable for this type of surgery, and confusion, poor compliance, and lack of concentration are contraindications to this type of surgery. For example, about 5%~10% of patients may feel confused, agitated, frightened, painful, etc., and cannot cooperate with the instructions of medical staff for intraoperative monitoring after being woken up during surgery. Therefore, if this happens during surgery, the anesthesiologist will put the patient back into a coma and the surgical team will opt for a more conservative approach to tumor resection.