Neurosurgeons' techniques providing better outcomes, less chance of injury
J.D. Day, MD, chair of the Department of Neurosurgery, University of Arkansas for Medical Sciences (UAMS), was born into a medical family with a father who was an OB\GYN before becoming a pathologist, and a mother who was a dietician. Early on, Day knew he wanted to become a physician, but when he told his mother that he had decided to specialize in neurosurgery, she cried.
In the 1960s and 70's, neurosurgery was a tough field. The chance patients were going to be significantly neurologically impaired or would die was high. His mother was afraid his career would be stressful and sad.
Little could Day's mother have envisioned the tremendous explosion in technology for neurosurgery since the 1980s, nor that her son would become an internationally known leader developing improved neurosurgery techniques, a specialist in microsurgery and tumors and vascular disorders of the brain and skull base. Day has since written four textbooks on skull base surgery, and published more than 80 articles in medical journals on neurosurgical topics. He has been on the editorial boards of Neurosurgery and Acta Neurochirurgica, and taught skull base surgery techniques and lectured extensively in the U.S., Europe, Africa and Asia.
"We're able to do things now that when I started in medical school in the 1980s, you would really not even think about doing because the chances of success were so low, especially with brain tumors," Day said. "We are able to do a much better job with less chance of causing major neurological injury to patients. A lot of that has to do with the development of complex surgical techniques."
Previously neurosurgeons would open up the skull, move the brain out of the way and attack the tumor. That typically didn't work out so well for patients. "We learned how to remove bone at the base of the skull, get around vessels and nerves traversing the base of the skull, how to expose the tumor, and then get to the base of the tumor in order to cut off the blood supply and safely remove it. Also, these techniques are utilized for access to vascular lesions and have made a tremendous difference in reducing neurological morbidity."
The tools for microsurgery are far superior to those available 30-40 years ago. Tumors can be broken up with ultrasonic waves and removed with ultrasonic aspirators with far better tissue differentiation than in the past. For deep-seated tumors, there are ways to get to them with much less injury to the brain.
"We use a computerized image guidance system to pre-plan a trajectory working through parts of the brain to get to a deep-seated tumor, and then pass a port the diameter of a nickel that spreads out the white matter instead of cutting it," Day said. "We view the deep area with the tumor with an exoscope, which gives a high-resolution digital image on a large screen that can also be viewed in 3-D. This is many times an improved view in comparison to our standard operating microscope."
This miniaturized computer guidance and imaging technology has only developed in the past eight or nine years. Day said it wasn't until around 2012 that technology caught up with people's ideas in this area of accessing deep brain tumors through a small tubular port.
"There have been huge changes in imaging, surgery options, and neuroanesthesia techniques," he said. "Combined, we can treat a lot of things neurosurgeons would have previously considered inoperable. They could do surgery, but with more risk."
Day's family is from this part of the country, but when he was a teenager, his family lived in Boise, Idaho, where Day played junior high and high school football and baseball. He graduated from Whitman College, a small liberal arts college in Walla Walla, Washington.
During college he worked as a phlebotomist.
"That was my first exposure to being around the hospital and sick patients," Day said. "That is how I knew I wanted to be a physician. When I was in medical school at the University of Washington School of Medicine, I wasn't sure what I was going to do, but I knew I would end up doing something surgical. I played a lot of sports and thought that would be the direction I would go. But my first neuroscience course really intrigued me. There was a lot to learn. I really liked that."
The second year he took neuroanatomy and loved it. It was also very stimulating when he did his neurosurgery rotation. He was trained at the LA County/University of Southern California Medical Center in Los Angeles, which he said was quite an experience in the late 1980s and early 1990s.
"An awful lot was going on with gang violence and so forth," Day said. "There were indigent people who came up from Mexico for their care with incredible problems. People would come in much later in their disease than we would see with the U.S. citizen population. It was a really exciting place to train."
Day said he has been really blessed in terms of his mentors at USC and his fellowship. He did his fellowship training in cranial base surgery and anatomy at the University of Vienna Medical School in Austria, training under pioneering neurosurgeon Dr. Wolfgang T. Koos. He worked with renowned neurosurgeon Dr. Takanori Fukushima in residency and then in practice for a year at Allegheny General Hospital in Pittsburgh. Day then joined the Lahey Clinic in Boston as Director of Cerebrovascular and Skull Base Surgery. In 1995 Day joined the faculty of the USC School of Medicine in Los Angeles, where he was also director of neurological surgery at the world-renowned House Ear Clinic.
In 2001, he returned to the Pittsburgh and Allegheny General Hospital as the director of the Center for Cerebrovascular Surgery and Stroke through 2004. He practiced in Colorado for the next three years, until being recruited to the University of Texas Health Sciences Center in San Antonio in 2007. He was named vice chairman for academic affairs and associate residency program director in the Department of Neurosurgery at UTHSC the following year.
Day thought he might finish his career in Texas, but ended up being recruited to UAMS, where he has been now for 11 years.
Every now and then Day will see someone who was diagnosed eight or ten years ago with a benign tumor. The patient may not have been referred to a neurosurgeon earlier because the patient was not symptomatic. But Day often ends up wishing he had seen the patient five years earlier when the condition could have been treated more easily.
"Waiting and following could be to a detriment in the future," Day said. "I do like it when I see somebody even before their physician thinks they would be headed for the operating room or some form of treatment. Sometimes instead of open surgery, the right choice is stereotactic radiosurgery. So, it is my preference to see someone sooner rather than later. There are plenty of people I'm just following. There are others that I tell it isn't going to get any easier than right now. It is going to be to your benefit to have an earlier operation before you have a lot of symptoms."
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